Shoulder cuff tendinopathy Flashcards
rotator cuff muscles
Supraspinatus (SST)
Infraspinatus (IST)
Teres Minor (TM)
Subscapularis (SSP)
where do the supraspinatus and infraspinatus fuse
15mm proximal
To their insertions
what 2 muscles are inseparable
infraspinatus and teres minor
Proximal to their MT junction
which muscle is most prone to injury
supraspinatus
subacromial space
Space between the under surface of the acromium and humeral head = 1cm
contents of subacromial space
Supraspinatus muscle
Long head of the biceps muscle
Subacromial bursa
Coracohumeral ligament
largest bursa in the body
subacromial bursa - separates deltoid above Rotator Cuff below
very pain sensitive
rotator cuff tendinopathy
Pain and weakness in the shoulder,
movements associated with RC tendinopathy
most commonly associated with elevation flexion abduction external rotation due to excessive load on rotator cuff tissues
characteristic of RC tendinopathy
Overuse injury
Collagen matrix disorganised
Tendon weaker
↑ apoptosis (cell death)
cause of RC tendinopathy
Altered loading
extrinsic factor
intrinsic mechanisms
extrinsic factors
as those causing compression of the RC tendons,
examples of altered loading
sports and occupations with high levels of shoulder loading
intrinsic factors
age related - tensile tendon strength, collagen content reduced vascularity - deficient vascular supply response of the tendons to tensile load other factors genetics
extrinsic factors
Anatomical factors anatomical variants of the acromion and AC joint spurs (associated with osteoarthritis) Thoracic spine kyphosis Abnormal scapular and humeral kinematics Internal impingement Unique subset of patients Younger, related to sports
signs and symptoms of rotator cuff tendinopathy in subjective examination
Pain in upper arm
Pain worse with arm movements, esp overhead
Pain can increase at night
signs and symptoms of rotator cuff tendinopathy in physical examination
Pain with Shoulder Movements
Painful arc: 70-120°- most accurate test (Hermans et al, 2013)
Pain and weakness with resisted testing
Resisted External Rotation most accurate
Tender supraspinatus tendon insertion
Shoulder Impingement Syndrome (SIS) aka
Subacromial Impingement
Rotator Cuff Impingement
Shoulder Impingement
Where a structure is compressed in the subacromial space between the acromium / coracoacromial arch / AC jt. (above) humerus (below) during movement
‘External Impingement’
clinical tests for RC tendinopathy
RESISTED STRENGTH TESTING
Resisted Abduction, Medial Rotation, Lateral Rotation in neutral AND 90° abd
Empty can/Full Can
Painful Arc
clinical tests for Shoulder Impingement Syndrome
Hawkins –Kennedy
Painful Arc
clinical tests for RC tear
more weakness than pain
Lift- off sign
External rotation lag sign
Drop arm test
painful arc test
Onset of pain as the humeral head passes under the acromial arch between 70 – 120° abduction
As the arm rotates and elevates further the impingement is reduced
May be more pronounced on lowering arm
empty can test
Arm in 90° flexion, midway abduction, internally rotated.
Apply resisted abduction- it should be painfree and show no weakness.
Positive if it reproduces the patient’s symptoms and /or
hawkins and kennedy test for shoulder impingement syndrome
Patient’s arm in 90° abduction over your arm with your hand on their shoulder
Medially rotate their humerus, then move anteriorly repeating medial rotation.
Positive if it reproduces the patient’s symptoms
how useful is imaging?
Poor correlation between imaging and Symptoms
shoulder symptom modification procedure
A group of four mechanical techniques that are applied sequentially while the patient performs the activity or movement that most closely reproduces their symptoms with the aim of identifying one or a series of techniques that reduce symptoms by either decreasing pain / symptoms and/or increasing movement and function
mechanical techniques in shoulder symptom modification procedure
Techniques to reduce the thoracic kyphosis
Scapular positioning techniques
Humeral head positioning procedures
Pain and symptom neuromodulation procedure
treatment for acute reactive tendinopathy
Offload tendon by altering activity
Avoid aggravating activity/ relative rest
Use of taping to unload
how is pain reduced in acute reactive tendinopathy phase
Pain medications
Manual Therapy may decrease pain
Steroid injection into Subacromial space may provide short-term relief, especially if Subacromial bursal involvement
type of exercise for acute reactive tendinopathy
ROM to ensure passive ROM is maintained
Low-load isometrics of Rotator Cuff
Avoid heavy loading exercise
exercise for chronic tendon disrepair
Reload the tendon using a supervised strengthening programme
Combination of isometric, concentric, eccentric
Functional positions
how is normal thoracic/scapulohumeral movement restored for chronic tendon disrepair
Thoracic Mobility exercises e.g. Thoracic extension
Manual therapy if any glenohumeral joint stiffness
Stretch any tight muscles in scapulothoracic region
Strengthen scapular stabilisers (low evidence)
symptoms of rotator cuff tear
Pain at rest and at night, particularly if lying on the affected shoulder
Pain when lifting and lowering the arm or with specific movements
Significant weakness when lifting or rotating the arm
what movements would there be weakness in the rotator cuff tear
(flexion/abduction, internal and external rotation)
signs of rotator cuff tear
Passive ROM is often normal
Significant loss of Active ROM esp flexion/abd/external rotation ( greater loss if full tear)
Significant loss of strength (flexion/abduction/ER)
what do signs of rotator cuff tear depend on
Depending on if partial /full tear
drop arm tests
Patient sitting or standing.
The arm is passively raised to above 90 abduction
The patient then actively lowers the arm to 90 abduction in internal rotation
what is a positive rotator cuff tear for drop arm test and what does it mean
If the arm approaches 90 and ‘drops’, the test is positive for a full thickness tear of the rotator tear.
external rotation lag test
Patient’s arm passively brought into approx 20º elevation in the scapular plane and approx 5º short of full External Rotation.
Remove your hand from their wrist, keeping other hand at elbow.
Ask them to maintain the external rotation position
what is a positive rotator cuff tear for external rotation lag test and what does it mean
Test is positive if the patient is unable to maintain ER position.
what would indicate a tear in supraspinatus or infraspinatus in external rotation lag test
Lag of 5-10º may indicate tear of either SST or IST or both or nerve lesion
subscapularis tear lift off test
Patient sitting so that dorsum of hand rests against mid lumbar spine
Lift the distal end of patient’s forearm away from the spine so that arm is in full IR
Ask patient to maintain position
what is a positive subscapularis tear for lift test and what does it mean
Positive lift off test indicates tear of SSB
Confirmed with MRI
what does long head of bicep attach to
attaches to the Supraglenoid tubercle and Superior Labrum. Can be implicated in SLAP lesion
long head of bicep pathologies
Bicipital Tenosynovitis / Tendinopathy
Rupture of long Head of Biceps
Subluxation of Biceps Tendon
why is long head bicep vulnerable to bicipital tendinopathy?
LHB takes part in all shoulder movements and is vulnerable in the groove, hence is prone to overuse symptoms
most usual site for bicipital tendinopathy
Most usual site is within the bicipital groove within synovial sheath
aetiology of bicipital tendinopathy
Overuse /Unaccustomed use Overhead motion Overhead serve in tennis Catch / pull through in swimming Follow through in golf swing
symptoms of bicipital tendinopathy
History of overuse /increased loading (e.g. biceps weight training)
Anterior shoulder pain which may radiate down anterior aspect upper arm.
Aggravated by lifting
Aggravated by elbow and shoulder flexion
+Hawkins and Kennedy test esp in greater horiz adduction
+/- Positive SLAP lesion tears
signs of bicipital tendinopathy
Point tenderness to palpation of biceps in bicipital groove
Pain on resisted biceps contraction: elbow flexion/ supination
Pain on stretch of biceps
Positive Speed’s Test /Yergason’s Test
clinical tests for bicipital tendinopathy
yergasons test
speeds test
Yergason’s test
Patient tries to supinate against resistance from therapist
speeds tests
Patients flexes shoulder to 90º against resistance while maintaining the elbow in extension and the forearm in supination
conservative management of bicipital tendinopathy
Relative Rest
Education on load management
Strengthening – isometric/eccentric/concentric
ROM exercise/joint mobs if ROM is restricted
Pain Meds e.g. Steroid Injection
rupture of Long head of Bicep
Complete/Partial Tear
most common patient group of rupture of long head bicep
Most common in middle-age/older people and is usually due to years of wear and tear on the shoulder
May occur in younger athletes occurs during weightlifting or from actions that cause a sudden load on the arm, such as hard fall with the arm outstretched
signs of long head of bicep rupture
Partial tear-pain and some weakness in supination
Complete tear-less pain, more weakness
Approx loss of 20% supination strength
Obvious deformity
‘Golf ball’ appearance in the upper arm.
symptoms of long head bicep rupture
Anterior shoulder pain
Sudden onset of pain assoc with event/activity
Audible ‘pop’
Pain worse with overhead activity or lifting (in supination)
management of long head bicep rupture
Surgical Repair if young and play sports
Otherwise generally conservative
Deal with symptom management
Strengthening with focus on functional requirements
long head bicep rupture may have ___% deficit
10-21
subluxation of bicep tendon
Normally held in place in groove by transverse ligament
Subluxation associated with shallow groove
what may cause of subluxation of bicep tendon
forced shoulder extension
abduction
signs and symptoms of subluxation of bicep tendon
Painful clicking especially on abd/ ER/ elbow flexion
Palpable click on medial and lateral rotation
Positive Speed’s test
management of subluxation of bicep tendon
Surgical repair
Post –Op Physiotherapy to restore glenohumeral
and scapulothoracic ROM and strength
common exercises used in shoulder pathology
Range of Motion (assisted active, active) Strengthening Rotator Cuff and Biceps Scapular Proprioception
