Subacromial and rotator cuff Flashcards
external impingement
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
internal impingement
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
Supraspinatus outlet
roof- acromion process and coracoacromial ligament
humeral Head and glenoid superior rim
Structures affected with external impingement
supraspinatus outlet
Glenohumeral joint capsule
Subacromial bursa
Long head of biceps
Rotator cuff tendons, supraspinatus most common
primary impingement
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
bigliani classification of acromion type 1
12%
Flat inferior aspect
bigliani class type 2
56%
Most common type
Curved parallel to humeral head with concave undersurface
Down slope of middle one third of acromion
bigliani class type 3
29%
Most anterior portion has a hooked shape
Downsloping in the anterior third of the acromion
Associated with increased incident of SAPS/impingement
bigliani class type 4
3%
Convex
a recent addition
Under surface of a chromium is convex near distal end
No correlation between type four and SAPS/impingement
classification of progression of impingement or rotator cuff tear- stage one
Younger, less than 25 years old, reversible
Characterized by edema and hemorrhage, no tears
Author suggests it should be managed conservatively
classification of progression of impingement or rotator cuff tear- stage 2
age 25 to 40 years
More permanent
Characterized by fibrosis and tendinopathy no tears
author Suggests subacromial decompression surgery
classification of progression of impingement or rotator cuff tear- stage 3
over age 40
Characterized by bone spurs and tendon rupture
Manage with subacromial, decompression, debridement, and repair
Extrinsic factors for disease progression
traumatic or cumulative impingement mechanism leads to tissue damage
Compression of the tissues within the subacromial space
intrinsic factors- tissue degeneration
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
intrinsic factors- vascular changes
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
patient complaints for primary subacromial pain
Anterolateral shoulder pain
Pain at night changes with repositioning
Pain with overhead activity
Complaints of stiffness
Cluster tests for primary subacromial pain
Hawkins Kennedy test
Painful arch sign
Infraspinatus muscle test
other tests for primary subacromial pain
ER resistance test
Empty can
Neer
Management of primary subacromial pain
mobilization
Exercise
Patient education
Neer’s stage 1-3 interventions
manual therapy- GH inferior glides to improve abduction, cervicothoracic region
Exercise - scapular strengthening, rotator cuff strength
secondary impingement
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
Patient interview for secondary subacromial pain
Younger age
Instability history
Pain with overhead activities
Hypermobility of the shoulder
Overhead athletes
examination findings for secondary subacromial pain
positive SAPS cluster
and
Positive instability tests
Scapular dyskinesia
Weakness of scapular stabilizers
interventions for secondary subacromial pain
Manual therapy- scapular mobilization and GH if appropriate
Exercise- rotator cuff strength, motor control, and proprioception
patient education
Internal impingement
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
Internal impingement patient interview
Young, pain with throwing
athlete pain overhead reaching , pain with throwing, aching posterior shoulder
internal impingement physical examination
Posterior impingement test positive
Positive instability tests
Scapular dyskinesia
weakness of scapular stabilizers
Hypermobility anterior capsule
Management of internal impingement
posterior capsule mobilization
Rotator cuff strength
Activity modification
Interventions for subacromial pain
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
scapular strengthening exercises improves
Upward rotation, posterior tilting, scapular external rotation/retraction
rotator cuff strengthening exercises improves
Force coupling of shoulder girdle
Stretching for subacromial pain
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
motor control, strength phase 1
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
Motor control, strength phase 2
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
Motor control, strength phase 3
body blade below 60°
Body blade above 60°
Lawnmower pull
Forearm push-up plus protraction plank
which tear has better outcomes due to parallel fibers
Vertical tears
patient interview for rotator cuff injury
Anterolateral shoulder pain
Paint at night changes with repositioning
Pain with overhead activity
Complaints of stiffness
physical exam for rotator cuff injury
Painful arc
Infraspinatus muscle test
Drop arm sign
Three positive= LR 15.6 and +28 if age is greater than 60
management for rotator cuff injury
manual therapy
Exercise - mobility scapular and RC strength, activity modification
Surgery
