shoulder 3 Flashcards
Tendinopathy:
- common in overhead athletes / labourer
- intrinsic: originates within the tendon, usually as a consequence of overuse or overloading
- or extrinsic includes compression or irritation of the upper part of the tendon to where the tendons come into contact with the shoulder blade when lifting the arm above head
- may have history of subluxation/instability
• Complains of:
o Night pain is common
o Pain at rest
o Pain in the inferior portion with overhead activity such as throwing, swimming and overhead shots in racquet sports
o Tenderness over supraspinatus tendon proximal to or at its insertion into the greater tuberosity of the humerus
phases of tendinopathy
Phase I: Pain during exercise that may go with warming up or be present for a short while later. No effect on ADLs.
Phase II: Pain during exercise that does not subside but does not interfere with activities of daily living.
Phase III: Pain starting to limit physical activity and activities of daily living.
Phase IV: Pain is interfering with ADLs and is consistent if not constant.
Tendinopathy Ax
• Palpation
o May be tenderness over the supraspinatus tendon - greater tuberosity of the humerus
• Movement examination
o Painful arc of abduction between 70 - 120 degrees
o less than 90 degrees of abduction are pain-free
o pain on extremes of passive sh. flexion
o Decrease in internal rotation ROM
o Ensure rotator cuff strength is tested with scapula well stabilised
o Symptoms often eased with scapular assistance test -
♣ One hand placed on upper trapezius, the other on the inferior medial scapular border
♣ The therapist assists scapular upward rotation as the arm is elevated.
- This helps to identify which patients will respond best to scapular stabilisation exercises
• Positive tests o Neer’s Impingement o Hawkin’s Kennedy o End of range passive flexion o Pain on resisted contraction of supraspinatus (empty can?)
Differential diagnosis
• Impingement (Neers & Hawkins-Kennedy)
• Supraspinatus tear (Empty Can test)
Other assessment
• MRI may reveal a partial thickness tear of the rotator cuff
• US can rule out a full thickness tear, define a partial thickness tear, identify a thickened subacromial bursa and can rule in or out an impingement of the bursa under the lateral acromion as the arm is abducted.
Tendinopathy Mx
Advice and education
• Avoid aggravating activity and apply ice locally
• NSAIDs
* stretching exercise recommended early to maintain joint mobility – one per day, everyday
* no sling - as can cause frozen shoulder
- once pain permites, - gentle activation > strength
- expect mild pain, no longer than 24hrs if so rest and ice.
Correct associated abnormalities • glenohumeral instability • muscle weakness o predisposes to rotator cuff tendinopathy o strengthen external rotators - imbalance btwn Ir and ER
Correct impaired scapulohumeral rhythm
- ELEVATION of the scapula is important
o Serratus anterior and rotator cuff co-conrtactions
- soft tissue tightness
o posterior capsule tightness is commonly associated with decreased IR and decreased rotator cuff strength
♣ horizontal adduction stretch with scapula stabilised
♣ sleeper stretch
Address training errors - collab with coach
particular pitcher p increased ER from repeated stress to ant. capsule in cocking phase and stretch, or degeneration of IGHL > ant stability or shoulder impingement
Rotator cuff tear
common in:
• Elderly (spontaneous (changes in tissue health), minimal or accumulative trauma)
• Athletes (acute or trauma or repetitive or eccentric overload)
• MOI o Falls (in older people) - FOOSH acute o MVA o Eccentric overload - degenerative o Unexpected movement, sudden load application, sudden release of load i.e. dropping a box
• Complains of
o Pain at rest (even if complete rupture, due to overstress on adjacent structure)
o Inability to sleep on affected shoulder
o Limited ROM
- pain at lateral arm over over insertion at greater tuberosity of humerus
Rotator cuff tear Ax
• Observation
o Hitching of shoulder
o Decrease in muscle bulk of supraspinatus, infraspinatus and deltoid
• Movement exam
o Loss of ER or IR strength
o Decreased ability to maintain the correct position of the HOH
♣ Anterior and superior translation of HOH leading to microtrauma can lead to subacromial impingement
o Unable to abduct shoulder to greater than 90 degrees
o Decreased stability of GHJ
o Reduced range in ABD, FL, IR, ER
• Positive tests: o Empty can o MLT for rotator cuff will be positive o Impingement signs o Weakness of supraspinatus
Other assessment • MRI • US Differential diagnosis • SLAP lesion • BBLH tear
Rotator cuff tear Mx
Older patients
• Conservative management indicated
• Use principles from tendinopathy with a greater focus on RICER (for inflammation and pain)
Younger patients
• Re-attachment and debridement of fraying fibres
o Post-surgery Pendular exercises and AAROM as for adhesive capsulitis
Neuromuscular control
• Force couples
• SA, LT, UT, MT, Infra, Subscap, Supra
• Elevation and abduction pathomechanics
conservative recommended:
- reduce symptoms: avoid positions, no sling – frozen shoulder, ice
- stretching exercise recommended early to maintain joint mobility – one per day, everyday
- once pain permites, - gentle activation > strength
- expect mild pain, no longer than 24hrs if so rest and ice.
- If doesn’t improve – look into surgical
- Generally 6 months of rehap after surgical repair
- maintain fitness
SLAP
Superior Labrum Anterior to Posterior
Injuries to the labrum that extend from anterior
to the biceps tendon to posterior to the tendon
There are 4 classifications of SLAP lesions:
- Type 1: frayed and degenerated labrum
- Type 2: detached superior labrum and biceps tendon from glenoid rim.
- Type 3: bucket handle tearing of superior labrum. Remaining labral tissue remains attached to glenoid rim.
- Type 4: Extension of displaced bucket handle tear into the biceps tendon.
Prevalence
• Overhead athletes/ labourers
• Baseball pitchers
• Military personnel
- Deceleration/late cocking phases of throwing
- More common in males, overhead athletes - around 40yo for F and Ms
• MOI
o Traction on the arm (carry heavy object pulls bicep tendon) or compression loading on the shoulder from a fall on the hand in forward shoulder flexion and abduction
o Deceleration/late cocking phases of throwing
• Complains of:
o Pain at the posterosuperior aspect of the shoulder joint line
o Pain is intermitted and is exacerbated by overhead activities and behind the back motions
o Decreased throwing power
o May report feelings of instability and clicking/catching/snapping
SLAP Ax
• Palpation = Tenderness over posterosuperior joint line of the shoulder
• Observation
o Functional tasks
♣ Overhead and behind the back arm motions may produce poorly localised pain at the shoulder
♣ Throwing?
• Movement exam
o inc. in shoulder ER w/ dec IR due to TIGHT POSTERIOR CAPSULE
♣ GIRD
o Pain upon ER/cocking in 90 degrees of shoulder abduction
o Possible pain on resisted biceps contraction (types 2 and 4)
o Clicking, popping, catching snapping
o Glides > posterior capsule length tests
• positive tests ♣ Positive biceps load test ♣ Positive pain provocation test ♣ Dynamic labral shear test o Other ♣ Apprehension test ♣ O’Brien’s ♣ Crank test
Differential diagnosis
• OA via x-ray
• Biceps
• Rotator cuff partial thickness tear (Painful arc, MMT)
• Biceps brachii long head tendinopathy (pain in bicipital groove that radiates down anteriorly, MMT)
• Posterosuperior internal impingement syndrome (Hawkin’s and Neer’s impingement)
SLAP Mx
- Improve awareness and control of scapular position
• PNF techniques
o Anterior elevation and posterior depression of scapula
• Active assisted movements
o With pulley, targeting serratus anterior
• Lower trapezius and serratus anterior activation - Decrease tightness of the posterior capsule
• AP glide
o with the patient positioned in supine and their hand behind their back
o Progress: grade, duration, position (could start in neutral).
o AP glide whilst they are in horizontal flexion
• Sleeper stretch - can do at home
- side lye, 90 elbow flex, lower arm down with unaff. arm
Lie on affected shoulder (side lying) with head well supported by pillows. Shoulder in 90 degrees ABD and elbow in 90 degrees FL. Place a rolled towel under the upper arm
or
• Across body stretch
o Sustained horizontal stretch: 5x 30 second holds
o Progress: possibly do a compound movement, adding in internal rotation
* MUST HAVE STABLE SCAP - NO MVMT
- Progress to functional activity > throwing program
• Body and shoulder position
• Load, velocity, power
• Duration/volume
Surgery
• Arthroscopic with suture anchors
Prognosis
• Success in conservative Mx = RTS at 3-6 months
• Success in surgical repair and rehabilitation = return to function at 6-10 months
• Recovery influenced by concomitant pathologies and extent of lesion
