Post on 08-Apr-2018
transcript
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 1/68
IMPINGEMENT SYNDROMEBY, NEHA GAGGAR (MPT)
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 2/68
CONTENTS
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 3/68
IMPINGEMENT SYNDROME
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 4/68
DEFINITION
Shoulder impingement occurs when the rotator cuff tendons are
impinged as they pass through the sub-acromial space
(b/w acromian coraco-acromial arch & AC joint above & GH joint below)
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 5/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 6/68
Impingement
Mechanical irritation
Inflammation
Swelling
Damage to the tendons
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 7/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 8/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 9/68
Functional anatomy:
The rotator cuff comprises four muscles The
subscapularis, the supraspinatus, the infraspinatusand the teres minor and their musculotendinous
attachments.
The subscapularis muscle is innervated by thesubscapular nerve and originates on the scapula. It
inserts on the lesser tuberosity of the humerus.
The supraspinatus and infraspinatus are both
innervated by the suprascapular nerve, originate in
the scapula and insert on the greater tuberosity.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 10/68
The teres minor is innervated by the axillary nerve,
originates on the scapula and inserts on the greater
tuberosity.A bursa in the subacromial space provides lubrication
for the rotator cuff.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 11/68
The rotator cuff is the dynamic stabilizer of the glenohumeral joint.
The static stabilizers are the capsule and the labrum complex, including
the glenohumeral ligaments.
Although the rotator cuff muscles generate torque, they also depress
the humeral head. The deltoid abducts the shoulder. Without anintact rotator cuff, particularly during the first 60 degrees of humeral
elevation, the unopposed deltoid would cause cephalic migration of
the humeral head, with resulting subacromial impingement of the
rotator cuff.
In patients with large rotator cuff tears, the humeral head is poorly
depressed and can migrate cephalad during active elevation of the
arm.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 12/68
E tiology:
1. Extrinsic causes:
A- Bony factors: The type I acromion, which is flat, is the "normal"
acromion.
The type II acromion is more curved and downward
dipping, The type III acromion is hooked and downward
dipping, obstructing the outlet for the supraspinatustendon and therefore may impinge on the rotator cuff
on elevation of the arm. Osteophytes under the acromioclavicular joint reduces
the subacromial space and can also lead to cuff impingement and therefore failure" '
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 13/68
Type I Type II Type III
Figure 22 : Types of anatomical acromion variation: Flatacromion, curved and hoocked
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 14/68
B- Soft tissue factors Examples include
Thickened coracoacromial ligament.
2. Intrinsic causesa. Degenerative cuff failure :
This constitutes the commonest cause of cuff failure andusually occurs in the older individual. Degeneration of thecuff may later result in partial tears which may progress to
complete tears. The precise cause of degenerative cuff tear isunknown. One possible theory relates to the 'critical vascularzone' of the cuff tendon where the blood supply is precarious,and relative ischemia leads to degenerative changes.
b. Traumatic cuff failure:
This may occur when the upper limb is subject to aviolent force and the rotator cuff sustains a traumatic tear. Inthe younger individual where the tendinous part of the cuff-bone complex is stronger than the bony part, the tendonsmay avulse with a piece of bone.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 15/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 16/68
c. Reactive cuff failure:
Calcific rotator cuff tendinitis is an example of
reactive cuff failure. The calcifying mass inside thetendon may give rise to a swelling which leads to
impingement under the subacromial arch, hence
resulting in cuff failure.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 17/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 18/68
STAGE 1 STAGE 2 STAGE 3
Oedema &
inflammation
Fibrosis & tendinitis Bone spurs & tendon
ruptures
Reversible lession Not reversible by
activty modification
Not reversible
< 25 yrs 25-40 yrs > 40 yrs
Tenderness : GT, ant
ridge of acromion
Stage 1 + soft tissue
crepitus
Stage 1 & 2
AROM > restriced
Painfull arc : 60-120 Catching sensation :
lowering of arm to 100
Atrophy of muscle
Impingement sign : + AROM,PROM : limited Weakness of abductors
& int rotators
ROM : decreased MMT : decreased Biceps tendon involved
MMT : normal AC jt tenderness
MMT : decreased
NEERS CLASSIFICATION OF ROTATOR CUFF DISEASE
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 19/68
TYPES OF IMPINGEMENT
EXTERNAL INTERNAL
�Primary
�Secondary
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 20/68
PRIMARY EXTERNAL IMPINGEMENT
Narrowing of the sub-acromial outlet : d/t
Abnormal bony relationship between rotator cuff & C-A arch
Other primary factors like
1. AC joint :congenital anomaly
degenerative spur formation
2. Acromion :
unfused acromiondegenerative spur
malunion/nonunion of #
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 21/68
Contd...
3. Corocoid :congenital anomaly
abnormal shape after surgery or trauma
4.Rotator cuff :thickening of tendon from calcific deposits
thickening of tendon after surgery or trauma
5.Humerus :
increased prominence of GT from congenital anomaly,
malunion
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 22/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 23/68
CLINICAL FEATURES
Age > 40 yrs
Pain : anterior shoulder , lateral arm
Inability to sleep on aff ected arm
Difficulty performing overhead activities
Loss of ROM
Weakness of rotator cuff muscle str ength
Hawkins sign : +ve
Neers sign : + ve May also complaint of AC joint discomfort
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 24/68
SECONDARY EXTERNAL
IMPINGEMENTRelative narrowing of subacromial space
Secondary factors like :
glenohumeral instability
scapulothoracic instability
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 25/68
Loss of stability of rotator cuff muscles
Abnormal superior translation of humeral head
Decr eased depr ession of the humeral head during
throwing & less clearance
Mechanical impingement of rotator cuff on the C-A
arch
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 26/68
Scapular instability
Improper positioning of the scapula with r elation to humerus
Insufficient r etraction of scapula
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 27/68
Posterior capsule tightness
Oblique translation of the humeral head on rotator cuff
in anterior & superior dir ection
impingement
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 28/68
INTERNAL IMPINGEMENT
Also called as glenoid impingement
Mainly in overhead athletes during the late cocking
stage of throwing (ext+abd+ext rot )
Impingement of undersurface of rotator cuff against the
post-sup surface of glenoid
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 29/68
TENDINITIS / BURSITIS
Neer identified tendinitis/bursitis as a stage 2 of
impingement syndrome.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 30/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 31/68
I HISTORY :
� Site of pain : lateral brachial r egion
r ef err ed below e elbow in c5, c6� natur e of pain : shar p twings f elt during movement
abduction, putting on jacket, r eaching above shoulder level
� Onset of pain : gradual with no known trauma
occupation or r ecr eational overuse
II EXAMINATION :
1. OBSERVATION
� Postural assessment
� Forward head
� Rounded shoulders
� Flattening of thoracic spine � Shoulder girdle asymmetry
� biomechanical scr eening
� antalgic movement pattern
� functional assessment
�Scapulo humeral rhythm
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 32/68
2. INSPECTION :
atrophy may be noticed in chronic cases
swelling
3, cervical scr eening
4. Upper limb ROM :
�Active movements : painful arc 60-120 degr ees
�Passive movements
�RIC
5. PALPATION
tenderness
cr epitus
6. Special¶s test : Neer¶s sign
hawkins sign
empty can
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 33/68
INFRASPINATIS TENDINITIS
Inflammation of infraspinatis tendon
MECHANISM OF INJURY :
Decellaration (eccentric) injury d/t overload during r epetative or forceful throwing activity
CLINICAL FEATURES :
pain : end range ext rot
upper arm ,slightly over back of the armRIC : weak & painful ext rotators
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 34/68
SUBSCAPULARIS TENDINITIS
Inflammation of subscapularis tendon
Rar ely occurs
Pain during internal rotation
Weakness of internal rotators
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 35/68
BICIPITAL TENDINITIS
Inflammation of biceps tendon
Persistence friction of the inflammed tendon leads
to tearing of the tendon
Pain over anterior shoulder r egion, arm &
sometimes passing through the upper limb
Pr essur e on the groove is painful
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 36/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 37/68
SUBACROMIAL BURSITIS
Bursitis occurs secondary to calcific tendinitis in which the deposit migrates
superficially into the floor of the subacromial bursae.
SIGNS AND SYMPTOMS :
PAIN : lateral brachial r egionActive movements : marked r estriction in all planes with sever e pain
while elevating arm
Passive movements : r estriction by pain in a noncapsullar pattern,
empty end f eel, rotation with arm at side : fr ee, but abduction beyond
60 and flexion past 90 extr emely painful.
RIC : pain during abduction caused by squeezing of the bursae. Palpation : warmth , swelling , tenderness.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 38/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 39/68
Rehabilitation Protocol
Conservative (Non operative)Treatment of Shoulder
Impingement
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 40/68
Phase 1:
Maximal Protection-Acute Phase
Goals
� Relieve pain and swelling.� Decr ease inflammation.
� Retard muscle atrophy.
� Maintain/incr ease flexibility.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 41/68
Phase 1 contd...1.Active Rest
� Eliminate any activity that causes an incr ease in symptoms
(e.g., throwing).
2.Range of Motion
� Pendulum exercises.
� Active-assisted ROM -limited symptom-fr ee available range
� Rope and pulley
� Flexion.
� L-bar
� Flexion.� Neutral external rotation.
3.Joint Mobilizations
� Grades 1 and 2.
� Inf erior and posterior glides in scapular plane.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 42/68
Phase 1 contd ....
4.Modalities
� Cryotherapy.
� Transcutaneous electrical stimulation (TENS),
5.Strengthening Exercises
� Isometrics-submaximal� External rotation.
� Internal rotation.
� Biceps.
� Deltoid (anterior, middle, posterior).
6.Patient Education and Activity Modif ication� Regarding activity, pathology, and avoidance of overhead activity, r eaching, and
lifting activity.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 43/68
Phase 2: Motion Phase-Subacute Phase
Criteria for Pr ogression to Phase
2
� Decr eased pain and/or symptoms.
� Incr eased ROM.
� Painful arc in abduction only.
� Improved muscular function.
Goals
� Reestablish nonpainful ROM.
� Normalize athrokinematics of shoulder complex.
� Retard muscular atrophy without exacerbation of pain.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 44/68
Phase 2 contd...
1.Range of Motion� Rope and pulley
� Flexion.
� Abduction (symptom-fr ee motion only).
� L-bar
� Flexion.
� Abduction (symptom-fr ee motion).� External rotation in 45 degr ees of abduction, progr ess to 90 degr ees of abd.
� Internal rotation in 45 degr ees of abduction, progr ess to 90 degr ees of abduction.
� Initiate anterior and posterior capsular str etching.
2.Joint Mobilizations
� Grades 2, 3, and 4.� Inf erior, anterior, and posterior glides.
� Combined glides as r equir ed.
� str etching of the posterior capsule.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 45/68
Phase 2 contd...
3. Modalities
� Cryotherapy.
� Ultrasound/phonophor esis.� Str engthening Exercises
� Continue isometrics exercises.
� Initiate scapulothoracic str engthening exercises
� Initiate neuromuscular control exercises.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 46/68
Phase 3: Intermediate Strengthening
Phase
Criteria for Pr ogression to Phase 3
� Decr ease in pain and symptoms.
� Normal active-assisted ROM.
� Improved muscular str ength.
Goals
� Normalize ROM.
� Symptom-fr ee normal activities.
� Improve muscular performance.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 47/68
Phase 3 contd...
1.Range of Motion
� Aggr essive L-bar active-assisted ROM in all planes.
� Continue self-capsular str etching (anterior-posterior).
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 48/68
Phase 3 contd...
4.Str engthening Exercises
� Initiate isotonic dumbbell program
Side-lying neutral
� Internal rotation
� External rotation
Prone� Extension.
� Horizontal abduction.
Standing
� Flexion to 90 degr ees.
� Supraspinatus.
� Initiate serratus exercises
� Wall push-ups.
� Initiate tubing progr ession in slight abduction for internal
and external rotation str engthening.
� Initiate arm er gometer for endurance.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 49/68
Phase 4: Dynamic Advanced
Strengthening
Criteria for Pr ogression to Phase 4
� Full, nonpainful ROM.
� No pain or tenderness.
� 70% of contralateral str ength.
Goals
� Incr ease str ength and endurance.
� Incr ease power.
� Incr ease neuromuscular control.
Isokinetic Testing
� Internal and external rotation modified neutral.
� Abduction-adduction.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 50/68
Phase 5: Return to Activity Phase
Criteria for Pr ogression to Phase 5
� Full, nonpainful ROM.
� No pain or tenderness.
� Isokinetic test that fulfills criteria.
� Satisfactory clinical examination.
Goal
� Unr estricted symptom-fr ee activity.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 51/68
Phase 5 contd...
Isokinetic Test
� 90/90 internal and external rotation, 180 degr ees/sec,
300 degr ees/sec.
� Abduction-adduction, 180 degr ees/sec, 300 degr ees/sec.
Initiate Interval Thr owing Pr ogr am
� Throwing.
� Tennis.
� Golf.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 52/68
Phase 5 contd...
Maintenance Exercise Pr ogr am
Flexibility Exercises
� L-bar
� Flexion.
� External rotation.
� Self-capsular str etches.
Isotonic Exercises
� Supraspinatus.
� Prone extension.
� Prone horizontal abduction.
Theratubing Exercises� Internal and external rotation.
� Neutral or 90/90 position.
� Serratus Push-ups
� Interval Throwing Phase II for Pitchers
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 53/68
Rehabilitation Protocol
After Arthroscopic Subacromial
Decompression-Intact Rotator Cuff (Distal Clavicle Resection)
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 54/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 55/68
Phase 1 contd...
Immobilization
� Early motion is important.
� Sling immobilization for comfort only during the first 2 wk.
� Sling should be discontinued by 2 wk after sur gery.
� Patients can use sling at night for comfort.
Pain Contr ol� Reduction of pain and discomfort is essential for r ecovery
� Medications
� Narcotics-lO day-2 wk following sur gery.
� Nonsteroidal anti-inflammatory drugs (NSAIDs)-for patients with
persistent discomfort following sur gery.
� Therapeutic modalities� Ice, ultrasound.
� Moist heat befor e therapy, ice at end of session.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 56/68
Phase 1 contd..
Motion: Shoulder
Goals
� 140 degr ees of forward flexion.
� 40 degr ees of external rotation.
� 60 degr ees of abduction.
Exercises� Begin with Codman pendulum exercises to promote early motion.
� Passive ROM exercises.
� Capsular str etching for anterior, posterior, and inf erior capsule, using the
opposite arm.
� Active-assisted ROM exercises.
� Shoulder flexion.� Shoulder extension.
� Internal and external rotation.
� Progr ess to active ROM exercises as comfort improves.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 57/68
Phase 2: Weeks 4-8
Criteria for Pr ogression to Phase 2
� Minimal pain and tenderness.
� Nearly complete motion.
� Good "shoulder str ength" 4/5 motor.
Restrictions� Progr ess ROM goals to
� 160 degr ees of forward flexion.
� 45 degr ees of internal rotation (vertebral level Ll).
Immobilization
� None.
h d
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 58/68
Phase 2 contd...
Pain Contr ol� NSAIDs-for patients with persistent discomfort.
� Therapeutic modalities
� Ice, ultrasound.
� Moist heat befor e therapy, ice at end of session.
� Subacromial injection: lidocaine/steroid - for patients with acute
inflammatory symptoms that do not r espond to NSAIDs.Motion
Goals
� 160 degr ees of forward flexion.
� 60 degr ees of external rotation.
� 80 degr ees of abduction.
� 45 degr ees of internal rotation (vertebral level Ll).Exercises
� Incr easing active ROM in all dir ections.
� Focus on prolonged, gentle passive str etching at end ranges to
incr ease shoulder flexibility.
� Utilize joint mobilization for capsular r estrictions, especially the
posterior capsule
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 59/68
Phase 2 contd...
Muscle Strengthening
� Rotator cuff str engthening (only thr ee times per week to avoid rotator
cuff tendinitis)
� Begin with closed-chain isometric str engthening
� Internal rotation.
� External rotation.� Abduction.
� Progr ess to open-chain str engthening with Therabands
� Exercises performed with the elbow flexed to 90 degr ees.
� Starting position is with the shoulder in the neutral position of forward
flexion, abduction, and external rotation (arm comfortably at the
patient's side).� Exercises ar e performed through an arc of 45 degr ees in each of the
five planes of motion.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 60/68
Phase 2 contd ...
Six color-coded Theraband bands ar e available; each provides incr easing r esistance from 1 to 6 pounds, at incr ements of one pound.
Progr ession to the next band occurs usually in 2to 3-wk intervals.
Patients ar e instructed not to progr ess to the next band if ther e is any
discomfort at the pr esent level.
Theraband exercises permit both concentric and eccentric str engthening of
the shoulder muscles and ar e a form of isotonic exercises
� Internal rotation.
� External rotation.
� Abduction.
� Forward flexion.� Extension.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 61/68
Phase 2 contd...
Progr ess to light isotonic dumbbell exercises
� Internal rotation.
� External rotation.
� Abduction.
� Forward flexion.
� Extension.
Scapular stabilizer str engthening
� Closed-chain str engthening exercises
� Scapular r etraction (rhomboideus, middle trapezius).
� Scapular protraction (serratus anterior).
� Scapular depr ession (latissimus dorsi, trapezius, serratus anterior).
Progr ess to open-chain scapular stabilizer str engthening
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 62/68
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 63/68
Phase 3 contd...
Motion
� Achieve motion equal to contralateral side.
� Utilize both active and passive ROM exercises to maintain
motion.
Muscle Strengthening
� Advance str engthening of rotator cuff and scapular stabilizers as tolerated.
� Eight to 15 r epetitions for each exercise, for thr ee sets.
� Continue str engthening only thr ee times per week to avoid rotator cuff tendinitis
from overtraining.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 64/68
Phase 3 contd...
Motion
� Achieve motion equal to contralateral side.
� Utilize both active and passive ROM exercises to maintain motion.
Muscle Strengthening� Advance str engthening of rotator cuff and scapular stabilizers as tolerated.
� Eight to 15 r epetitions for each exercise, for thr ee sets.
� Continue str engthening only thr ee times per week to avoid rotator cuff tendinitis
from overtraining.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 65/68
Phase 3 contd...
Functional Strengthening
� Plyometric exercises
For Patients with Concomitant Distal Clavicle Resections
� Now begin cross-body adduction exercises
� First passive, advance to active motion when AC joint pain is minimal.
Ph 4 W k 12 16
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 66/68
Phase 4: Weeks 12-16
Criteria for Pr ogression to Phase 4
� Full, painless ROM.
� No pain or tenderness.
� Shoulder str ength that fulfills established criteria.
� Satisfactory clinical examination.
Goals
� Progr essive r eturn to unr estricted activities.
� Advancement of shoulder str ength and motion with a home exercise
program that is taught throughout r ehabilitation.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 67/68
Phase 4 contd...
Pr ogressive, Systematic Interval Pr ogr am for Retur ning to Sports
� Throwing athletes (see p. 190).
� Tennis players (see p. 192).
� Golf ers (see p. 195).
� Institute "Thrower's Ten" program (p. 165) for overhead athlete.
Maximum improvement is expected by 4 - 6 mo following an
acromiopIasty, and 6 - 12 mo following an acromiopIasty combined with
a distal clavicle r esection.
8/7/2019 my seminar tendinitis
http://slidepdf.com/reader/full/my-seminar-tendinitis 68/68
Phase 4 contd...
War ning Signals
� Loss of motion-especially internal rotation.
� Lack of str ength progr ession-especially abduction.
� Continued pain-especially at night.
Treatment of above "Pr oblems"
� These patients may need to move back to earlier routines.
� May r equite incr eased utilization of pain control modalities
as outlined above.
� If no improvement, patients may r equir e r epeat sur gical as outlined
� It is important to determine that the appropriate sur gical procedur e
was done initially.
� Issues of possible secondary gain must be evaluated.