2CCSP - Overuse Injuries

8/8/2019 2CCSP - Overuse Injuries

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Sport Specific Overuse Injuries


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Overuse Injuries in Tennis Players

External rotators of elite junior tennis players tend to

tire faster than the internal rotators w/isokinetic

testing at 90 abduction.

College tennis players had significant increases in

strength in internal rotation at 90 abduction in the

dominant shoulder, with no differences in external

rotational power.5


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Overuse Injuries in Tennis Players

ROM: q internal rotation and o external

rotation due to posterior capsule tightness.

Posterior capsule tightness could result in

increased anterior translation.


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Sport Specific Overuse Injuries

Baseball


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Sport Specific/Overuse Injuries in

Tennis PlayersRelative Speeds

Overhand Serve Forehand BackhandRotational

Velocity: 1500/sec 387/sec 895/sec

Hand Speed @Ball Impact: 47 mph 37 mph 33 mph 1


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Throwing Motion: 5 Phases

1. Wind up: 0.5 to 1s.

2. Early cocking: front foot contact.

3. Late cocking: shoulder @ MER;0.1-0.15s.

4. Acceleration: MER to release;0.1 0.3s.Total: 0.7 to 1.45s

5. Follow through: 1st third is deceleration portion.

Begins at max. int. rotation of shoulder.Ends with foot contact.

0.1 to 0.3s


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Throwing Motion

At release: Angular velocity is 6000 /s @ shoulder.

Angular velocity is 4500 /s @ elbow. 1


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Maximum External Rotation

Posterior RC and subscapularis steer humeralhead to decrease translation.

Flexor/pronator group counteract valgus

forces at the elbow joint.


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Maximum External Rotation


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Overuse Injuries - Baseball

Rotator Cuff

Glenoid Labrum

GH Ligaments

Biceps Anchor


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Overuse Injuries - Baseball

Rotator Cuff Injuries


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1. Full Thickness Tears (traumatic)

A. AC joint separation

B. GH dislocation

2. Impingement/InstabilityA. 1

B. 2

C. Chronic RC Injury

1. RC

Tendinitis2. Partial tears

3. Bicipital Tendinitis

D. Subacromial Bursitis


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RC Tendons

Superior surface: bursal

surface.

Inferior surface: articular

surface. 1st affected: INTERNAL

IMPINGEMENT.

Ant. aspect of

supraspinatus tendon

adjacent to long head ofbiceps tendon.


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Different approach with older populations.

Traditionally three Mx: Primary impingement.

Secondary impingement d/t underlying instability.

Tensile overload.


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RC Tears

Full thickness tears: acute, severe trauma.

Dislocation, fall from height, MVC.

More Chronic Conditions: continuum.

1. RC cuff tendinitis.

2. Partial tears.

3. Bicipital Tendinitis

4. Subacromial Bursitis.


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RC Tendinitis

Athletes in 20s & 30s.

Usually supraspinatus tendon.

Flxn/Abdpmechanical impingement.

Max @ abd in scapular plane with int. rot.

Part of throwing motion.


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2 Impingement

Increased GH translation due to instabilityresults in increased propensity for subacromial

impingement.


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Subacromial Bursitis

2 to Impingement.

Distinguishing from tendinopathy may not berelevant as treatment is aimed at q

mechanical impingement.


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Drop-arm Test

Examiner abducts arm to 90.

Ask patient to slowly lower arm to side.

Pain or inability to control motion are positive

signs.

+ rotator cuff tear.


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Supraspinatus Test

Patients arm abducted to 90 with no

rotation.

Manual resistance. Internally rotate arm, horizontally adduct to

30.

Again apply manual resistance. + is pain and weakness.


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Impingement Syndrome


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Primary Impingement

RC impinging on the coraco-acromial arch.

Types II & III assoc with greater incidence.

Rarely the cause of of disease in young

athletes.


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Primary Impingement

Acromion types

I flat, straight

undersurface

II downward curve

III hooked

Acquired or Congenital?

YES!


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Primary Impingement

XR:

ALVIS View

DJD AC joint

Os Acromial


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Impingement Clinical Findings

Relatively gradual onset.

Activity related Sy. overhead activity.

Difficulty localizing pain around delt. DDx: AC jt. Sy. more localized

2 Impingement overlap Sy. of RC patholgy

Painful RC

with older pts.p AdhesiveC

apsulitis


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RC Impingement: S & Sy

1. Crunching with movement (calcific).

2. Poorly localized deep ache in shoulder

following overhead activity.3. Pain @ night, esp. with lying on shoulder.

4. CLASSIC: pain radiating down lateral arm.


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RC Impingement

Stage I: younger pt. tendinitis type Sy.

Stage II:

30 40 YO Tendon has irreversible fibrotic changes.

Stage III:

40 50 YO

Partial to full thickness tear of underside of

supraspinatus tendon at insertion of gr. tub.


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RC Impingement

Stages:

I: Edema & hemorrage.

II: Fibrosis & tendinitis (-osis?)III: Tears of RC, rupture of biceps tendon, bony

changes.

What are our treatment goals at each stage?


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Impingement Syndrome

Mechanism:

Supraspinatus weakness/inhibition allows deltoidto overpower its ability to stabilize/compress the

humeral head, allowing superior migration.


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Impingement Ortho. Tests

Neer/Hawkins sensitive, not specific.

Apprehension posterior GH jt. pain, thinkInternal Impingement.

Relocation - indicates 2 impingement due to

anterior instability.


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Impingement: Imaging

XR: when pain persists after several weeks &

doesnt respond to activity modification.

Calcific tendonitis, degeneration of AC/GH jts.

Superior migration of H. headp large RC tear

Not much inter-observer reliability. 3

Outlet view: lateral view of scapula with tube

angled 10 caudally.


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1 Impingement: Outlet View


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Impingement: Imaging

Arthrogram & US: full thickness RC tears only.

MR:

Correlate clinically.

High in false +s, tendinopathic changes in

normal individuals.


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Impingement: MRI


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Impingement Test

PP: supine

DP: head of table

CH: contralateral hand at humeral head,

ipsilateral hand on wrist.


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Impingement Test cont

MX: move arm into 180 abduction and full

lateral rotation.

No history of subluxation/dislocation.+ = reproduce symptoms, anterior or posterior

shoulder pain; anterior translation2

impingement grade II or III according toJobes Classifications.


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Impingement Test cont


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Alternate Impingement Sign

Abduct to 90, internally rotate to maximum.

Over pressure is applied in horizontaladduction.

Pain is positive sign.


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Reverse Impingement Sign

Performed if pt has painful arc or pain on

lateral rotation.

PP, DP, CH: same as for impingement test.

MX: push humeral head inferior as arm is

abducted and laterally rotated.

+ = reduction of symptoms.


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Hawkins-Kennedy Impingement Test

PP: seated.

DP: in front of patient. CH: contralat. hand on elbow, ipsilat. hand on

wrist.

MX: forward flex arm to 90, forcefullymedially rotate humerus.


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Hawkins-Kennedy Impingement Test


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Internal Impingement

Abd. & Ext. rot. of humerus causes direct

contact of the RCs undersurface with the

posterior glenoid labrum.

Part of cocking phase.

Partial undersurface RC tears with corresponding

posterior shoulder pain in throwing athletes. 2

More posterior location than supraspinatus path.pmost cases of impingement syndrome.


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Internal Impingement

Breakdown of the

undersurface of the

tendon due to

frictional force oftendon over glenoid

rim.


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Impingement

Triggers immediate protective guarding of

shoulder ERs & overall IR.

Limited IR: tight posterior capsule or

contraction of infraspin/teres to minimize

compression within the suprahumeral space.


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Impingement

Posterior tightness

causes anterior-

superior shift of

humeral head withflexion.

2 Impingement


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Impingement: Treatment

Activity modifications.

Controlled strength/flexibility program.

Scapular stabilizers/core strengthening. Anti-inflammatory measures?

Inflammation not dominant feature!

Injections?


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Impingement: Treatment

Rehab. 2-3 mos.

Sx: if 4-6 mos. rehab. doesnt work

Stage II: improved success rates with Sx stillquestionable

Anterior acromioplasty, os acromial (fusion)

Subacromial decompression: not as good in older

populations 1 degeneration of tendon, noteffected by decompression


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Overuse Injuries

Biceps Tendinitis/Subluxation

Primarily a Tendinosis


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Biceps Tendon

Originates from ant/post labrum &

supraglenoid tubercle.

4 types

Intra-articular but extrasynovial.

Avg. length is 9 cm. 6

Max stretch in ext. & add.

2 blood supplies.


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Biceps Tendon

Secured in rotator interval: coracohumeral &

superior GH ligs. are main structures

responsible for securing the tendon. The

transverse humeral lig. is not believed to have

a substantial role. 6,7

In pts. with intact RCs, Pawolainen et. al.8,

were unable to dislocate the biceps aftersectioning the THL.


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Biceps Tendon


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Biceps Tendon

1 role is elbow deceleration in throwing.

Tendon does not slide in groove(abbynormial).

Humerus moves under a fixed biceps T. duringshoulder motion. 5,9

Lucas10: biceps has a resultant force to act as ahumeral head depressor.

Habermeyer & Walch6: stabilizer during 1st 90abd., >90 helps as elevator.


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Biceps Tendon

Itoi et. al.11:

Long & short heads function as anterior stabilizers

in humeral abd. & ext. rotation.

Stabilizing role increased after Bankhart lsn.

Ting et. al.12:

During arm adb. & flxn., EMG activity was greater

in shoulders with RC tears.


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Biceps Tendon

As tendon passes from

its origin to the

bicipital groove, it

makes an angled turnof 30-40.

Dislocation is always

assoc. with pathology

of the subscapularis.


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Biceps Tendinitis(?)

Tendinitis: often used to describe tendon

overuse or degeneration; however, several

authors have shown that tendon degeneration

is associated infrequently with inflammatory

cells in the tendon itself. 1,2


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Biceps Tendinitis

Overuse tendon injuries are distinctly different

from acute tendon injuries in two ways:

Absent/few inflammatory cells

Predominant degenerative changes are thought to

result from cell matrix adaptation to failed self

repair. 3


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Biceps Tendinitis

Tendon degeneration without inflammation is

Tendinosis

B. Tendinitis: clinical syndrome of pain

origination from the biceps tendon, its sheath,

or both, not histopathological condition.


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Biceps Tendinitis

1 B.T. ~ 5% of cases (younger individuals) 2 to impingement & RC disorders 4,5

@RC Tear/Impingementp check for

Bicipital Tendinitis


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Bicipital Tendinitis: Clinical Presentation

Pain in bicipital groove, may radiate to deltoid

insertion

Pain at night may exist

Usu. no Hx. of acute trauma

Repetitive overhead activities

Instability with snap during throwing motion


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Tenderness in Motion Test

Point tenderness over bicipital groove.


10 int. rot. intertubercular groove faces

forward.

Palpate for tenderness

Turn arm laterally

+ if tenderness moves laterally Burkhead et all 13: most specific finding


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Bicipital Tendinitis: Speeds Test

Forearm supinated, elbow extended.

Examiner resists forward flexion of

shoulder.

Positive result is pain in the bicipitalgroove.


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Speeds test


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Bicipital Tendinitis: Tx

Conservative treatment followinginflammatory stage - highly successful

ROM

Avoid horizontal abduction

Posterior capsular stretches

RC strengthening/re-coordinating

Injections into subacromial space, nottendon


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TOS: Etiology

Compression of the neurovascular bundle

Brachial plexus, subclavian artery/vein

Between:

1st rib (cervical rib) & clavicle (callous from clavicleFx.): Costoclavicular syndrome.

Anterior & middle scalenes: Scalenus Anticussyndrome.

Pec minor muscle & coracoid process:Hyperabduction syndrome.


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TOS: Symptoms

Pain, paresthesia, cold sensation, impaired

circulation in fingers, muscle weakness &

atrophy, and radial nerve palsy

Clinical diagnosis: reproduce symptoms


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Allen Maneuver: Hyperabduction

Abduction to 90, elbow flexed to 90, lateral

rotation and horizontal extension

Palpate radial pulse

Have patient rotate head away from test side

Test is positive if pulse is absent when head is

turned


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Allen


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Anterior Scalene Test: Adsons

Patients head rotated to face affected side

and extended.

Laterally rotate and extend arm.

Patient instructed to breathe deep and hold it

while examiner monitors brachial pulse.

Disappearance of pulse is positive sign.


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Adson


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Halstead Maneuver

Patient head is extended and rotated away

from affected side

Traction is placed on arm as brachial pulse is

monitored

Absence of pulse indicates positive test


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Halstead


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Costoclavicular Syndrome Test

Examiner palpates radial pulse

Patients shoulder is drawn down and back

Absence of pulse is positive sign


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2CCSP - Overuse Injuries

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