Shoulder Treatment FT400 PT600 PDF

Orthopedic Treatment FT400 PT600 Shoulder Module Section 3 - Common Conditions Tendons 2 Tendonitis (Tendinopathy) Definition: This is an overuse injury that causes inflammation to the tendons involved in repetitive movements. Etiology: Commonly SITS muscles (though ra...

Orthopedic Treatment FT400 PT600 Shoulder Module Section 3 - Common Conditions Tendons 2 Tendonitis (Tendinopathy) Definition: This is an overuse injury that causes inflammation to the tendons involved in repetitive movements. Etiology: Commonly SITS muscles (though rarely teres minor) & biceps brachii MOI - repetitive upper limb (especially overhead) movements > swimming, throwing sports, volleyball, golf, etc - occupations that require repetitive movements – dry walling, painting, etc. Supraspinatus Tendinopathy The supraspinatus is a dynamic ligament and is therefore being constantly challenged to maintain stability and congruency of the joint It experiences repetitive movements and strain through: i.) Sports or other activities (abduction and flexion) ii.) Postural changes (kyphosis) causing the rotator cuff to undergo fatigue & stress from constant use The rotator cuff has poor vascularity especially the supraspinatus and infraspinatus muscles. Hypovascularity > poor nutrition and repair > degenerative changes > inflammation > scar tissue > calcification > tear Age, overuse, & abuse may lead to Impingement Syndrome, bursitis, or adhesive capsulitis Bicipital Tendonitis The biceps acts as a humeral stabilizer and elbow decelerator Tenosynovitis may develop with continued compression of the biceps tendon in the bicipital groove Inflammation may adhere tendon to groove decreasing the gliding motion Continual cortisone injections may cause weakening of the tendon therefore if repetitive movements continue a rupture of the biceps long head may occur (usually proximal to distal) If the transverse humeral ligament is torn or if the bicipital groove is compromised – subluxation of tendon out of groove Calcific tendonitis This occurs in the later stages of rotator cuff tendonitis (especially in the supraspinatus tendon). Fibroblasts change to chondrocytes and calcified deposits fill up the intercellular spaces of tendons causing an increase in size. As the tendon grows bigger, this may lead to impingement under the acromial arch. This condition is now thought to be a self-healing mechanism. The deposits are eventually reabsorbed (self-limiting). During this time there is increased circulation, inflammation, swelling and pain; may lead to complications like tendon rupture. Bursitis may commence if the calcium deposits rupture into the bursa. Calcific tendonitis is confirmed with an x-ray. Tendinopathy Signs & Symptoms In general, provoked by - Contraction against resistance (strengthen) (RROM/MMT of that muscle) - Stretch/elongation (lengthen) (AROM in opposite movement of that muscle) - Palpation (the site of tissue damage; the origin, the insertion) The above is true for all musculotendinous tissue damage Tendinopathy Signs & Symptoms Referral pain at lat brachial region (supraspinatus) or ant brachial region to the insertion of the biceps (bicipital, never supraspinatus) Note: pain referred below elbow is very rarely due to GH joint injury Sleep disturbance if guest sleeps on affected side Soft tissue swelling, atrophy, redness, etc. Pain with palpation of the tendon(s) Shoulder Tendinopathy - Special Tests Speed’s Biceps tendon Empty Can Supraspinatus tendon Drop Arm Supraspinatus strain Tendonitis-Bursitis Differentiation test Ddx supraspinatus v subacromial bursa MMT E.g. infraspinatus Tendinopathy - Treatment Acute = Rest and ice Chronic = Break & Build Decrease inflammation Decrease restrictions/adhesions Reduce HT in affected mm’s, TrPs Muscle tone, TrPs Maintain available ROM, Friction therapy if needed Decrease pain Mobilize hypomobile joints Compensatory areas Stretch to maintain new length of functional scar RROM to help realign fibres and return strength Increase circulation and decrease edema in the shoulder Strengthen Tendinopathy - Treatment Precautions and CI’s: Calcific tendonitis to the supraspinatus tendon Tenosynovitis of the bicipital tendon Anti-inflammatory medications Bursae 12 Bursitis This is the inflammation of the bursa. In the shoulder there are 8 to 9 present but only 2 have clinical significance. Subacromial (aka subdeltoid) – this bursa is situated on top of the supraspinatus muscle (tendon and belly) and underneath the acromion and deltoid muscle. As a result of this positioning, this bursa is susceptible to impingement by the acromial arch especially when inflamed or affected by a calcified supraspinatus tendon. Subscapular – this bursa lies over the anterior joint capsule and under the subscapularis tendon. As a result of lying atop the articular joint capsule, joint effusion may be apparent because of inflammation of the bursa. Bursitis Etiology: Usually secondary to other conditions like calcific tendonitis Overuse of the structures surrounding the bursa > excessive friction upon bursa > inflammation of bursa. Contributing factors include: Repetitive movements Poor biomechanics/technique in sport Muscle imbalance Postural changes and a lack of flexibility Trauma (blunt force or FOOSH), infection (from a needle) Pathologies (arthritis) may also cause bursitis Bursitis - Signs and Symptoms Pain over the lateral brachial region (sometimes referred below elbow (acute)) Pain may affect sleep especially if bursa is compressed Acute = Inflammation, heat and swelling, pain is deep, constant, intense, Burning and present at rest and with activity; Onset is sudden over 12 –72 hours and builds Severe debilitation lasting for 2 weeks Chronic = pain is more localized and expressed with activity or direct Compression Other conditions may be present i.e. – tendonitis Protected positioning and guarded movements With chronic inflammation = fibrosis and adhesions Bursitis ROM: AROM = all ROM restricted especially elevation (60˚), a painful arc may be present PROM = non-capsular pattern, empty end-feel (with pain or anticipation of it) RROM = most hesitation with abduction because of pain and the squeezing of the inflamed bursa. Other movements may yield strong and painless contractions if performed carefully Bursitis - Special Tests Painful arc Present - requires differentiation Neer Impingement Present - requires differentiation Hawkins-Kennedy Present - requires differentiation Tendonitis-Bursitis Differentiation test Ddx supraspinatus v subacromial bursa Bursitis - Treatment Treating bursitis is similar to tendonitis Manage inflammation first then address the structures contributing to the bursitis i.e.- tendonitis Precautions and Contraindications: Avoid compressing an inflamed bursa , therefore techniques should work around the affected area until inflammation subsides before performing onsite Avoid tissue drag around superficial bursae Hydro precautions If infected, refer to MD for medical attention Impingement 19 Impingement Syndrome This is an inflammatory condition that involves the coracoacromial arch and the space between the acromioclavicular and glenohumeral joints (subacromial space) Tissue is impinged in this space. - Rotator cuff (supraspinatus MC) - Long head biceps tendon - Subacromial bursa Impingement Syndrome Etiology: In Kessler there are three theories: mechanical-anatomic theory vascular compromise theory kinesiological factors (poor scapular rotation or coordination) Coracoacromial arch = ‘roof’ of the shoulder Coracoid process Coracoacromial and anterior acromioclavicular ligaments Acromion Morphology Impingement Syndrome Etiology: The rotator cuff tendons (especially the supraspinatus), biceps tendon and subacromial bursa undergo trauma and wear & tear when the head of the humerus is repeatedly being pushed up into the coracoacromial arch. Impingement Syndrome Etiology: Factors that may cause this repeated trauma include: Failed muscle force-coupling Loss of passive stability Poor external rotation humerus Supraspinatus and bicipital tendonitis, subacromial bursitis, calcific tendonitis Poor vascularity in the rotator cuff muscles especially supraspinatus and infraspinatus Age and gender (more prevalent in ‘older’ (>30) and females) Sports with repeated upper limb movements or occupation/activities that require Working with the arm in a horizontal or higher position Impingement Syndrome Stage 1 - Reversible with conservative care Self-limiting, overuse syndrome Supraspinatus mostly involved; lesser extent: the biceps tendon Pain with activities and progresses to ADLs Edema and hemorrhaging of the subacromial bursa Stage 2 - Reversible with conservative care Tendinitis and bursitis persist Fibrosis occurs with repeated episodes of stage 1 Stage 3 - Probably requires surgery Development of boney changes = bone spur formation and even eburnation of the Humeral tuberosity, or associated bony changes to the acromion and AC joint Tears or ruptures may occur with the tendons (complete or incomplete) Surgery is indicated (arthroscopy, sutures, debridement of spurs) Impingement Syndrome Signs and Symptoms: Insidious onset of toothache like pain over the lateral brachial region with sharp twinges felt on certain movements (ADL’s involving abduction) AROM/PROM - earlier stages have a painful arc but relatively full range, this may decrease in the later stages - later stages may yield empty end feels b/c of pain or abnormal hard end feel b/c of boney changes RROM - pain when relevant muscles contract maximally. - Strong but painful with an intact tendon, weak and painful indicates a tear Holding patterns and postural changes may be present Impingement Syndrome - Special Tests Painful arc Empty Can Present - requires differentiation Supraspinatus tendon Neer Impingement Speed’s Present - requires differentiation Long head biceps tendon Hawkins-Kennedy Scapulohumeral rhythm Present - requires differentiation Scapulothoracic function Tendonitis-Bursitis Differentiation test Ddx supraspinatus v subacromial bursa Impingement Syndrome Precautions and contraindications: As for bursitis and tendonitis If there is boney change, avoid joint mobilizations Possible corticosteroid injections to the shoulder Clinical Impression & Approach to Treatment We can work with biceps tendonitis / supraspinatus tendonitis / subacromial bursitis with a similar approach to treatment 1. Improve subacromial space Precautions - Humerus glides - inferior, distraction - Abduction / arm position - Scapula rotation - stim serratus anterior / - Stage of healing / inflammation decrease traps, levator, pec minor 1. Decrease affected tissue (muscle belly) - Biceps - Supraspinatus 1. Improve neuromuscular control - Home care scapula rotation scapula stability muscular endurance GH Instability 30 Shoulder Instability Shoulder Dislocation / luxation Complete/partial dissociation of the articulating surfaces of the glenohumeral joint This occurs usually anteriorly (subcoracoid, subglenoid, subclavicular) and less often Posteriorly Shoulder Instability - Dislocation Etiology: Anterior dislocation - MOI excessive abduction and external rotation of the humerus - either direct trauma with shoulder in this position (football) or indirect trauma (FOOSH) Posterior dislocation - MOI flexion, adduction and internal rotation (person breaking their forward fall on an outstretched hand/elbow) Inferior Dislocation (least common) - MOI - usually forced ABDuction with fixed hand 33 Shoulder Instability Signs & Symptoms: Joint subluxed - reduction is usually needed Severity of injury depends on the extent of tissue damage (joint and muscle) Sulcus sign – visible deformity, loss of deltoid ‘roundedness’ Shoulder Instability Acute: Subacute: Chronic: Pain Unstable joint – muscles provide Localized joint capsule pain Severe bruising stability, Bruising gone Protective muscle spasm TrP Joint is a little more stable except of Joint effusion Decrease in ROM direction of injury (unless surgically Possible hemarthrosis/tears/strains Adhesions develop around the joint repaired) holding pattern to protect joint Pain and edema slowly diminish Restricted ROM Matured adhesions Hypertonicity andTrp Weakness, disuse atrophy Decreased proprioception, Protective posturing Sulcus Sign Shoulder Instability Complications ROM TESTING Rotator cuff tears Apprehension in direction of injury Glenoid labrum tear Avulsion fracture (greater tubercle) Shoulder Apprehension Sign (AROM) Nerve and blood vessel injury Instruct Patient to slowly move the arm and joint into the Avascular necrosis MOI (e.g. AB + ER+EXT) Muscle atrophy (true or disuse) Adhesive capsulitis Patient apprehension indicates unstable joint capsule *If present, do not perform PROM to avoid further injury to GH joint Shoulder Instability - Special Tests Rockwood Anterior instability Push-pull Posterior instability Feagin Inferior instability AC Shear AC joint sprain / shoulder separation *Not a GH injury Shoulder Instability - Treatment Acute: First 3-4 weeks the guest is usually immobilized Position for comfort and stability Reduce pain, decrease SNS firing, decrease edema, maintain local circulation, and address compensatory structures with general Swedish, petrissage, and MLD techniques. Ice if needed Subacute: As per acute stage Reduce but do not remove protective muscles spasm Maintain available ROM (PROM) Prevent disuse atrophy (Isometric contractions) Late subacute/chronic Prevent excess adhesion formation: begin cross-fibre Frictions Reduce hypertonicity Restore ROM and strength Shoulder Instability - Treatment Contraindications & treatment considerations: Use only Pain Free AROM in the acute and subacute stages of healing Do not remove protective muscle splinting in acute and subacute stages of healing Do not promote circulation at or distal to the joint in acute and subacute stages of healing Do not place back in MOI or at end-range or challenge the vulnerable part of the joint capsule Do not perform joint play or joint mobilisation if the joint remains unstable Make sure isometric, mid-range strength of the muscles crossing the joint is strong before taking the joint to end range in any movement If ligaments or the capsule were surgically repaired, do not restore full ROM in a way that challenges the repaired tissues Shoulder Separation (AC) 40 Shoulder Separation (aka AC separation or sprain) This is the sprain or rupture and possible displacement of the AC joint The structures involved are - AC joint capsule and ligaments - coracoclavicular complex – trapezoid and conoid ligaments Etiology: Direct trauma – downward force applied on top of AC joint Fall landing on the AC joint or FOOSH Shoulder Separation (aka AC separation or sprain) Shoulder Separation (AC) Grade I damage to AC joint (ligaments and joint capsule) with no clavicular displacement Coracoclavicular complex intact Mild inflammation Grade II Disruption to the AC joint (ligaments and joint capsule) Subluxation of the clavicle (partial or incomplete dislocation) : mild step deformity Some damage to the coracoclavicular complex More inflammation and edema Grade III Rupture of the AC and CCC ligaments Severe step deformity (clavicle rides superior to acromion) Severe inflammation Medical intervention needed Shoulder Separation (AC) Shoulder Separation (AC) - Signs & Symptoms Step deformity observed with grade II and III Muscle spasm and guarding Holding pattern – IR and AD of shoulder, elbow flexed and hand rests against opposite shoulder. Other hand supports AROM = limited and guarding, pain may or may not be present PROM = pain with ER, IR, horizontal AD, AB CAPSULAR PATTERN RROM = painful and weak Shoulder Separation (AC) - Special Tests Acromioclavicular shear test Integrity of AC joint AC horizontal adduction test Integrity of AC joint; not so much for a separation, more so for inflammation or perhaps mild grade 1 sprain without instability Shoulder Separation (AC) - Treatment Acute: First 3-4 weeks the guest is usually immobilized Position for comfort and stability Reduce pain, decrease SNS firing, decrease edema, maintain local circulation and address compensatory structures with general Swedish, petrissage and MLD techniques. Ice if needed Subacute: Reduce but do not remove protective muscles spasm (MTP’s) Maintain available ROM (PROM) Prevent disuse atrophy (Isometric contractions) Late subacute – prevent excess adhesion formation – begin cross-fibre frictions Chronic: Cross fibre frictions to prevent adhesions and maintain mobility between structures Reduce hypertonicity Restore ROM and strength Shoulder Separation (AC) Precautions and contraindications: - As per general orthopedic treatment - In the acute stage, testing or challenging beyond available AROM should be avoided to prevent further damage - If the AC joint has not been surgically reduced, joint play should be avoided in an unstable joint or until after surgical reduction Clinical Impression & Approach to Treatment We can work with instability (hypermobility/fracture/dislocation/AC separation/post-immobilisation/disuse atrophy) conditions with a similar approach to treatment 1. Improve tissue health Precautions - Muscle - Position of injury - Joint - Stretching - Fragile tissue 2. Stabilise and strengthen area - Stage of healing - Re-educate neuromuscular control of area - Hardware - Stim muscles - Surgical repair - Home Care 3. Prevent contractures/adhesions/dysfunctional scars - MFR Adhesive Capsulitis (Frozen Shoulder) 50 Adhesive Capsulitis Self-limiting inflammation and fibrosis of the joint capsule Significant pain in early stages Significant reduction in ROM More than 1 range, normally in a capsular pattern – ER > Abd > IR A severe condition is with pain radiating below elbow Etiology: Ages 40 to 70 - RA, DJD W>M High association with hyperkyphosis Adhesive Capsulitis Contributing factors: Arm not being used because of some painful condition (pain causes loss of motion) Disuse - immobilization Fibrosis of joint capsule New school thoughts: Loss of motion is responsible for pain. The guest will continually use the arm through pain Restriction begins to present itself (difficulty with ADL’s) Guests usually don’t seek medical help until the shoulder has loss about90˚ abduction, 60˚ flex, 60˚ ER and 45˚ IR Adhesive Capsulitis Structures affected: Axillary Recess – inferior fold/pleat that stretches out during abduction. This is obliterated in frozen shoulder Inflammatory repair is said to be at the subsynovial layer (membranous layer) then at the synovial layer suggesting the easy tearing with AB and ER=inflammation Triangular area between subscapularis and biceps tendons is the initial area of adhesion; development spreads to surrounding rotator cuff muscles, glenoid rim, and coracohumeral ligament (fig.34.1 p. 458 – Rattray) Adhesive Capsulitis Primary Frozen Shoulder - Idiopathic Secondary Frozen Shoulder Impingement syndrome Subacromial bursitis Tendonitis or tears (rotator cuff or biceps) Trigger pints in the subscapularis (decrease ER and influences satellite TPR’s in surrounding muscles = decrease vascularity =inflammation =fibrosis of joint capsule Postural dysfunction – hyperkyphosis Disuse following shoulder injury or immobilization Extrinsic disorder: MI, hemiplegia, pulmonary disorders, breast surgery, bypass surgery, humeral fractures) Systemic disease (diabetes – type II higher chance and hyperthyroidism) Adhesive Capsulitis - Stages/Phases Phase 1 - Freezing phase or painful phase - Gradual onset of pain - Severe pain at night and unable to lie on affected side. - Pain on the lateral brachial region is the main complaint - Lasts several months (3-9) Phase 2 - Blends with acute – Frozen phase or stiffening phase - Severe pain diminishes but stiffness becomes primary complaint - ADL’s affected – capsular pattern - Disuse atrophy – deltoid and rotator cuff - Last for 4 – 12 months Adhesive Capsulitis - Stages/Phases Phase 3 - Thawing phase or Resolution phase - Pain begins to localize and continues to diminish - Motion and function gradually return - Full ROM isn’t always regained - Supposed to spontaneously resolve over 2 years however, symptoms may last for years (5-10). - Length of painful phase corresponds to length of recovery time These phases may be referred to as acute/subactue/chronic) Adhesive Capsulitis - ROM AROM Decrease ROM – reverse scapulohumeral rhythm or 1:1 Substituted movements – “cheating” PROM Capsular pattern of restriction RROM Pain and strength depends on if there is a tear or tendonitis Strong/painless = no significant lesion Strong/painful = minor lesion Weak/painful = possible partial rupture or inhibition form a more serious lesion Weak/painless = complete rupture or neural compromise Adhesive Capsulitis - Special Tests ROM & Scapulohumeral rhythm What findings would make you consider the presence of adhesive capsulitis? Some authors advocate for an adhesive capsulitis abduction test; it is not in your notes, but we can discuss it Adhesive Capsulitis - Treatment Acute: Help manage pain and inflammation Maintain available ROM Mobilize hypomobile joints (gr 1 and 2) Address muscle hypertonicity and fascial restrictions AAROM Subacute: Cont to manage pain and inflammation Cont to address HT, fascial restrictions, and hypomobile joints (G3/4) Maintain and begin to increase ROM Chronic: Maintain and increase ROM – capsular stretch Maintain and increase strength Re-educate movement and proprioception Adhesive Capsulitis - Standard of Care Medical intervention: Medication – anti-inflammatories and pain-killers Steroid and anesthetic injections Saline injections to breakdown adhesions Manipulation under anesthesia – hematoma, fractures, dislocation High grades of joint play too early in the condition Clinical Impression & Approach to Treatment Adhesive Capsulitis 1. How much of this is neuromuscular (changeable) vs capsular (self-limiting)? 2. Is it getting better on its own without pain? - If no - all we can do is maintain tissue health, TrPs etc…leave the capsule alone - If yes - we can challenge the capsule gently to try and increase rate of healing Clinical Impression & Approach to Treatment Adhesive Capsulitis Key Questions Precautions Has your range been improving on its own? - Abduction / arm position Has your pain been improving, worse, or the same? - Stage of healing / inflammation Have you had or are you having pain below the elbow? - End range / when to challenge capsule/joint Previous injuries or shoulder problems? How long was the painful phase (phase 1)?