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Shoulder cuff tendinopathy Flashcards

1
Q

rotator cuff muscles

A

Supraspinatus (SST)
Infraspinatus (IST)
Teres Minor (TM)
Subscapularis (SSP)

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2
Q

where do the supraspinatus and infraspinatus fuse

A

15mm proximal

To their insertions

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3
Q

what 2 muscles are inseparable

A

infraspinatus and teres minor

Proximal to their MT junction

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4
Q

which muscle is most prone to injury

A

supraspinatus

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5
Q

subacromial space

A

Space between the under surface of the acromium and humeral head = 1cm

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6
Q

contents of subacromial space

A

Supraspinatus muscle
Long head of the biceps muscle
Subacromial bursa
Coracohumeral ligament

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7
Q

largest bursa in the body

A

subacromial bursa - separates deltoid above Rotator Cuff below
very pain sensitive

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8
Q

rotator cuff tendinopathy

A

Pain and weakness in the shoulder,

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9
Q

movements associated with RC tendinopathy

A 
most commonly associated with 
elevation
flexion
abduction
external rotation 
due to excessive load on rotator cuff tissues
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10
Q

characteristic of RC tendinopathy

A

Overuse injury
Collagen matrix disorganised
Tendon weaker
↑ apoptosis (cell death)

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11
Q

cause of RC tendinopathy

A

Altered loading
extrinsic factor
intrinsic mechanisms

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12
Q

extrinsic factors

A

as those causing compression of the RC tendons,

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13
Q

examples of altered loading

A

sports and occupations with high levels of shoulder loading

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14
Q

intrinsic factors

A 
age related - tensile tendon strength, collagen content reduced
vascularity - deficient vascular supply 
response of the tendons to tensile load
other factors
genetics
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15
Q

extrinsic factors

A 
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
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16
Q

signs and symptoms of rotator cuff tendinopathy in subjective examination

A

Pain in upper arm
Pain worse with arm movements, esp overhead
Pain can increase at night

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17
Q

signs and symptoms of rotator cuff tendinopathy in physical examination

A

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

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18
Q

Shoulder Impingement Syndrome (SIS) aka

A

Subacromial Impingement

Rotator Cuff Impingement

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19
Q

Shoulder Impingement

A

Where a structure is compressed in the subacromial space between the acromium / coracoacromial arch / AC jt. (above) humerus (below) during movement
‘External Impingement’

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20
Q

clinical tests for RC tendinopathy

A

RESISTED STRENGTH TESTING
Resisted Abduction, Medial Rotation, Lateral Rotation in neutral AND 90° abd
Empty can/Full Can
Painful Arc

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21
Q

clinical tests for Shoulder Impingement Syndrome

A

Hawkins –Kennedy

Painful Arc

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22
Q

clinical tests for RC tear

A

more weakness than pain
Lift- off sign
External rotation lag sign
Drop arm test

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23
Q

painful arc test

A

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

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24
Q

empty can test

A

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

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25
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
26
how useful is imaging?
Poor correlation between imaging and Symptoms
27
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
28
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
29
treatment for acute reactive tendinopathy
Offload tendon by altering activity Avoid aggravating activity/ relative rest Use of taping to unload
30
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
31
type of exercise for acute reactive tendinopathy
ROM to ensure passive ROM is maintained Low-load isometrics of Rotator Cuff Avoid heavy loading exercise
32
exercise for chronic tendon disrepair
Reload the tendon using a supervised strengthening programme Combination of isometric, concentric, eccentric Functional positions
33
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)
34
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
35
what movements would there be weakness in the rotator cuff tear
(flexion/abduction, internal and external rotation)
36
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)
37
what do signs of rotator cuff tear depend on
Depending on if partial /full tear
38
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
39
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.
40
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
41
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.
42
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
43
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
44
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
45
what does long head of bicep attach to
attaches to the Supraglenoid tubercle and Superior Labrum. Can be implicated in SLAP lesion
46
long head of bicep pathologies
Bicipital Tenosynovitis / Tendinopathy Rupture of long Head of Biceps Subluxation of Biceps Tendon
47
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
48
most usual site for bicipital tendinopathy
Most usual site is within the bicipital groove within synovial sheath
49
aetiology of bicipital tendinopathy
``` Overuse /Unaccustomed use Overhead motion Overhead serve in tennis Catch / pull through in swimming Follow through in golf swing ```
50
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
51
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
52
clinical tests for bicipital tendinopathy
yergasons test | speeds test
53
Yergason’s test
Patient tries to supinate against resistance from therapist
54
speeds tests
Patients flexes shoulder to 90º against resistance while maintaining the elbow in extension and the forearm in supination
55
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
56
rupture of Long head of Bicep
Complete/Partial Tear
57
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
58
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.
59
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)
60
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
61
long head bicep rupture may have ___% deficit
10-21
62
subluxation of bicep tendon
Normally held in place in groove by transverse ligament | Subluxation associated with shallow groove
63
what may cause of subluxation of bicep tendon
forced shoulder extension | abduction
64
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
65
management of subluxation of bicep tendon
Surgical repair Post –Op Physiotherapy to restore glenohumeral and scapulothoracic ROM and strength
66
common exercises used in shoulder pathology
``` Range of Motion (assisted active, active) Strengthening Rotator Cuff and Biceps Scapular Proprioception ```

NMSKI (38 decks)

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