Rotator cuff tendinopathy Flashcards
what are the 4 rotator cuff muscles?
-supraspinatus
-infraspinatus
-subscapularis
-teres minor
what is the anterior cuff vs the posterior cuff?
- subs cap - anterior cuff - biggest RC muscle
-infraspinatus, supraspinatus and teres minor make up the posterior cuff
what other muscle gives the shoulder some anterior support?
the long head of biceps muscle
in shoulder flexion met, are the anterior or posterior cuff muscles working?
- flexion - posterior cuff muscles are working
in shoulder extension, are anterior or posterior cuff muscles working?
anterior cuff muscles are working during extension
how is the function of a tendon in the lower limb different to a tendon in the lower limb for eg, the achilles tendon?
- the tendons in the lower limbs are like springs, also the body weight is the load
-upper limb tendons are not as reactive as lower limb tendons, they absorb energy and compressive forces swell as controlling friction and shear
what does tendon pathology occur with?
it occurs with a change in load or function
what are the 3 phases of tendinopathy?
-reactive tendinopathy
-tendon dysrepair
-degenerated tendon
what is 66-85% of ALL shoulder complaints down to?
rotator cuff related shoulder pain (RCRSP)
what is rotator cuff related shoulder pain?
- pain & weakness in the shoulder, most commonly associated with elevation (flex/abduction) and external rotation due to excessive load on the RC tissues
what is the most common age for rotator cuff related shoulder pain?
those aged 40+
what are extrinsic mechanisms that are related to rotator cuff pathology?
-those with originate external to the tendon that cause compression or shear
what are intrinsic mechanisms in relation to rotator cuff pathology?
-those which originate within the tendon eg degenerative processes associated with aging
what are some examples of intrinsic risk factors that could cause rotator cuff pathology?
-male sex
-menopause
-genetics
-systemic inflammatory or autoimmune conditions
-diabetes
-increased BMI
-increased adiposity
-structural or biomechanical abnormalities
what are examples of extrinsic risk factors related to rotator cuff pathology?
- change in load (over or under) applied to the tendons eg training amount, activity levels, repeated overhead activity
-change in muscle;e activity of the shoulder and scapular muscles - smoking
-alcohol
upon subjective exam, what are signs and symptoms of rotator cuff related shoulder pain?
-pain in super/lateral and anterior shoulder
-pain worse with overhead activity
-pain worse with compression eg night pain (laying on shoulder)
-pain at rest
what are signs and symptoms of RCRSP during physical examination?
-pain with shoulder mats
-painful arc - between 70-120 degrees ( abduction - arm is at heaviest at these angles)
-pain & weakness when testing RC in neutral and through range
-special tests will all reproduce pain
-pain on palpation of cuff +/- tendon
what is the full can test?
- test used to assess the function of the supraspinatus muscle and tendon of the shoulder complex
-patient flexes arm to 90 degrees and externally rotates the arm with thumbs pointing up and physio should apply a downward force
-positive test -pain and or weakness
what is the empty can test?
- assesses for lesions in supraspinatus muscle and tendon
-patient flexes arms to 90 degrees and internally rotate arms with thumbs down
-physio applies a downward resistance
-positive test = patients pain is reproduced and or weakness
Describe the painful arc
- arc is a test during ROM assessment - active abduction
-onset of pain between 70-120 degrees due to poor RC control- could be due to the fact that at this point the arm is the heaviest etc
what is Neers test?
- the physio should stabilise the patients scapula with 1 hand while passively flexing the arm while it is internally rotated
-if the patient reports pain in this position, then the result of the test is positive
what is Hawkin’s Kennedy test?
-shoulder is placed in 90 degrees of forward flexion & bending the elbow
-the shoulder is forcibly internally rotated
-positive if pain is reproduced
what is the belly press test?
- a test used to isolate the subscapularis muscle and assess for a tear or dysfunction
-patient sits or stands with the elbow flexed to 90 degrees, with the palm of the hand on the upper abdomen, patient is asked to press the palm of the hand against the abdomen, through shoulder internal rotation
-positive test is there is compensation with wrist flexion, shoulder adduction and shoulder extension
what is the problem with RCRSP special tests?
they are not specific
how is RCRSP managed?
-patient education
-setting realistic goals
-address anxiety and fear of moving
-reviewing baseline activity and modify
-lifestyle modification - eg weight, alcohol, smoking
how would a physio manage acute reactive tendinopathy?
-offload tendon by altering activity - ie keep exercise that is not pain provoking
-reduce pain - eg manual therapy, short course NSAIDS
-exercise should be non-provocative - gradual load of RC through range and avoiding heavy loading exercise initially
how should chronic tendon disrepair in RC be managed with exercise?
-combination of isometric, concentric, eccentric - add range, low weight and high reps
-functional positions
-heavy slow resistance has shown no additional benefit to date - upper limb
other than exercise, how can chronic RC tendon disrepair be managed?
-manual therapy if any joint stiffness
-stretch any tight muscles
what are important characteristics with a RC tear of someone aged less than 40?
-traumatic
-increased risk with overhead or contact sports
-respond very well to surgery
-long road to recovery
-account for less than 10% of RC tears
what are characteristics of RC tears for older population?
-greater than 40 years
-degenerative
-end stage of tendinopathy
-can reach 30% of population of 60+ years
-can be pain free but will be weak
upon subjective, what are signs / symptoms of a rotator cuff tear?
- history of trauma or fall
if older - no trauma - but difficulties to do ADLs eg changing
-inability to lift arm
-pain at rest, at night or with activity
-heaviness and weakness
-loss of function
upon an physical exam, what are the signs and symptoms of a rotator cuff tear?
-wasting at scapula and deltoid
-positive break tests
-pain with resisted tests
-often have near full PROM but limited in AROM
-acute tears can be stiffer
what are examples of important tests for rotator cuff tears?
- break test - need to demonstrate that the muscle is intact
-drop arm
-lag sign
-belly press
-Oxford scale
Describe a rupture of the long head of biceps and important points about it
- can be a complete or partial tear
-most common in older people
-often happens with low or no trauma
-patient will report sharp pain with a mvt
-will have associated bruising
-popeye sign
what does the conservative management of long head biceps rupture involve?
-relative rest and avoid aggregating exercises
-working the cuff muscles
-education on load management
-can regain full function and pain free mat
Describe calcific tendinitis?
- a build up of Ca2+ in the rotator cuff
-calcium builds up in the tendon and it can cause a build up of pressure in tendon
-severe pain and sudden in onset
-pain at rest and night
-seen in ages 30-50, rare in 70+
-more common in females than males
how is calcific tendinitis managed?
-NSAIDS
-surgical removal of Ca2+
