my seminar tendinitis

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IMPINGEMENT SYNDROMEBY, NEHA GAGGAR (MPT)



CONTENTS



IMPINGEMENT SYNDROME



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)





Impingement

Mechanical irritation

Inflammation

Swelling

Damage to the tendons







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.



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.



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.



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" '



Type I Type II Type III

Figure 22 : Types of anatomical acromion variation: Flatacromion, curved and hoocked



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.





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.





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



TYPES OF IMPINGEMENT

EXTERNAL INTERNAL

�Primary

�Secondary



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 #



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





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



SECONDARY EXTERNAL

IMPINGEMENTRelative narrowing of subacromial space

Secondary factors like :

glenohumeral instability

scapulothoracic instability



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



Scapular instability

Improper positioning of the scapula with r elation to humerus

Insufficient r etraction of scapula



Posterior capsule tightness

Oblique translation of the humeral head on rotator cuff

in anterior & superior dir ection

impingement



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



TENDINITIS / BURSITIS

Neer identified tendinitis/bursitis as a stage 2 of

impingement syndrome.





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



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



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



SUBSCAPULARIS TENDINITIS

Inflammation of subscapularis tendon

Rar ely occurs

Pain during internal rotation

Weakness of internal rotators



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





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.





Rehabilitation Protocol

Conservative (Non operative)Treatment of Shoulder

Impingement



Phase 1:

Maximal Protection-Acute Phase

Goals

� Relieve pain and swelling.� Decr ease inflammation.

� Retard muscle atrophy.

� Maintain/incr ease flexibility.



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.



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.



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.



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.



Phase 2 contd...

3. Modalities

� Cryotherapy.

� Ultrasound/phonophor esis.� Str engthening Exercises

� Continue isometrics exercises.

� Initiate scapulothoracic str engthening exercises

� Initiate neuromuscular control exercises.



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.



Phase 3 contd...

1.Range of Motion

� Aggr essive L-bar active-assisted ROM in all planes.

� Continue self-capsular str etching (anterior-posterior).



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.



Phase 4: Dynamic Advanced

Strengthening


� 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.



Phase 5: Return to Activity Phase


� Full, nonpainful ROM.


� Isokinetic test that fulfills criteria.

� Satisfactory clinical examination.

Goal

� Unr estricted symptom-fr ee activity.



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.



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



Rehabilitation Protocol

After Arthroscopic Subacromial

Decompression-Intact Rotator Cuff (Distal Clavicle Resection)





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.



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.



Phase 2: Weeks 4-8


� Minimal pain and tenderness.

� Nearly complete motion.

� Good "shoulder str ength" 4/5 motor.

Restrictions� Progr ess ROM goals to


� 45 degr ees of internal rotation (vertebral level Ll).

Immobilization

� None.

h d



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


� 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



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


� 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.



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



� Abduction.

� Forward flexion.� Extension.



Phase 2 contd...

Progr ess to light isotonic dumbbell exercises



� 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





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.



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.



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



Phase 4: Weeks 12-16


� Full, painless ROM.


� 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.



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.



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.

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