9/27 - Rotator Cuff NonOp Flashcards
what are 3 different terms that all describe subacromial shoulder pain
subacromial impingement syndrome
rotator cuff tendinopathy
rotator cuff related shoulder pain
scapulohumeral rhythm ratio for 180deg of shoulder elevation
2deg of GH motion for every 1deg of ST motion
180deg shoulder elevation
- 120deg humeral elevation
- 60deg scap rotation
the coordinated effort in scapulohumeral rhythm is important for what function
overhead function
- shoulder elevation
what is the primary function of the rotator cuff
offset force of deltoid
- the ER and IR that it also does is less important
what does the RC provide at the GH joint
dynamic stabilization by compressing humeral head into glenoid
what is the relationship of the RC muscles to the GH joint capsule
RC muscles blend w capsule & create dynamic ligament tension
- since fibers blend, when cuff contracts provides tension in the capsule
what are the force couples at work in the shoulder joint
deltoid - RC
anterior-posterior RC
upper trap - serratus anterior
what happens when there is an unopposed deltoid
superior migration
what ms are included in the anterior and posterior force couple
anterior - subscap
posterior - infra and teres minor
why would an isolated supraspinatus injury have a good prognosis
not part of a force couple
what osteokinematics is the upper trap - serratus anterior force couple responsible for
shoulder elevation
upward rotation of the scap
what are 4 functions of the upper trap - serratus anterior force couple
- optimal position of glenoid
- deltoid length - tension
- prevents impingement
- stable base to recruit scap musculature
how does the upper trap - serratus anterior force couple prevent impingement
creates posterior tipping which inc the subacromial space
what are extrinsic mechanisms behind subacromial impingement
subacromial compression
- acromial arch shape
- posture (more forward, less space)
- ms performance (dec, less upward rotation)
what are intrinsic mechanisms for subacromial impingement
age
- dec vascularity >40yo (healing potential declines)
- tendon degeneration
hypercholesterolemia
DM
smoking
what do all intrinsic mechanisms play a role in? where else does this apply other than non-op cases?
tissue’s ability to heal
relates to post op
- quality of tissue relates to how well do after surgery
what is in the subacromial space? what role do these play in subacromial impingement?
tendons of RC
LHB tendon
subacromial bursa
superior capsule
all can create sx if compressed
how does sub acromial space change w shoulder motion
in a normal shoulder - space gets smaller as you get up and above head
space is 1/2 the size it was w shoulder down when shoulder raised at 90deg
what is a hypothesis for subacromial impingement
dec ST upward rotation inc risk for RC compression d/t dec clearance in subacromial space
what combined motion w shoulder elevation can inc sub acromial clearance if reduced scap upward rotation
max IR
- RC insertions may have passed under lateral acromion at 90deg
what motions inc the acromiohumeral distance at 45deg of elevation
inc ST upward rotation
posterior tilt
what can change the impact of dec ST upward elevation on subacromial space
depends on angle of elevation
how does dec ST upward rotation change the risk of compression
shifts risks to lower angles
the subacromial space is the smallest between what angles
50-70deg
how does the position of the RC change during shoulder elevation? what is the relevance of this when it comes to sx of compression
RC already medial to acromion in most at 90deg elevation
- RC compression at lower angles may become sx in midrange due to inc force production
what would sx >90deg of elevation be related to
internal impingement (RC vs glenoid) or biceps
what was the old school of thought behind the mechanism of impingement? why is this not thought anymore?
a mechanical problem
- run out of space and pinch stuff in between
- true mechanical = compression of tissues
hasn’t been shown in all pts
pts can have nonmechanical impingement
- from tension in musculature
how does mechanical vs nonmechanical impingements differ in treatment plans
they don’t - overall treatment is the same
- interventions for hypomobility and dec strength
what are 5 etiology behind shoulder impingement
- humeral head depressor weakness / fatigue
- GH instability
- posterior capsule tightness
- scap dyskinesia / ms weakness
- subacromial crowding (ie bone spurs, other anatomical changes)
is acute or chronic etiology more commonly seen w shoulder impingement
acute is rare
chronic more common - usually overuse
what are 3 chronic etiologies of shoulder impingement
repetitive microtrauma
throwing sports
vocational demands
how do the presenting sx differ in the late cocking phase on location of path
anterior instability = anterior pain
posterior impingement = posterior pain
what does it mean to have painful arc? when is this typically seen?
hurts starting at 50-70deg and then as get more flexion, starts to feel better
- seen in subacromial pain syndrome
what are sx of subacromial pain syndrome
ant lat shoulder pain
pain >/= 90deg
painful arc
pain worse at night
what sx are seen w a RC tear
ant lat shoulder pain
dec strength**
night pain
pain wakes from sleep***
what sx are seen w posterior internal impingement
post shoulder pain in ABD-ER
overhead athletes have dec performance
what sx are seen w long head of biceps tendinopathy
ant shoulder pain w shoulder flex and arm sup
what role does the biceps play in the function of an overhead athletes
deceleration phase of throwing
what frequently leads to LHB tendinopathy bc of one of its functions
can provide stability, esp if ligamentous structures slacking
- has to work harder, esp if RC path
r/i findings for subacromial pain syndrome
(+) impingement signs
painful arc
pain w resisted ER
(+) LHB tests
r/i findings for substantial RC tear
age >60yo
(+) lag signs
weakness
atrophy
what type of problem should you think if lacking AROM and PROM
joint problem (ie adhesive capsulitis)
what type of problem should you think if poor AROM but good PROM
muscular problem
what is the biggest differential between subacromial pain syndrome and RC path
whether dec strength or not
what are 6 general areas of predisposing factors that can lead to impingement if impairments occur at those areas
- AC joint
- bursa
- capsule/ligaments
- scapula
- acromion
- RC
what impairment at AC joint could lead to impingement
degenerative bone spurs
- where acromion and clavicle meet is a common place for bone changes
what impairment of the bursa can lead to impingement
chronic thickening
- the more irritation, will get thicker
- won’t have same properties
what impairment of the capsule/ligaments can lead to impingement
hypermobility
hypomobility
what impairment at the scapula can lead to impingement
abnormal position/rhythm
- winging
- anterior tipping
anterior tipping may be d/t pec minor tight
- brings acromion forward and dec space
what impairment at the acromion can lead to impingement
shape
- if curved or hooked
what impairment at the rotator cuff can lead to impingement
impaired force couples
unopposed delt
what does a shrug sign indicate
delt overpowers the RC
- RC should hold joint in place while delt does that
etiology of a primary impingement
disruption of normal mechanics
what is a characteristic of primary impingement
hypomobile
what are important things to look at in subacromial pain syndrome bc can often have similar sx as impingements
strength and ROM
what are ways to normalize motion when treating primary impingement
capsular tightness
- inferior and posterior mobs
soft tissue adaptive changes
- pec minor
- if ms length issues
whaat muscles should be rehabed to improve dynamic stability when treating a primary impingement
posterior cuff
scap ms
what are 5 treatment interventions for primary impingement
- dec pain/inflammation
- normalize motion
- improve dynamic stability/endurance
- postural correction
- pt ed / activity modifications
what should you be educating your patients on when treating primary impingement
avoid repetitive microtrauma
sx of secondary impingement
hypermobility of static stabilizers
MOI of secondary impingement
overuse leads to loss of dynamic stability provided by rotator cuff
common pt population of secondary impingement
younger - 15-40yo
etiology of secondary impingement (8)
- static stabilizers stretched
- inc GH translation
- RC fatigues (RC working harder to keep joint stable)
- overuse tendinitis
- tendon fibers fail
- RC unable to control HOH during elevation (and offset force of delt)
- superior migration occurs
- RC dysfunction & pain
what is the goal of treatment for secondary impingement
help provide dynamic stability by inc strength of RC and scap stabilizers
secondary impingement treatment interventions
cuff strengthening
- focus posterior
scap stabilization
- retraction
- protraction
- depression
NM influences
avoid repetitive microtrauma
how does a normal shoulder translate
posterior
MOI for posterior internal impingement (4)
- ABD & ER (late cocking phase)
- overhead athletes have excessive anterior translation & GH ER
- compressive force b/w greater tub and posterior/superior labrum
- undersurface of supraspinatus and infraspinatus implicated
pathophys of primary and secondary impingements
outlet impingement
- abutting superior surface of HOH on acromion
presentation of posterior internal impingement
pain w excessive ER at 90deg ABD
sx w overhead activities
hx of recurrent sx
loss of control and velocity
test to r/i posterior internal impingement
(+) jobe subluxation/relocation
interventions for posterior internal impingement are similar to interventions of what?
secondary impingement
- difference is where sx are which is d/t where and how the tissues are being impacted
physical exam for posterior internal impingement
posterior pain on palpation
- infraspinatus tendon
anterior capsule laxity
posterior shoulder tightness
normal ROM
- inc ER and dec IR
- GIRD
weak external rotators
weak scap ms
why do you see anterior capsule laxity in overhead athletes
so much ER allowed
describe how IR/ER arc of motion changes in overhead athletes
shoulder IR/ER arc = 180deg
- arc shifts w inc ER so less IR
where do you want to especially promote dynamic stability via perturbations for posterior internal impingement
challenging positions
- aka late cocking phase
PT interventions for posterior internal impingement
dec pain/inflammation
- avoid irritating motions/activities
dynamic stability of RC
- rhythmic stabilization
- closed chain drills
scap ms training
- emphasize retraction & depression
NM training
- perturbaiton
proper throwing mechanics
what structures are involved w posterior internal impingement that sx may be coming from (6)
subacromial bursa
RC ms/tendons
acromion
coracoacromial ligament
capsule
intra-articular structures
what are factors that should be addressed when treating posterior internal impingement (4)
- altered shoulder kinematics (2deg capsular tightness
- RC/scap ms dysfunction
- overuse
- poor posture
what are interventions for posterior internal impingement dependent on
pts and reactivity
weak = stronger
stiff = move
what types of treatments have strong recs for posterior internal impingement
exercise
- home and/or clinic
- pain <5/10
- (+) resistance
- 12wks
exercise & manual therapy
- joint mobs, MWM, STM, manips
who is appropriate for a corticosteroid injection as an intervention for posterior internal impingement
if reactivity is high
- pain w ADLs not performance of sport
can’t work on deficits until reactivity calms down
what modality should you not use on posterior internal impingement
laser
what modalities have no evidence of effectiveness in treating posterior internal impingement
US
extracorporeal shockwave therapy
why is extracorporeal shockwave therapy making a comeback to treat posterior internal impingement
option if can’t do corticosteroid bc of DM
what are the best interventions for posterior internal impingement
therex
mobs
op vs nonop w a RC tear
do well w/o surgery if go to PT
try PT before surgery
