E3- Shoulder Impingement-Tendinosis Flashcards
what is the functional ROM of the shoulder for washing hair in the shower
120 flexion for hair
70 flexion for trunk
what is the functional ROM for donning a shirt in the shoulder
90 flexion
what is the functional ROM for reaching high shelf in the shoulder
150 flexion
what is the functional ROM for fasten a bra behind back in the shoulder
50 + extension
70 horizontal ADD
full IR
what bones and jts move with the shoulder complex motion
scapula
humerus
clavicle
upper thoracic
SC
AC
GH
scapulothoracic
movement of the humerus is accompanied by what other movements
scapula
AC,SC, upper thoracic
what is important about companion motions
assists with optimal motion
prevent impingement
keeps actin and myosin overlap efficient
what is active insufficiency
so much overlap of muscle they can not wok properly
why does companion motion prevent active insufficiency
more force due to cross bridging
what humeral motions do you observe during 150 degree overhead
FLX
ABD
ER
what scapular motion do you observe with 150 degree overhead
protraction
elevation
upward RT
what are the eccentric controls of humerus with overhead movement to 150
EXT/ADD- post deltoid, lat dorsi, teres major, LH triceps, pec major
IR- subscapularis, pec major, lat dorsi, teres major, ant deltoid
what are the concentric controls of humerus with overhead movements to 150
FLX- ant/mid deltoid, coracobrachialis, bicep brachii
ABD-supraspinatus
ER- infraspinatus, teres minor, post deltoid
what are the concentric controls of scapula with overhead movements to 150
elevators- levator scapulae, upper trap, rhomboids
protractors- serratus anterior and pec minor
upward rotators- SA and U/L trap
what are eccentric controls of scapula with overhead movement to 150
depressors- LT, Lat dorsi, pec minor, subclavius
retractors- MT, LT, rhomboids
downward rotators
what is the result of sh. complex motion to 150 degrees due to the scapula
max tension on brachial plexus as clavicle rotates post
what is the motion, concentric and eccentric controls of the humerus with overhead motion to 200 degrees
same as 150
what is the motion of the scapula when reaching overhead between 150-200 deg
depression
retraction
post tilt - SC jt
what is the concentric and eccentric controls of the scapula when reaching overhead between 150-200 deg
same plus lower trap
what motion is the upper thoracic producing with reaching overhead in 150-200 deg
ipsilateral SB, RT, and EXT
why is unilateral motion of the upper thoracic spine important
triggers concenteric control of LT along with subclavius for scapula and clavicle motion
prevents tension on brachial plexus
what can happen if the upper thoracic has a unilateral restriction
GH and AC become hypermobile
inhibit LT activity leading to impaired scap motion
what can happen to the brachial plexus with an upper thoracic unilateral restriction
allows excessive post clavicle RT and excessive tension on med cord cutting off the median and ulnar n with overhead motion
misdiagnosed as TOS
what is the motion of humerus with reaching behind your back
hyper extension
add
ir
what is the motion of the scapula when reaching behind your back
elevation
downward RT
retraction
what are the concentric controls of the humerus when reaching behind your back
EXT/ADD- post deltoid, lat dorsi, teres major, LH triceps, pec major
IR- subscapularis, pec major, lat dorsi, teres major, ant deltoid
what are the eccentric controls of the humerus when reaching behind your back
FLX- ant/mid deltoid, coracobrachialis, bicep brachii
ABD-supraspinatus
ER- infraspinatus, teres minor, post deltoid
what are the concentric controls of the scapula when reaching behind your back
elevators- levator scapulae, upper trap, rhomboids
retractors- MT, LT, rhomboids
downward rotators
what are the eccentric controls of the scapula when reaching behind your back
depressors- LT, Lat dorsi, pec minor, subclavius
protractors- serratus anterior and pec minor
upward rotators- SA and U/L trap
which muscles in the shoulder complex would be inhibited and the most important focus
SITS
lower trap
rhomboids
how can we activate the RTC
tighter grip with activities
preposition the humerus in ER
what muscles are activated when we ER the humerus
lower trap
mid trap
rhomboids major and minor
levator scapulae
when does SA have most activation
closed chain activities
what TE can we do for more SA activation
wall slides - push the wall as we slide up
weight shifts
push ups
off/on unstable surface
why do I, T, W, Y in prone
eliminate the upper trap and isolate the shoulder muscles
why do both arms during MET exercise
more motor coordination activation with the uninjured UE
what has to happen to local m before higher level or global m happen
activation
endurance
strength
coordination
what are the benefits of cervical manip for sh complex
diminished pain
improve sh and neck mobility
what are the benefits of C5-6 JM for sh complex
immediate increase in m strength of ER
what are the benefits of C/T JM for sh complex
improved symptoms and function
why can cervical issues cause sh issues
regional interdependence- cervical dysfunction (innervation) can alter sh m activity due to shared innervation
what are 4 (+) for a good prognosis in sh issues
lower baseline
lower symptoms at rest
higher pt expectation
higher self efficacy despite symptoms
what is SAPS
subacromial pain syndrome
what is a syndrome
cluster of symptoms
does not indicate definitive signs or causes
what are the two most common structures that are impinged
supraspinatus and long head of bicep
how can the tendon develop tendinopathy
sub and coracromial space is compromised resulting in impingement or compression of tendon
what can happen with increased tension in an impingement
increased activation on tendons when loaded as they wrap around the bone can result in compression
what is the most common structure involved in impingement
supraspinatus tendon
what other structures are involved with impingement
long head bicep tendon
labrum
subacromial bursa
how can the subacromial bursa be affected with impingement
result of everything else causing inflammation and coming into the bursa
what is primary impingement syndrome
limited motion
how can persistent FHP cause primary impingement
leads to shortened IR/ant capsule that limits ER
how can regional interdependence cause primary impingement
insufficient motion of sh m due to cervical dysfunction
what can cause the spurring and hooking of the acromoin
inflammatory repair phase producing more fibrotic tissue due to the bone taking on more compression
what is secondary impingement
excessive motion
what can cause primary impingement
fibrotic capsular change
disuse/immobilization
persistent FHP
regional interdependence
spurring/hooking of acromion
what can cause secondary impingement
trauma resulting in adjacent jt hypomobility
disuse/immobilization
regional interdependence
how can regional interdependence cause secondary impingement
insufficient sh stabilization
proprioceptive impairment at higher elevation
motion is worse than proprioceptive impairment= more coordination
can there be a combo of primary and secondary impingement
if so, how
yes
scapular hypo and GH hyper
what is PSGI
post-sup glenoid impingement
more overhead athletes
ER and ant GH glide = excessive
impingement of post labrum = breakdown
what can the pt tell you if they have impingement
pain at the tip and lateral shoulder
pain with reaching, lifting, pushing, pressing activities, and reaching behind back
how would you know if nociplastic pain is occuring with impingement
how long the pain is occuring and sensation the pt is feeling
what ob signs are with impingement
FHP
increased elevation due to UT compensating
inconsistent upward RT
scapular dyskinesia
what are the scapula alteration test
help move scapual bc muscles are doing it
testing to see if function or symptoms change with help
what is the scapular assistance test
passive upward RT
what is scapular repositioning test
passive upward RT and post tilt
what is the scapular retraction test
voluntary retraction
what function/ROM signs are present with impingement
limited and painful reaching overhead and behind back and with lifting
painful into FLX, ABD, ER and possibly IR
what does post sh pain indicate
posterior impingement
what are RST/MMT signs with impingement
inhibited scapular and cuff muscles- ER is weaker
proprioceptive impairments
what can happen with accessory motion in impingement
hypo=primary, post sh tightness with limited post glide
hyper= secondary
what is glenohumeral IR deficit special test for impingement
IR/ER at 90 deg ABD > 1
ER increases and IR decreases in overhead athletes
influences humeral head position in glenoid
what is infraspinatus or ER special test for impingement
in 0 ABD
painful or giving way
high spec
what is IR restisted strength special test for impingement
IR weaker than ER at 90 deg ABD
what does research say about imaging with impingement
pathology not associated with impingement symptoms
what is tendon made of
type 1 collagen
low elastin
fibrocytes
parallel fibers for more unidirectional loads
what does a tendon resist
tension and releases energy with muscle action
why is stiffness better for a tendon
better force transmission or storing of potential energy
describe mid portion of tendon
hypovascular
hyponeural
describe insertion of tendon
hypervascular
hyperneural
what is tendinitis
uncommon
inflammation of tendon without structural changes due to overuse
what are the S&S of tendinitis
typically acute
TTP
pain with limitation with lengthening
pain with resisted testing/MMT, particularly in lengthened position- may be weak
what is tendinosis
most common
degenerative changes with some inflammation
what can cause tendinosis
repetitive stress and tendinitis
impingement patho
neural/vascular insufficiency
exercise induced hyperthermia
older age
hormonal fluctuations
what are symptoms of tendinosis
persistent >4-6 wks often with failed PT
decreased tendon tolerance
what can be found in a scan for tendinosis that is persistent
ob- enlarged tendon due to fat
ROM- WNL
RST/MMT- WNL
palpation - TTP
why is tendinosis TTP
decreased pain thresholds
increased in growth of vessels and nerves
elevated pain neurotransmitters
what is pathologically going on with tendinosis
little to no inflammation
fiber changes seen on imaging
corticospinal (voluntary movement)
describe an acute tendon tear
rare
during fast eccentric loading
prior degeneration or tendinosis
what can cause a persistent tendon tear
elastin and vascularity decrease
atrophy and drying
shorter/smaller tendon= less pliable and durable
how can tendinitis be healed
POLICED
at most 4-6 wks
what is the main goal of treating tendinosis
proliferating tendon
when can we see initial tensile strength of tendinosis
3-5 wks
when does dense connective tissue fill in with tendinosis/tear
8-12 wks
how long does it take to see full strength with post op tendon tear
10-12 months
how do we treat tendinopathy
Pt edu- load management
POLICED
modalities
what can delay healing with tendinopathy
NSAIDS - if injury is at insertion
how can NSAIDS help tendinopathy
short term pain relief if acute
Why are NSAIDS have poor response to persistent tendinopathy
the problem is degeneration of the tendon not inflammation
what does bracing/taping do for tendinopathy
decrease resistance arm
how are modalities with tendinopathy
lack sufficient evidence
how do we treat tendinosis
Pt edu
manual therapy
MET
Pt asks if they should take anti-inflammatory since they are sore due to their tendinopathy, what is your response
soreness rule
if the mild pain increases during your exercise or up to 24 hours after activity and no change in movement quality
what is the primary purpose of MET with tendinosis
tendon proliferation
what are parameters for MET with tendinosis after acuity settles
heavy load
slower eccenteric
possible 3 sec muscle actions
what are our sets and reps for the m that has tendinosis
2-3 sets of 10-15 reps to fatigue
2-3 exercises
8-12 wks
every other day
mild to mod pain - soreness rule!
what are the precautions with heavy loads for tendinosis
deconditioned population
peri-pubescent population until growth plate fuses
what are complication of healing with tendinosis
predisposition of failed healing response
obesity
diabetes
low grade inflammation
why is obesity a complication of healing for tendinosis
excessive fat absorbs inflammatory cells away from tendon
why is diabetes a complication of healing for tendinosis
excessive glucose impairs collagen production and remodeling
why is a low grade inflammation a complication of healing for tendinosis
systemic disease and a poor diet
limits proliferation and remodeling
what are MD Rx for tendons
cortisone injection - short term benefits
glycerin trinitrate patch
sclerosing injections - stiffen tendon for pain relief
surgical debridement
what are the benefits for scapular taping in impingement syndome
improved short term pain
may provide window for MET and limit ADL provocation
no difference at 6 wks
what are the research for JM for impingement syndrome
strong
how does JM for thoracic spine benefit the sh
reduces pain
with added exercise it more more effective than exercise alone
what is the MET parameters for the inhibited m that could have caused the overworked m to get tendinosis
3x30
want to recreate activation, coordination, endurance, and strength
what is the most common region in the neck that gives sh pain
C5-6
what can dysfunction with reaching overhead due to C5-6 cause
excessive recruitment of IR
inhibited and protective ER
imbalance of position and m activity limits optimal motion
what can happen due to excessive IR recruitment because of C5-6 dysfunction
humeral head pulled ant of coracoid process
excess tension/compression on LHB could lead to tendinopathy
brings greater tubercle under the acromion
what can happen due to inhibited ER because of C5-6 dysfunction
greater tubercle wont fully move out from under the acromion
impinged SS and LHB lead to tendinopathy
what can dysfunction with reaching overhead due to C2-3 cause
excessive scapular elevators
inhibited and protective depressors
GH and AC jt compensation
imbalance of position and m activity limits optimal motion
what can happen due to inhibited depressors in C2-3 dysfunction
scapula wont depress
impingement after 150
impinged SS and LHB
why can impingement occur due to inhibited depressors from a C 2-3 dysfunction
depressors pull the scapula down and out of the way in the last bit of ROM
what can happen due to excessive sh elevation from C2-3 dysfunction
scapula elevated or elevation
excess tension/compression on SS
