Tendinosis & Subacromial Impingement Syndrome Gene Desepoli, LMT, D.C.
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Transcript of Tendinosis & Subacromial Impingement Syndrome Gene Desepoli, LMT, D.C.
Tendinosis & Subacromial Impingement Syndrome
Gene Desepoli, LMT, D.C.
What is the shoulder joint?
• Shoulder joint or shoulder “region?”
• There is an interrelatedness of all moving parts of the shoulder and dysfunction in one joint may cause dysfunction and pain in the others!
“He who treats the site of pain is lost.
- Karel Lewit
7 Joints of the Shoulder Region
1. Glenohumeral
2. Subdeltoid (false joint)
3. Acromioclavicluar
4. Scapulothoracic (false joint)
5. Sternoclavicular
6. Costosternal
7. Costovertebral
The 7 Joints of the Shoulder Region
Bony Anatomy Review
• Scapula
Bony Anatomy Review
• Humerus
Soft Tissue Review
Soft Tissue Review
9 Bursae of Shoulder Region
• Only 2 are clinically important: 1. Subacromial (subdeltoid) bursa
susceptible to impingement, esp. if swollen or inflamed. Frequently
ruptures due to a calcium deposit.
2. Subscapular bursa between anterior scapula and rib
cage
• Note: Bursitis is rarely a primary condition !!!!
Muscle Review
1. Supraspinatus2. Infraspinatus3. Teres Minor4. Subscapularis5. Levator Scapulae 6. Upper Trapezius 7. Serratus Anterior8. Biceps brachii
assists abduction when arm is externally rotated.
9. Deltoid: impingement!
Rotator Cuff
Rotator Cuff
• Muscles do not attach as discreet tendons but blend to form a continuous cuff surrounding the glenoid head.
• Provides dynamic stabilization of the joint due to blending into the capsule.
• Tendons of rotator cuff blend with joint capsule
Rotator Cuff
• Supraspinatus…………Abduction
• Infraspinatus…………..External rotation
• Teres Minor……………External rotation
• Subscapularis…………Internal rotation
Rotator Cuff: Supraspinatus
• Abduction
• Passes under
acromion process
• Most commonly injured or torn
• “Suitcase muscle”
Hypovascularity of the Supraspinatus
• Supraspinatus is considerably hypovascular with respect to the other cuff tendons: “critical zone”
• Tendonitis in this region correlates to hypovascualrity (that progress with age)
Rotator Cuff - Infraspinatus
• External rotation
• Pulls humerus downward with abduction
• Eccentric contraction
Rotator Cuff – Teres Minor
• External rotation
• Pulls humerus downward with abduction
Rotator Cuff - Subscapularis
• Internal Rotation
• Adduction
• Stabilizes humerus
• Pulls humerus downward w/ abduction
• Eccentric contraction
Glenohumeral Joint
• Designed for flexibility at the expense of stability
• Static stabilizers – capsule and ligaments
• Dynamic stabilizers – rotator cuff muscles
Posture and the Glenohumeral Joint
Glenohumeral Joint
Assuming good, normal posture:
• Gravity’s tendency to pull the humerus downward is overcome by superior joint capsule tightness. (vector: pulls humeral head inward for stability)
• Little or no deltoid or rotator cuff muscular effort is needed. (even w/ a small weight in the hand)
Glenohumeral Joint
• With thoracic kyphosis (round shoulders): the rotator cuff must increase tone to compensate for loss of capsular stabilization. Round shoulders may even be a cause of frozen shoulder!!!!
• Increased capsular stress leads to increased collagen production and increased fibrosis
Capsular Support
Capsule taut Capsule loose
Glenohumeral Joint
• With the arm elevated or with round shoulder posture:
• Tension is lost in sup. joint capsule• The rotator cuff muscles contract to provide stabilization. Over time, they fatigue!
• Conditions which compromise stabilization: 1. postural changes - round shoulders = downward scapular rotation 2. rotator cuff weakness/ dysfunction / trigger points
Biomechanics of Abduction of the Humerus
Abduction of Humerus
● Scapula rotates upward (scapulohumeral rhythm) from upper traps and serratus anterior
● Clavicle elevates & rotates backward
● Upper thoracic vertebrae must extend, rotate and bend to same side. The contribution of spinal movement to full arm elevation is often overlooked!
Abduction
• There is the danger of the greater tubercle
hitting the acromion, subjecting the soft
tissue to repeated trauma!
• The head of the humerus must be guided
into inferior glide / depression to prevent
impingement during abduction (actively or
passively) AND it must externally rotate!
Biomechanics of Abduction
External rotation of the humerus occurs due to untwisting of the capsule
Tight internal rotators my prevent this!
Impingement (pinching)
• Bones: acromion and greater tubercle
• Soft tissue:
supraspinatus tendon
& subacromial bursa
Coracoacromial Ligament
Runs from coracoid process to the acromion.Important for a/c joint stabilityMay be a source of impingement
Forms a protective arch over the glenohumeral areatogether with the acromion and clavicle (functions as asecondary restraining arch to prevent superior humeralhead dislocation
Can impinge the supraspinatus tendon and subdeltoidbursa.
Coracoacromial Arch
• An additional site of impingement
Altered Biomechanics
Impingement is prevented by proper biomechanics and by the proper placement of the humerus during abduction.
Causes of impingement therefore can be: muscle imbalance, trauma, trigger points, weakness,
inhibition, pain, arthritis, capsular tightness, muscle memory following injury
eg. scapula doesn’t rotate bursa is swollen and the space is reduced
Shoulder forward shrugging causes impingement.
Scapulohumeral Rhythm
Deltoid Muscle
Muscular Force Couple
• During abduction the humerus must be properly situated for full pain-free movement.
• Force coupling occurs to create smooth pain free movement
eg. trapezius and serratus anterior rotator cuff muscles with deltoid
Abduction of Humerus
• Infraspinatus & Teres Minor
Force Coupling
The Painful Arc
• There is pain during abduction in the range from 45-60 to 120 degrees.
Assessment Tests
• Painful Arc
• Hawkins’ Test / Speeds Test +++
• Subacromial push button (Dawbarn’s)
• Rotator cuff tendonitis assessment
• A/C joint tests
• Labrum disruption tests
• Rotator cuff tears
Progression of Rotator Cuff Tears
Tight pectoral muscles Round shoulders Impingement Supraspinatus Tendonosis/
Tendonitis Calcific Tendonitis Rotator cuff tear !!
• Surgery may be preventable.
• The real heroes and competent level of massage therapy deals with early recognition and prevention.
Corrective exercises
• Correct round shoulders/ergonomics• Restore mobility• Eliminate trigger points• Stretch tight muscles• Strengthen weak muscles• Rehabilitate supraspinatus with scaption. glenoid cavity faces forward, laterally and superiorly
Tendonitis / Tendonosis
Tendonitis / Tendonosis
• Causesoveruse
poor body mechanics
• Pathology
muscle cell damage (tearing, irritation)
microinflammation
fibroblasts
microscarring
Tendinosis / Tendonitis
• Not a true inflammatory condition
• Cell damage causes fibroblasts to
proliferate
• Creates a disorganized scar
(massage and movement)
• Leads to pain and further micro-tearing
Tendinitis / Tendinosis
• Accurate Assessment! 1. pinpoint pain
2. painful active (resisted) contraction3. painful passive overstretching
Highly accurate! Can be applied to any muscle for assessment.
Rotator Cuff Tendinosis
• Supraspinatus:
pinpoint pain at greater tubercle
painful active abduction
painful passive adduction stretch
Rotator Cuff Tendinosis
• Infraspinatus & Teres Minor:
pinpoint pain at greater tubercle
painful active external rotation
painful passive internal rotation stretch
Rotator Cuff Tendinosis
• Subscapularis:
pinpoint pain at lesser tubercle
painful active internal rotation
painful passive external rotation stretch
Treatment of Tendinosis• General Massage
• Remove TrPs which maintain a shortened / tight muscle
• Transverse Friction massage creates a mobile flexible scar causes “good damage” to allow healing
• Strengthen muscle / tendon to tolerate more stress
• Full recovery = the patient can perform 3 sets of 10 strong repetitions
• Ice may be needed before and after Tx. to decrease pain