Shoulder Complex- Tendon Rx thru Regional Interdependence Flashcards by Jessica Chambers

What should patient education with tendons be?

Load management

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What do NSAIDs do with tendon healing?

Short term pain relief in acute presentation
Delays healing if injury at insertion
poor response and no support in persistent presentation

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What does bracing do? What are some examples?

decreases resistance arm
- neoprene sleeves on involved muscles / taping PRN/ straps

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What are modalities with tendon rx? What is the issue with these?

Iontophoresis
ultrasound
phonophoresis
low-level laser treatment

** lack sufficient evidence

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What is the soreness rule with ADLs?

Symptom reproduction is not what we want with exceptions
- ok for mild symptoms during or 24 hours after activity but NO longer

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What is manual therapy used for with tendon rx?

restore accessory motion as needed

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What should be the primary and ultimate goal for tendinosis based on what is happening?

Repair
collagen production
tendon proliferation
strength

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What are the primary purposes of MET with tendinosis?

tendon proliferation
possible spinal stabilization if regional interdependance

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What are the parameters for tendinosis MET?

Implement after any acuity settles and for all structural changes in tendon, including tears

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What is the load for tendinosis?

Heavy

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What actions do we want for tendinosis?

Slower eccentrics
Possibly 3 second muscle actions ( concentric/ isometric/ and eccentric)

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What actions and ranges do we want with tendinosis?

isometric loading without compression from lengthening - in a shortened position
isometric loading without compression from lengthening - neutral to a shortened position
isotonic loading with compression from lengthening - isotonics from a. lengthened position
isometric loading in weigh bearing
plyometric loading

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How many sets and reps with tendinosis?

2-3 sets of 10-15 reps to fatigue (heavy load)

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How many exercises do we want to be doing with the involved tendon?

2-3

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What increase in pain can we expect as an activity response?

mild to moderate - up to a 5/10

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How long until pain should ease back to baseline levels?

before repeating exercises - 24-48 hours

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How often can we repeat the exercises a week?

Every other day but may increase to daily in higher level patients

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How long is the program for tendinosis?

8-12 weeks

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Why would we have precautions with heavy loads to fatigue? (What populations)

deconditioned population
peri-pubescent population until growth plates fused

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What growth plates do we need to fuse to do heavy loads to fatigue?

humeral head epiphysis at shoulder

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What growth plates are the last to fuse?

ASIS, Ischial tube, and base of 5th metetarsal

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What are some potential complications with tendinosis rx?

predisposition or prevalence of “failed healing response”
obesity = excessive fat absorbs inflammatory cells away from tendon
diabetes = excessive glucose impairs collagen production and remodeling
low grade and persistent inflammation

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What is low grade and persistent inflammation associated with?

Systemic diseases and SAD

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What does low grade inflammation and persistent inflammation limit?

Proliferation and remodeling

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Are there benefits for cortisone injections for tendon rn?

short term benefits yes

What is a rx that effectively increases circulation?

glycerin trinitrate

What can stiffen the tendon for pain relief?

Sclerosing injections

why is surgical debridement less ideal and last option?

Expensive modest success

What are some future options for tendon rx?

growth factors and stem cells

What do we need to know about modalities with impingement syndrome?

Most not beneficial US, LASER, EXTRA-CORPOREAL SHOCKWAVE lack evidence

What can scapular taping help with?

Improved short term pain an earlier window for MET and limit ADL provocation

What do we know about Jm for impingement syndrome?

Strongly recommended GH jt

Why are earlier JM benefits throughout the cervicothoracic spine beneficial?

support regional interdependance

What can JM do for the thoracic spine?

Accelerated recovery and reduced pain / disability immediately

When are JMs most effective?

added to exercise

How would we know if its tendinosis or not?

timing - 3 months / enough for changes to occur TTP Unsuccessful past PT

What would happen if the condition was a mix of excess motion & tendinosis?

Hypermobile - coordination is impaired - will become tendinosis eventually

How many sets and reps of exercises for tendinosis?

3 sets 30 reps mild loads

What is more superior to conventional low dose exercises for impingement syndrome?

High dose MET

Which is more, kinesthetic impairment or proprioceptive?

Kinesthetic -more difficult for shoulder, more symptoms the farther the arm is from the body due to a longer moment arm

How long for us to know it's tendinosis?

more than 6 months of symptoms, up to three years

What kind of exercises should we do with tendinosis?

Cuff (SIT) and scapular exercises (MT/LT/Rhom/SA)

What are the MET parameters for tendinosis?

1-2x a day

What can we expect at 3 months after seeing tendinosis using proper MET parameters?

70% will have improved pain/function (vs. 25% with traditional exercises - reduced need for subacromial decompression

How long is the average symptom duration for tendinosis?

12 months

What does tendinosis include?

Partial tears, NOT full musculotendon tears

What do we want to focus on with MET for tendinosis involving the RC?

scapular eccentric control and movement patterns

At three months how many will have improved pain? function?

8/10 improved pain, 10/10 improved function

What would you do with a tendinosis case that lasts 41 months?

HEP & supporting PT - targeting supraspinatus eccentric control with pulley - MET 2x day

How many/ what kind of tendinosis patients can we expect to avoid surgery using proper MET?

5 of 9 patients except those with labral tears and full tendon tears

In what cases would we expect earlier improvements with impingement syndrome?

no tendinosis or tears

Does MET as described for tendinosis provide benefits? what kind?

Yes LONG TERM

Is there sufficient evidence for cortisone injections for impingement syndrome?

NO Conflicting evidence

What is subacromial decompression?

partial anterior acromioplasty due to hooking - distal clavicle resection and coracoclavicular ligament - coracomial ligament resection

What are the outcomes of a subacromial decompression?

Equally or NO more effective and more expensive than exercise alone - no differences with pain, function, or quality of life vs. placebo or other intervention

When should a subacromial decompresson not be performed?

if atraumatic and present less than 3 months

What is regional interdependance?

Differing body regions are biomechanically and neurophysiologically interdependent and impairment in one region can contribute to impairment in another, particularly if persistent.

What areas have significantly lower strength with persistent neck pain?

neck, shoulder and scapular strength - ALSO lower hip and LB strength with persistent neck pain

What is a risk-factor for neck pain? (co-existing pain here)

LBP

What may play a role in regional interdependance?

Central mechanisms such as the motor cortex

What groups do we need to reach overhead?

- concentrically: flexors, ER, abductors - eccentrically: extensors, adductors, and IRs - RECRUIT WHAT YOU NEED

What most common segment for regional interdependance?

c5-6 joint dysfunction

What action is affected with C5-C6 dysfunction?

Overhead reaching - imbalanced

Why is overhead reaching affected with C5-6 dysfunction?

Excessively recruited IRs that share innervation from C5-C6, 6 segment and inhibition of ERs

What happens to the humeral head when reaching overhead with regional interdependance?

humeral head pulled anterior and into IR

What happens when the humeral head is pulled anterior and into IR?

-creates excess tension and compression underneath long head of biceps - ERs wont efficiently move humeral head and greater tubercle fully out from underneath acromion

What can excessively recruited IRs lead to?

Tendinopathy

What can happen with C2,3 jt dysfunction?

Also imbalance with overhead reaching

Why is overhead reaching affected with C2,3 dysfunction?

- Excessively recruited scapular elevators that share innervation from that segment - Inhibition of depressors

What happens with excessively recruited scapular elevators?

Scapula elevated or elevation compensation - creates excess tension and compression underneath supraspinatus tendon and tendinopathy

What happens with inhibition of depressors while overhead reaching?

Scapula wont depress efficiently - impingement especially over 150 degrees due to the SS not coming back and down out of the way - biceps tendon also impinged

What can the excessive recruitment of scapular elevators and inhibition of depressors lead to?

tendinopathy GH and AC jt hypermobility/instability

What do inhibited muscles develop at rest?

Protective hypertonicity (AKA tightness)

What interventions are only partly healpful with inhibited muscles?

Symptomatic interventions such as dry needling. modalities, etc - ONLY TEMPORARY

What do we need to address with rx for regional interdependance? (very non specific)

mechanics and involved tissues

What is there a growing body of evidence for involving RX for regional interdependence?

Treating adjacent areas, particularly the spine, can influence outcomes at another area that may seem unrelated