Painful Shoulder Syndromes

PAINFUL SHOULDER SYNDROMES • • • • IMPINGEMENT SYNDROMES Mechanical compression and irritation of the soft tissues (rotator cuff and subacromial bursa) in the suprahumeral space Most common cause of shoulder pain Pain with overhead reaching, a painful arc mid-range, and Pain at a certain degree positive impingement tests Caused by excessive or repetitive overhead activities SITS Based on Progressive Microtrauma (Jobe’s Classification) Group 1. Pure impingement (usually in an older recreational • athlete with partial undersurface rotator cuff tear and subacromial bursitis) Group 2. Impingement associated with labral and/or • capsular injury, instability, and secondary impingement Group 3. Hyperelastic soft tissues resulting in anterior or • multidirectional instability and impingement (usually attenuated but intact labrum, undersurface rotator cuff tear) Group 4. Anterior instability without associated • impingement (result of trauma; results in partial or complete dislocation) Based on Degree and Frequency • Instability → subluxation → dislocation • Acute, recurrent, fixed Categories of Painful Shoulder Syndromes Based on Degree or Stage of Pathology of the Rotator Cuff (Neer’s Classification of Rotator Cuff Disease) **common*** Stage I. Edema, hemorrhage (patient usually <25 years of • age *active lifestyle*) Stage II. Tendonitis/bursitis and fibrosis (patient usually 25 to • 40 years of age) Stage III. Bone spurs and tendon rupture (patient usually >40 • years of age) Degenerative changes Based on Impaired Tissue • Supraspinatus tendonitis • Infraspinatus tendonitis • Bicipital tendonitis • Superior glenoid labrum and/or biceps tendon instability • Subdeltoid (subacromial) bursitis • Other musculotendinous strains (specific to type of injury or trauma) o Anterior – from overuse with racket sports (pectoralis minor, subscapularis, coracobrachialis, short head of biceps strain) o Inferior – from motor vehicle trauma (long head of triceps, serratus anterior strain) Based on Mechanical Disruption and Direction of Instability or Subluxation • Multidirectional instability from lax capsule with or without impingement • Unidirectional instability (anterior, posterior, or inferior) with or without impingement • Traumatic injury with tears of capsule and/or labrum • Insidious (atraumatic) onset from repetitive microtrauma • Inherent laxity Special Tests 1. To confirm physician’s dx 2. Rule out (prevent misdiagnosis) Intrinsic Impingement (Rotator Cuff Disease) Intrinsic factors are those that compromise the integrity of the musculotendinous structures: Vascular = blood supply • Vascular changes in rotator cuff tendons • Tissue tension overload • Collagen disorientation and degeneration Extrinsic Impingement (Mechanical Compression of Tissues) Extrinsic impingement is a result of mechanical wear of the rotator cuff against the anteroinferior one-third of the acromion in the suprahumeral space during elevation activities of the humerus. Microtrauma – repetitive motions Flexion and more of abduction without ER Primary Extrinsic Impingement Primary extrinsic impingement result from anatomical or biomechanical factors. 1. Anatomical factors: Bony spurs • Structural variations in the acromion or humeral head Hyper trophic degenerative changes in the AC joint • Other trophic changes in the coracoacromial arch or humeral head 2. Biomechanical factors: • Altered orientation of the clavicle or scapula during movement • Increased anterosuperior humeral head translation May be d/t laxity of lig or atrophy or weakness of mm • • Neer suggested that the size and shape of the structures that make up the coracoacromial arch are related to rotator cuff impingement. Variations of the acromion were identified and classified into three shapes: o Type I: flat o Type II: curved > more common o Type III: hooked Rotator cuff pathology is often associated with types II and III Secondary Extrinsic Impingement • Mechanical compression of the suprahumeral tissues due to: o Hypermobility or instability of the GH joint – may be caused by laxity and sublaxation, weak musculatures o increased translation of the humeral head • Instability may be multidirectional or unidirectional and can occur with: o Compromised static restraints (GH ligaments) o Dynamic rotator cuff insufficiency (force imbalances or fatigue) § Imbalances brought by atrophy, overworked/fatigued (training, etc.), tightness Mm imbalance = one is tight, one is weak 1. Multidirectional instability - athletes • Physiologically increased connective tissue extensibility causing excessive joint mobility • Increased extensibility allows larger than normal humeral head translations in all directions o Individuals involved in overhead activities develop laxity of the capsule from continually subjecting the joint to stretch forces • A hypermobile GH joint may be supported by strong rotator cuff muscles; but with muscle fatigue, poor humeral head stabilization leads to faulty humeral mechanics, trauma, and inflammation of the suprahumeral tissues. • Mechanical impingement of tissue in the suprahumeral space is a secondary effect of the increased humeral head translation. Secondary problems: • o Impingement o Subluxation o Dislocation o Rotator cuff tendinitis o Bone spurs o Tendon rupture o Capsular restrictions and frozen shoulder Instability - atrophy 2. • • Unidirectional instability with or without Impingement Physiologically lax connective tissue Result of trauma and usually involves rotator cuff tears • Anterior instability o occurs with force against the arm when it is in an abducted and externally rotated position, and it frequently involves detachment of the anterior capsule and glenoid labrum (Bankart lesion) • Posterior Instability o Result of a forceful thrust against a forward-flexed humerus or fall on an outstretched arm FOOSH • • • • • • • • • • Internal Extrinsic Impingement Internal impingement occurs in a position of elevation, horizontal abduction, and maximum ER. Mechanical entrapment of the posterior supraspinatus tendon between the humeral head and the labrum. Associated with combination of posterior GH capsule tightness and scapula kinematic alterations. Tendonitis Bursitis (Stage II Impingement Syndrome) Supraspinatus Tendonitis Difficult to differentiate from subdeltoid bursitis Painful arc with overhead reaching Pain with impingement tests and pain on palpation of the tendon Pain on palpation of the tendon Infraspinatus Tendonitis Painful arc with overhead, forward, or cross body motions (anything that involves horizontal adduction) It may present as a deceleration (eccentric) injury due to overload during repetitive or forceful throwing activities Pain occurs with palpation of the tendon Insidious Onset (Atraumatic Onset) No specific MOI Rupture/tear of tendon • Rotator cuff tears à Stage III impingement syndrome Typically occurs in persons over age of 40 after repetitive microtrauma to the rotator cuff or long head of the biceps. • • 1. • • Bicipital Tendonitis Long tendon of the biceps in the bicipital groove Pain occurs with Speed’s test and on palpation of the bicipital groove Front mm – tight Decreased Thoracic ROM • Decreased thoracic extension decreases the functional range of humeral elevation 3. Rotator Cuff Overuse and Fatigue • Failure to provide the dynamic stabilizing, compressive, and translational forces that support the joint and control the normal joint mechanics Neuropathies like long thoracic nerve palsy Tight posterior capsule • Increases anterior translation of the humeral head 6. • Subacromial/Subdeltoid Bursitis When acute, the symptoms of bursitis are the same as those seen with supraspinatus tendinitis Once the inflammation is under control, there are no symptoms with resistance Other Impaired Musculotendinous Tissues Muscles subjected to microtrauma: 1. Pectoralis minor 2. Short head of biceps 3. Coracobrachialis o During racquet sports requiring a controlled backward, then a rapid forward swinging of the arm. 4. Scapular retractors (mid traps, rhomboids) o Functions to control forward motion of the scapula Back mm – weak 2. 4. 5. • Common Impairments Related to Painful Shoulder Syndromes Impaired Posture and Muscle Imbalances • Increased thoracic kyphosis, forward head, abducted and forward-tipped scapula à decreased suprahumeral space à irritation of rotator cuff tendons • The pectoralis minor, levator scapulae, and shoulder internal rotators are tight • Lateral rotators of the shoulder and upward rotators of the scapula test weak • • • • • 1. Common Functional Limitations/Disabilities: • When acute, pain may interfere with sleep • Pain with overhead reaching, pushing, or pulling. • Difficulty lifting loads. • Inability to sustain repetitive shoulder activities • Difficulty with dressing, particularly putting a shirt on over the head. Maximum Protection Phase Control Inflammation and Promote Healing Patient Education on how to modify activities/motions that triggers pain/cause injuries; posture Maintain Integrity and Mobility of the Soft Tissues Control Pain and Maintain Joint Integrity Develop Support in Related Regions Control inflammation and promote healing • Modalities and low-intensity cross-fiber massage are Muscles that may be injured during MVA (motor vehicular applied to the site of the lesion. Prevents scar accidents) Not exercises < formation which could limits of motion d/t 1. Long head of the triceps inextensibility of the tissue 2. Scapular stabilizers (serratus ant, rhomboids, lev scap, trap) • Immobilization using a sling. (not an exercise) o During MVA, the driver holds firmly to the steering wheel on impact 2. Maintain integrity and mobility of the soft tissues • PROM, AAROM, Self-assisted ROM (pain-free range) • Injury, overuse, or repetitive trauma can occur in any muscle • Muscle setting à Multiple angle muscle setting (done being subjected to stress. Only to provide cxn to delay in various ranges) Pain occurs when the involved muscle is lengthened or when • 6 SH x 10reps x 3 sets atrophy contracting against resistance. (mm isn’t fully healed yet) 3. Control pain and maintain joint integrity Palpation the site of the lesion causes the familiar pain. • • Pendulum exercises without weights (Codman’s Exercise) 4. • • • • • • 1. Develop support in related regions • Postural awareness and correction techniques (verbal cues ex. Paki-diretso po ang balikat, etc.) • Supportive techniques such as shoulder strapping or scapular taping, tactile cues, and mirrors Management-Controlled Motion Phase à no signs of inflammation Patient education à less pain Develop Strong, Mobile Tissues à to avoid disruption of healing Modify Joint Tracking and Mobility process Develop Balance in Length and Strength if Shoulder Girdle Muscles Develop Muscular Stabilization and Endurance Progress Shoulder Function 3. Develop Balance in Length and Strength if Shoulder Girdle Muscles Stretching exercises for: • o Pectoralis major, Pectoralis minor o Latissimus dorsi and Teres major o Subscapularis o Levator scapulae o Upper Trapezius To prevent hyperventilation • 15sh x 10 reps x 3 sets “Active exercises” – with breathing component Develop strong, mobile tissues 6 SH x 10 reps x 3 sets • Cross-fiber massage Multiple angle isometrics • • Verbal and tactile cues to improve posture A. Clavicular Portion. B. Sternal Portion 2. Modify joint tracking and mobility • Mobilization with movement • Posterolateral glide upon shoulder elevation