Impingement Syndrome, Supraspinatus Tendinitis, and Cuff Disruption PDF

IMPINGEMENT SYNDROME, SUPRASPINATUS TENDINITIS AND CUFF DISRUPTION Prepared by Dr. SAHAR MOWAD LECTURE OF ORTHOPEDIC PHYSICAL THERAPY , BENI SUEF UNIVERSITY The commonest cause of pain around the shoulder is a disorder of the rotator cuff. This is sometimes referred to rather loosely as...

IMPINGEMENT SYNDROME, SUPRASPINATUS TENDINITIS AND CUFF DISRUPTION Prepared by Dr. SAHAR MOWAD LECTURE OF ORTHOPEDIC PHYSICAL THERAPY , BENI SUEF UNIVERSITY The commonest cause of pain around the shoulder is a disorder of the rotator cuff. This is sometimes referred to rather loosely as ‘rotator cuff syndrome’, which comprises at least four conditions four conditions with distinct clinical features supraspinatus impingement syndrome and tendinitis tears of the rotator cuff acute calcific tendinitis biceps tendinitis and/or rupture  pain and/or weakness during certain movements of the shoulder Referred pain or paresthesias into the region of the deltoid insertion and upper lateral arm A thorough examination of the upper extremity and axial spine is necessary to rule out other pathology that can produce similar symptoms or co-exist with impingement syndrome. The role of proximal segments (i.e., trunk and hips) should also be considered and assessed in the comprehensive evaluation of the patient with impingement syndrome  Rotator cuff impingement, regardless of the type, alters muscular function of the cuff and results in diminished dynamic control of the glenohumeral (GH) joint Until optimal strength and neuromuscular control are established, continued use of the arm at or above the level of the shoulder will produce further impingement of the rotator cuff If cuff impingement is not recognized and corrected early the problem can progress to degradation of tissue and resultant tears in the rotator cuff  (NEER’S) PROGRESSIVE STAGES OF SHOULDER (PRIMARY) IMPINGEMENT STAGE 1: EDEMA AND STAGE 2: FIBROSIS AND INFLAMMATION TENDINITIS Tenderness to palpation over the Greater degree of soft tissue greater tuberosity of the humerus. crepitus may be felt because Tenderness along anterior ridge or of scarring in the subacromial acromion. space. Painful arc of abduction between 60 and 120 degrees, increased with Catching sensation with resistance at 90 degrees. lowering of arm at Positive impingement sign. approximately 100 degrees. Shoulder ROM may be restricted with significant subacromial inflammation. Limitation of active and passive ROM.  (NEER’S) PROGRESSIVE STAGES OF SHOULDER (PRIMARY) IMPINGEMENT Limitation of ROM, more pronounced with active motion. Atrophy of infraspinatus. Weakness of shoulder abduction and external rotation. Biceps tendon involvement. AC joint tenderness.  Impingement Primary secondary  Primary Impingement  Primary subacromial impingement is the result of an abnormal mechanical relationship between the rotator cuff and the coracoacromial arch (acromion, coracoacromial ligament, and/or coracoid process)  It also includes other “primary” factors that can lead to narrowing of the subacromial outlet:  Congenital anomaly Degenerative spur formation Unfused acromion (Os acromiale) Structural Factors That Degenerative spurs on undersurface May Increase Malunion/nonunion of fracture Subacromial Joint Abnormal shape after surgery or trauma Impingement Thickening of tendon from calcific deposits Tendon thickening after surgery or trauma Upper surface irregularities from partial or complete tears Increased prominence of greater tuberosity from anomalies or malunions Chief complain Anterolateral shoulder and upper lateral arm pain an inability to sleep on the affected side shoulder weakness, which may be due to pain inhibition or true cuff pathology difficulty performing activities at or above the level of the shoulder. limitations and pain with forward elevation (flexion or abduction) and horizontal adduction Evaluation of rotator cuff strength with the patient’s arm at his or her side is often normal, whereas testing performed in positions of shoulder elevation more consistently reproduces symptoms of pain and weakness Special tests for diagnosis The Hawkin’s sign Neer impingement sign empty can sign (Jobe’s test) painful arc external and internal rotation resistance strength tests O’Brien’s test palpation of the GH joint, acromioclavicular joint (AC), and coracoid region can also assist in determining the source of the patient’s symptoms. Patients with primary impingement may have associated AC joint arthritis or a history of an AC joint sprain, which may ultimately contribute to pathologic compression of the rotator cuff.  Secondary Impingement Secondary impingement is a clinical phenomenon that results in a “relative narrowing” of the subacromial space results from excessive GH joint mobility or scapular dyskinesis GH hypermobility, with or without instability symptoms of secondary rotator cuff impingement are caused by excessive demands placed on the rotator cuff to dynamically stabilize the shoulder  While the rotator cuff may effectively stabilize the hypermobile GH joint, when this requirement is coupled with repetitive overhead movement (i.e., swimming or throwing) muscular fatigue is often produced. Rotator cuff fatigue leads to the loss of the stabilizing function and allows superior migration of the humeral head (decreased depression of the humeral head during throwing and less “clearance”) and is thought to result in mechanical compression of the rotator cuff on the coracoacromial arch In patients with scapular dyskinesis (limited or excessive scapular mobility), impingement results from improper positioning of the scapula with relation to the humerus Chief complain usually younger and often participate in overhead sporting activities such as baseball, swimming, volleyball, tennis, or weight lifting. Pain weakness with overhead motions are a common complaint Physical examination observation of postural or soft tissue asymmetries about the shoulder girdle ROM symmetry strength testing of the rotator cuff and scapular stabilizing muscles special provocative tests such as Hawkin’s test and Neer’s sign assessment of spinal mobility restrictions, primarily in the cervical and/or thoracic spine, should be assessed based on their potential role in impacting scapulothoracic and GH joint mobility Patients with tightness in the posterior shoulder will have a loss of internal rotation. Posterior capsular tightness leads to an obligate anterosuperior translation of the humeral head and resultant diminished subacromial outlet space, which is thought to contribute to the impingement problem Internal Impingement Posterior shoulder pain produced by contact of the greater tuberosity with the posterosuperior aspect of the glenoid, when the shoulder is abducted to approximately 90 degrees and fully externally rotated, produces impingement of the posterior rotator cuff, capsule, and labrum  While this “internal impingement” is present in normal physiologic motion it may become pathologic with repetitive overhead activities. The pathology consists of undersurface tears of the posterior supraspinatus and/or anterior aspect of the infraspinatus tendon and often includes superior labrum anterior to posterior (SLAP) tears Clinical picture under 35 years of age involved in repetitive overhead abduction and external rotation demand activities. Patient complaints often include posterior shoulder pain (specifically in the late cocking position), stiffness, and decreasing performance (i.e., loss of throwing velocity or control) Increased external rotation and decreased internal rotation are common in patients with internal impingement Physical examination localized symptom reproduction with special tests, posterior GH joint palpation, and ROM. Posterior impingement signs Jobe’s relocation test, with specific resolution of posterior GH joint pain Jobe’s relocation test Physical therapy rehabiltation  CONSERVATIVE (NONOPERATIVE) TREATMENT OF SHOULDER IMPINGEMENT Exercise progression is based on functional improvement and pain reduction, not a specific time frame. Patient education throughout all phases is important to ensure restoration of optimal shoulder girdle neuromuscular control and performance.  MODALITIES Heat applied before exercise may facilitate gains in ROM. Ice application following resistance exercises RANGE OF MOTION (PERFORMED 1–2 TIMES DAILY) Active and active-assisted ROM in the scapular plane Posterior capsule stretching  Progression to end-range stretching. End- range stretching should continue to be performed once full range of motion is achieved Posterior capsule stretching  MANUAL THERAPY Techniques applied by clinician to address specific GH joint capsular, scapulothoracic joint, or spinal mobility limitations. Manual therapy techniques should be initiated in the initial phase and may be necessary throughout all stages of rehabilitation  STRENGTH TRAINING (PERFORMED ON ALTERNATING DAYS; I.E., 3 TO 4 DAYS PER WEEK  Initial phase: scapular neuromuscular control, closed chain exercises, rotator cuff isometrics, and limited range isotonics (1–3 sets of 10–15 repetitions)  Scapular retraction, depression, PNFs, shoulder dump, scapular  clocks, prone row, and low row  Rotator cuff isometrics progressing from arm at the side to varying angles of shoulder elevation  Begin isotonics, limited to 0 to 90 degrees of shoulder elevation, when cuff isometrics can be performed without pain.  Progress to intermediate phase when normal scapulothoracic and glenohumeral motion are present through a 0- to-150 degree arc of shoulder elevation (concentric and eccentric control).  Intermediate phase: Progression of strengthening and attainment of full range of motion Scapular retraction with horizontal abduction(T) ,scapular “Y” shoulder punches, wall circles  PNFs and rhythmic stabilization exercises Seated press-ups and push-up “plus” progression (wall to incline to traditional) Isotonics: flexion, extension, adduction, abduction, IR/ER at 45 to 90 degrees Abduction, rows in standing Plyometric exercises  Progress to late phase when the patient is pain free and demonstrates normal scapulothoracic and glenohumeral mechanics throughout the full range of motion (both concentric and eccentric control) and 5/5 strength. Late phase: Focus on restoration of shoulder girdle strength,neuromuscular control, and maintenance of normal mobility. Individualize the rehabilitation progression to prepare the patient for specific occupational and athletic demands. Isokinetic exercises and testing Closed kinetic chain: push-up plus with diminishing support (i.e., single leg or on a physioball) and figure 8 exercises. Closed kinetic chain testing Strength training may include changing the stability of the base of support Gradual return to traditional weightlifting exercises. Caution is recommended when returning to barbell pressing movements (bench, incline, and military presses) and dips because these movements can result in a return of symptoms. Behind the neck pull-downs and military press should be avoided.  Strengthening of both the scapular musculature and rotator cuff should include increasing levels of resistance and volume of activity to improve muscular endurance. Readiness for return-to- overhead activities (sports or occupational demands) should be based on demand-specific analysis for optimal return of strength and mobility Return to highdemand activities based solely on absence of pain, without full return of requisite strength and mobility throughout the kinetic chain, will put the patient at risk for eventual return of impingement symptoms.