Subacromial and rotator cuff

Question 1

external impingement

Answer 1

Primary impingement- tissues in the subacromial space irritated due to structural changes in that space or expansion of the tissues in that space

Secondary impingement - tissues in subacromial or coal spaces due to changes in the kinematics of the GH joint due to other causes

Question 2

internal impingement

Answer 2

Posterior shoulder pain due to changes that occur with repetitive throwing activities

Under surface of posterior supraspinatus or anterior infraspinatus along the glenoid rim or labrum

Question 3

Supraspinatus outlet

Answer 3

roof- acromion process and coracoacromial ligament

humeral Head and glenoid superior rim

Question 4

Structures affected with external impingement

Answer 4

supraspinatus outlet
Glenohumeral joint capsule
Subacromial bursa
Long head of biceps
Rotator cuff tendons, supraspinatus most common

Question 5

primary impingement

Answer 5

Structural changes that impact structures in the supraspinatus outlet

Space between acromial arch and the humeral head

or the volume of the tissues within that space expanding

Relatively normal mechanics -
As humeral head rolls superiorly it should also glide inferiorly

Question 6

bigliani classification of acromion type 1

Answer 6

12%
Flat inferior aspect

Question 7

bigliani class type 2

Answer 7

56%

Most common type
Curved parallel to humeral head with concave undersurface
Down slope of middle one third of acromion

Question 8

bigliani class type 3

Answer 8

29%

Most anterior portion has a hooked shape
Downsloping in the anterior third of the acromion
Associated with increased incident of SAPS/impingement

Question 9

bigliani class type 4

Answer 9

3%

Convex
a recent addition

Under surface of a chromium is convex near distal end
No correlation between type four and SAPS/impingement

Question 10

classification of progression of impingement or rotator cuff tear- stage one

Answer 10

Younger, less than 25 years old, reversible

Characterized by edema and hemorrhage, no tears

Author suggests it should be managed conservatively

Question 11

classification of progression of impingement or rotator cuff tear- stage 2

Answer 11

age 25 to 40 years
More permanent

Characterized by fibrosis and tendinopathy no tears

author Suggests subacromial decompression surgery

Question 12

classification of progression of impingement or rotator cuff tear- stage 3

Answer 12

over age 40

Characterized by bone spurs and tendon rupture

Manage with subacromial, decompression, debridement, and repair

Question 13

Extrinsic factors for disease progression

Answer 13

traumatic or cumulative impingement mechanism leads to tissue damage

Compression of the tissues within the subacromial space

Question 14

intrinsic factors- tissue degeneration

Answer 14

tissue damage leads to an impingement mechanism

Force generation/tensile forces, dynamic stability, humeral head migration reducing subacromial space

Cells within the tendon suffer apoptosis, and senescence

Disorganization of fiber alignment, fraying of tendon

Question 15

intrinsic factors- vascular changes

Answer 15

Reduced vascularity leads to tissue degeneration and impingement mechanism

Tissue irritation, and critical zone 10 mm from attachment of supraspinatus

critical zone is an anastomosis of A/P circumflex humeral arteries, and thoracoacromial a

There is debate if vascular changes causes impingement, or impingement causes vascular changes

Question 16

patient complaints for primary subacromial pain

Answer 16

Anterolateral shoulder pain
Pain at night changes with repositioning
Pain with overhead activity
Complaints of stiffness

Question 17

Cluster tests for primary subacromial pain

Answer 17

Hawkins Kennedy test
Painful arch sign
Infraspinatus muscle test

Question 18

other tests for primary subacromial pain

Answer 18

ER resistance test
Empty can
Neer

Question 19

Management of primary subacromial pain

Answer 19

mobilization
Exercise
Patient education

Question 20

Neer’s stage 1-3 interventions

Answer 20

manual therapy- GH inferior glides to improve abduction, cervicothoracic region

Exercise - scapular strengthening, rotator cuff strength

Question 21

secondary impingement

Answer 21

Excessive mobility due to glenohumeral instability or laxity

Humeral head translation in a direction that may stress tendons of RC muscles

abnormal centering of the humeral head
Abnormal positioning of the glenoid
Abnormal position due to kinematics or strength balance

Question 22

Patient interview for secondary subacromial pain

Answer 22

Younger age
Instability history
Pain with overhead activities
Hypermobility of the shoulder
Overhead athletes

Question 23

examination findings for secondary subacromial pain

Answer 23

positive SAPS cluster

and

Positive instability tests
Scapular dyskinesia
Weakness of scapular stabilizers

Question 24

interventions for secondary subacromial pain

Answer 24

Manual therapy- scapular mobilization and GH if appropriate

Exercise- rotator cuff strength, motor control, and proprioception

patient education

Question 25

Internal impingement

Answer 25

posterior shoulder pain
Throwing athlete or repetitive activity

excessive external rotation, anterior capsular laxity, scapular dyskinesia

Posterior supraspinatus or anterior edge of infraspinatus and impinges against the GH capsule, glenoid and labrum

Question 26

Internal impingement patient interview

Answer 26

Young, pain with throwing

athlete pain overhead reaching , pain with throwing, aching posterior shoulder

Question 27

internal impingement physical examination

Answer 27

Posterior impingement test positive
Positive instability tests
Scapular dyskinesia
weakness of scapular stabilizers
Hypermobility anterior capsule

Question 28

Management of internal impingement

Answer 28

posterior capsule mobilization

Rotator cuff strength

Activity modification

Question 29

Interventions for subacromial pain

Answer 29

Manual therapy- glenohumeral, scapulothoracic, AC, SC, posterior capsule tightness, cervicothoracic region

exercise- effective at reducing pain within 6 to 12 weeks

Address motor control deficits

Scapular and rotator cuff strengthening exercises up to 90° abduction is beneficial

Stretching for mobility deficits

Question 30

scapular strengthening exercises improves

Answer 30

Upward rotation, posterior tilting, scapular external rotation/retraction

Question 31

rotator cuff strengthening exercises improves

Answer 31

Force coupling of shoulder girdle

Question 32

Stretching for subacromial pain

Answer 32

Thoracic extension
Pectoral stretch
Cross body posterior shoulder stretch
Shoulder external rotation stretch
Shoulder internal rotation stretch with towel
Shoulder flexion stretch with cane or wall

Question 33

motor control, strength phase 1

Answer 33

resisted shoulder external rotation
Resisted shoulder internal rotation
resisted shoulder extension
Resisted scapular retraction
Resisted scapular protraction
Active elevation with UT relaxation
chin tuck with scapular retraction

Question 34

Motor control, strength phase 2

Answer 34

Shoulder scaption 0 to 90°
Shoulder flexion 0 to 90°
Shoulder ER
Shoulder IR
Quadruped push-up, plus
Prone shoulder horizontal abduction with scapular retraction T
Prone scapular retraction and shoulder elevation T

Question 35

Motor control, strength phase 3

Answer 35

body blade below 60°
Body blade above 60°
Lawnmower pull
Forearm push-up plus protraction plank

Question 36

which tear has better outcomes due to parallel fibers

Answer 36

Vertical tears

Question 37

patient interview for rotator cuff injury

Answer 37

Anterolateral shoulder pain
Paint at night changes with repositioning
Pain with overhead activity
Complaints of stiffness

Question 38

physical exam for rotator cuff injury

Answer 38

Painful arc
Infraspinatus muscle test
Drop arm sign

Three positive= LR 15.6 and +28 if age is greater than 60

Question 39

management for rotator cuff injury

Answer 39

manual therapy

Exercise - mobility scapular and RC strength, activity modification

Surgery