RISK FACTORS.
* Age: 30 and over
* Always using the arm in an overhead position or throwing motion, as in:
o Tennis or other racquet sports
o Swimming
o Baseball
o Jobs (eg, overhead assembly work, butchering, or using an overhead pressing machine)
* Pre-existing degeneration.
* some medications
* collagen diseases (eg Marfan’s)
* genetics (eg blood group ‘O’)
* medical conditions such as rheumatoid arthritis or diabetes mellitus.
SIGNS AND SYMPTOMS.
Symptoms develop gradually over time and pain slowly increases with use.
* Pain (a dull ache) in the shoulder and upper arm
* Pain at night, especially when sleeping on the injured side
* Pain when trying to reach for a back zipper or pocket
* Pain with overhead use of the arm
* Shoulder weakness, usually due to pain with effort
* Shoulder stiffness with some loss of motion
Regardless of the site of the tendinopathy, the history is likely to be similar, and can usually be plotted against increased loading of the tendon. Symptoms develop gradually. Many clients will admit to a recent change in training volume and/or intensity. Pain and stiffness are often worse first thing in the morning, particularly after a hard training session the previous day, and will improve once they ‘get moving’. Pain at the onset of activity that settles during performance and worsens again afterwards is typical. As the condition intensifies, clients may report pain throughout training and competition and, in the worst cases, during rest. Often functional exercises are required to elicit pain
Saturday, July 31, 2010
PCL 4- Surgical repair of rotator cuff tendinopathy
SURGICAL REPAIR OF ROTATOR CUFF TEARS
The need to surgically repair a torn rotator cuff depends upon your age, activity level, and the severity of your tear.
- Surgical repair is usually recommended for people with a complete rotator cuff tear, especially if the person is young and/or active. Surgery is usually recommended soon after the injury, if possible, to prevent the tendon and muscle from shrinking.
- Conservative treatment is usually recommended first if one does not have a complete rotator cuff tear or are older, less active, or if there is minimal pain. Conservative treatments (eg, stretching and strengthening exercises, injection of a steroid) are usually recommended first.
- Surgery may be recommended if patient does not improve after stretching and strengthening exercises and have persistent pain, limited strength, have arthritis or spurs that cause pain and interferes with rehabilitation, or if a new injury occurs and the patient has a previous rotator cuff injury.
Surgery...
Surgery may be used to treat a rotator cuff disorder if the injury is very severe or if nonsurgical treatment has failed to improve shoulder strength and movement sufficiently. Subacromial smoothing involves shaving bone or removing growths on the upper point of the shoulder blade (acromion). It removes scar tissue and damaged tendon and bursa from the joint. The surgeon may also remove small amounts of bone from the underside of the acromion and the acromioclavicular joint (acromioplasty). The goal is to take away roughness while keeping as much of the normal supporting structures as possible. This surgery creates more room in the subacromial space so that the rotator cuff tendon is not pinched or irritated and can glide smoothly beneath the acromion.
There are several ways to repair the rotator cuff, including open and arthroscopic techniques.
• Open-shoulder surgery involves making a larger incision in the shoulder, to open it and directly view the repair.
• Arthroscopy uses a thin viewing scope called an arthroscope that is inserted into a joint through a small incision in the skin. Then the surgeon will remove loose fragments of tendon, bursa, and other debris from the shoulder (debridement). Additional instruments are then arthroscopically inserted to shave the bone or remove growths.
What Is Done In Rotator Cuff Surgery?
During rotator cuff surgery, the patient is put in a half-sitting position, with the head supported. Most operations are performed under general anesthesia, where the patient is asleep. Sometimes a regional (or local) anesthetic is used to block the nerves leading to the arm. In that case, the patient is conscious but cannot feel pain. Usually a sedative is also given, putting the patient in a conscious but dreamy state.
Rotator cuff surgery usually takes one to two hours.
Types of procedures include:
• Impingement surgery
• Rotator cuff repair
• Arthroscopic surgery
Impingement Surgery (Also Called Acromioplasty Or Subacromial Decompression)
If the space between the upper arm and the part of the shoulder blade known as the acromion is too narrow, the rotator cuff cannot move freely. Rotator cuff tendons get pinched between the two bones, gradually damaging the rotator cuff.
To resolve this problem, the surgeon shaves a small portion of bone from the underside of the acromion, giving the tendons more room to move and preventing them from being pinched. The surgeon also removes any bone spurs and either excises or removes swollen or irritated bursa.
Impingement surgery is sometimes performed to relieve severe, chronic tendinitis that does not respond to nonsurgical treatment. Impingement surgery is also done as part of most rotator cuff repair surgeries.
Rotator Cuff Repair
In order to repair a torn rotator cuff, the surgeon reattaches the damaged tendon (or tendons) to the upper arm (humerus). (Some rotator cuff injuries involve more than one torn tendon.)
This surgery involves several key steps:
• In order to gain access to the injured rotator cuff, the surgeon makes a two- to three-inch incision in the shoulder, then cuts through the deltoid muscle.
• The surgeon removes any scar tissue that has built up on the tendon.
• The surgeon carves a small trough at the top of the upper arm, then drills small holes through the bone.
• Finally, the surgeon sews the tendon to the bone, with the sutures going through the tiny holes in the upper arm. (Sometimes a surgeon will use permanent anchors to attach the tendon to bone.)
During this operation, the surgeon also removes bone spurs and releases any ligaments that are pressing on the tendon. If a bursa is inflamed, the surgeon excises or removes it. The surgeon also may remove a small portion of the acromion to make sure the repaired rotator cuff has enough room to move.
Afterwards, the patient's arm is placed in a sling. With time, healing occurs, as scar tissue connects the tendon to bone. Because tendons receive such poor blood supply, this is a slow process.
Arthroscopic Surgery
Arthroscopic surgery is a technique for performing an operation using pen-shaped instruments with a miniature video camera attached to the end.
• The surgeon makes a small incision in the shoulder about the size of a buttonhole.
• He or she then inserts the thin tube that contains the tiny video camera and surgical instruments.
• The surgeon performs the operation with these remotely controlled instruments while watching on a video screen.
Because arthroscopic surgery requires only limited surgical access, the incision is much smaller than is necessary for open surgery, resulting in fewer risks. The patient's recovery time is also shorter.
However, because repairing a torn rotator cuff can be a complicated procedure, it is often performed as an open procedure. However, arthroscopic repairs are becoming more common, especially for small size tears.
After Surgery...
You may go home a few hours after waking up from anesthesia. In some cases, the doctor may suggest that you stay overnight for help with pain management and for observation.
Discomfort after surgery may be relieved by:
• Applying ice to the surgical site 3 times a day.
• Taking pain medicines as prescribed.
• Immobilizing and protecting your shoulder by wearing a sling as directed. Your health professional will advise you whether you need a sling after surgery. Some health professionals do not recommend this, because the shoulder joint may become stiff.
With a doctor's approval, you may be able to return to light work within a few days after surgery even if you are using a sling.
Risks
In addition to the general risks of surgery, such as blood loss or problems related to anesthesia, complications of subacromial smoothing surgery for rotator cuff disorders may include:
• Persistent pain.
• Nerve damage.
• Stiffness.
• Infection.
Benefits of Arthroscopic Surgery
The benefits of needing only arthroscopic surgery for subacromial smoothing rather than open surgery include:
• A shorter recovery time.
• A shorter hospital stay, which may cost less.
• Keeping the deltoid muscle attached, which aids rehabilitation.
• The surgeon's ability to inspect and debride both surfaces of the rotator cuff, rather than just the outside.
• Detecting other damage to the inside of the shoulder joint.
After Surgery
Physical therapy after surgery is crucial for a successful recovery. A typical rehabilitation schedule includes the following:
• Range-of-motion exercises may start the day after subacromial smoothing surgery.
• Strength training may begin several weeks after arthroscopic surgery.
When normal shoulder strength and range of motion return, usually after about 6 to 8 weeks, one can gradually resume playing sports.
Arthroscopic Surgery vs Traditional "Open" Surgery?
Open surgery, a procedure using larger incisions and enabling the surgeon to look inside the joint, may be better for certain procedures under certain circumstances.
Arthroscopic surgery has some advantages--smaller incisions, less tissue damage--but these are usually not helpful if the overall procedure cannot be performed as well
Return to activities
After surgical repair, most people require 6 months of rehabilitation before strength and shoulder function return to normal. Post-surgical rehabilitation is necessary and use of the shoulder must be limited. Immediately after surgery, you will be allowed to use the affected arm with your elbow at your side for eating, using the keyboard, using the telephone, and driving. Above-the-shoulder activities are not usually allowed for three months after surgery.
Sporting activities can be gradually restarted, including golfing at four months, light weight lifting at four months, swimming at five months, and throwing and tennis playing at five to six months.
Rotator Cuff Tendinopathy and Swimming...
Swimming is rough on the rotator cuff, especially if the form is not good. Most triathletes do not have good swimming form.
So the athlete is encouraged to have a coach video tape their swimming stroke and make sure shoulder movements during swimming are showing proper form.
Rotator cuff exercises during healing are generally not done until after a few Prolotherapy sessions. If caught early only a few session of Prolotherapy are needed. If the problem has been going on a long time then up to six sessions may be needed. Soft tissue oral nutritional supplements again are ordered. The athlete can of course cycle and run during the Prolotherapy healing. Often times, the triathlete can do some swimming drills as these do not cause the pain. If a drill reproduced the pain, this then is not practiced.
The need to surgically repair a torn rotator cuff depends upon your age, activity level, and the severity of your tear.
- Surgical repair is usually recommended for people with a complete rotator cuff tear, especially if the person is young and/or active. Surgery is usually recommended soon after the injury, if possible, to prevent the tendon and muscle from shrinking.
- Conservative treatment is usually recommended first if one does not have a complete rotator cuff tear or are older, less active, or if there is minimal pain. Conservative treatments (eg, stretching and strengthening exercises, injection of a steroid) are usually recommended first.
- Surgery may be recommended if patient does not improve after stretching and strengthening exercises and have persistent pain, limited strength, have arthritis or spurs that cause pain and interferes with rehabilitation, or if a new injury occurs and the patient has a previous rotator cuff injury.
Surgery...
Surgery may be used to treat a rotator cuff disorder if the injury is very severe or if nonsurgical treatment has failed to improve shoulder strength and movement sufficiently. Subacromial smoothing involves shaving bone or removing growths on the upper point of the shoulder blade (acromion). It removes scar tissue and damaged tendon and bursa from the joint. The surgeon may also remove small amounts of bone from the underside of the acromion and the acromioclavicular joint (acromioplasty). The goal is to take away roughness while keeping as much of the normal supporting structures as possible. This surgery creates more room in the subacromial space so that the rotator cuff tendon is not pinched or irritated and can glide smoothly beneath the acromion.
There are several ways to repair the rotator cuff, including open and arthroscopic techniques.
• Open-shoulder surgery involves making a larger incision in the shoulder, to open it and directly view the repair.
• Arthroscopy uses a thin viewing scope called an arthroscope that is inserted into a joint through a small incision in the skin. Then the surgeon will remove loose fragments of tendon, bursa, and other debris from the shoulder (debridement). Additional instruments are then arthroscopically inserted to shave the bone or remove growths.
What Is Done In Rotator Cuff Surgery?
During rotator cuff surgery, the patient is put in a half-sitting position, with the head supported. Most operations are performed under general anesthesia, where the patient is asleep. Sometimes a regional (or local) anesthetic is used to block the nerves leading to the arm. In that case, the patient is conscious but cannot feel pain. Usually a sedative is also given, putting the patient in a conscious but dreamy state.
Rotator cuff surgery usually takes one to two hours.
Types of procedures include:
• Impingement surgery
• Rotator cuff repair
• Arthroscopic surgery
Impingement Surgery (Also Called Acromioplasty Or Subacromial Decompression)
If the space between the upper arm and the part of the shoulder blade known as the acromion is too narrow, the rotator cuff cannot move freely. Rotator cuff tendons get pinched between the two bones, gradually damaging the rotator cuff.
To resolve this problem, the surgeon shaves a small portion of bone from the underside of the acromion, giving the tendons more room to move and preventing them from being pinched. The surgeon also removes any bone spurs and either excises or removes swollen or irritated bursa.
Impingement surgery is sometimes performed to relieve severe, chronic tendinitis that does not respond to nonsurgical treatment. Impingement surgery is also done as part of most rotator cuff repair surgeries.
Rotator Cuff Repair
In order to repair a torn rotator cuff, the surgeon reattaches the damaged tendon (or tendons) to the upper arm (humerus). (Some rotator cuff injuries involve more than one torn tendon.)
This surgery involves several key steps:
• In order to gain access to the injured rotator cuff, the surgeon makes a two- to three-inch incision in the shoulder, then cuts through the deltoid muscle.
• The surgeon removes any scar tissue that has built up on the tendon.
• The surgeon carves a small trough at the top of the upper arm, then drills small holes through the bone.
• Finally, the surgeon sews the tendon to the bone, with the sutures going through the tiny holes in the upper arm. (Sometimes a surgeon will use permanent anchors to attach the tendon to bone.)
During this operation, the surgeon also removes bone spurs and releases any ligaments that are pressing on the tendon. If a bursa is inflamed, the surgeon excises or removes it. The surgeon also may remove a small portion of the acromion to make sure the repaired rotator cuff has enough room to move.
Afterwards, the patient's arm is placed in a sling. With time, healing occurs, as scar tissue connects the tendon to bone. Because tendons receive such poor blood supply, this is a slow process.
Arthroscopic Surgery
Arthroscopic surgery is a technique for performing an operation using pen-shaped instruments with a miniature video camera attached to the end.
• The surgeon makes a small incision in the shoulder about the size of a buttonhole.
• He or she then inserts the thin tube that contains the tiny video camera and surgical instruments.
• The surgeon performs the operation with these remotely controlled instruments while watching on a video screen.
Because arthroscopic surgery requires only limited surgical access, the incision is much smaller than is necessary for open surgery, resulting in fewer risks. The patient's recovery time is also shorter.
However, because repairing a torn rotator cuff can be a complicated procedure, it is often performed as an open procedure. However, arthroscopic repairs are becoming more common, especially for small size tears.
After Surgery...
You may go home a few hours after waking up from anesthesia. In some cases, the doctor may suggest that you stay overnight for help with pain management and for observation.
Discomfort after surgery may be relieved by:
• Applying ice to the surgical site 3 times a day.
• Taking pain medicines as prescribed.
• Immobilizing and protecting your shoulder by wearing a sling as directed. Your health professional will advise you whether you need a sling after surgery. Some health professionals do not recommend this, because the shoulder joint may become stiff.
With a doctor's approval, you may be able to return to light work within a few days after surgery even if you are using a sling.
Risks
In addition to the general risks of surgery, such as blood loss or problems related to anesthesia, complications of subacromial smoothing surgery for rotator cuff disorders may include:
• Persistent pain.
• Nerve damage.
• Stiffness.
• Infection.
Benefits of Arthroscopic Surgery
The benefits of needing only arthroscopic surgery for subacromial smoothing rather than open surgery include:
• A shorter recovery time.
• A shorter hospital stay, which may cost less.
• Keeping the deltoid muscle attached, which aids rehabilitation.
• The surgeon's ability to inspect and debride both surfaces of the rotator cuff, rather than just the outside.
• Detecting other damage to the inside of the shoulder joint.
After Surgery
Physical therapy after surgery is crucial for a successful recovery. A typical rehabilitation schedule includes the following:
• Range-of-motion exercises may start the day after subacromial smoothing surgery.
• Strength training may begin several weeks after arthroscopic surgery.
When normal shoulder strength and range of motion return, usually after about 6 to 8 weeks, one can gradually resume playing sports.
Arthroscopic Surgery vs Traditional "Open" Surgery?
Open surgery, a procedure using larger incisions and enabling the surgeon to look inside the joint, may be better for certain procedures under certain circumstances.
Arthroscopic surgery has some advantages--smaller incisions, less tissue damage--but these are usually not helpful if the overall procedure cannot be performed as well
Return to activities
After surgical repair, most people require 6 months of rehabilitation before strength and shoulder function return to normal. Post-surgical rehabilitation is necessary and use of the shoulder must be limited. Immediately after surgery, you will be allowed to use the affected arm with your elbow at your side for eating, using the keyboard, using the telephone, and driving. Above-the-shoulder activities are not usually allowed for three months after surgery.
Sporting activities can be gradually restarted, including golfing at four months, light weight lifting at four months, swimming at five months, and throwing and tennis playing at five to six months.
Rotator Cuff Tendinopathy and Swimming...
Swimming is rough on the rotator cuff, especially if the form is not good. Most triathletes do not have good swimming form.
So the athlete is encouraged to have a coach video tape their swimming stroke and make sure shoulder movements during swimming are showing proper form.
Rotator cuff exercises during healing are generally not done until after a few Prolotherapy sessions. If caught early only a few session of Prolotherapy are needed. If the problem has been going on a long time then up to six sessions may be needed. Soft tissue oral nutritional supplements again are ordered. The athlete can of course cycle and run during the Prolotherapy healing. Often times, the triathlete can do some swimming drills as these do not cause the pain. If a drill reproduced the pain, this then is not practiced.
PCL4- prognosis
Rotator cuff tear
-People with a rotator cuff injury typically recover well with treatment. However, it's common to injure the same shoulder again, especially if you do not change the way you use your shoulder. Elderly people are prone to rotator cuff problems and have a harder time recovering because their shoulders have a less robust blood supply.
If the tear is small, a prolonged period of rest, lasting 4–9 months, may relieve symptoms. Range-of-motion exercises are also recommended, unless they cause significant discomfort. If this fails to control the symptoms, surgical repair of the tear is recommended.
Rehabilitation lasts from 6 months to a year with gradual exercise progression needed to restore normal, or near-normal function, and strength. This varies with the tear size repaired and type of surgery performed. Typically, immediately after the procedure, passive motion and isometric strengthening exercises start, along with elbow, hand, and grip strengthening exercises. At 6 weeks, the athlete may be able to begin low-intensity active strengthening exercises against gravity. The goals are to bring the athlete to normal strength with a functional, pain-free range of motion.
Yet some individuals with a partial-thickness tear have persistent or recurrent symptoms. If a conservative program of exercises and gradual return to activity does not lead to steady improvement, then further diagnostic evaluation with ultrasonography, MRI, or arthroscopy may be helpful. Arthroscopic debridement of the abnormal cuff may promote healing in athletes with partial-thickness posttraumatic tears. Following debridement, immediate resumption of range-of-motion and muscle-strengthening exercises begins. Typically, it requires 6–12 months for a throwing athlete to return to athletics following arthroscopic debridement of a partial-thickness rotator cuff tear.
Rotator cuff tendonitis
If rotator cuff tendonitis is adequately treated, there can be complete recovery.
If treatment of any rotator cuff problem is delayed or inadequate, it can lead to the affected person being cautious about moving their shoulder because of pain. This means that the shoulder can stiffen up and can lead to adhesive capsulitis (frozen shoulder)
Most people recover full function after a combination of medications, physical therapy, and steroid injections. For patients with tendinitis and a bone spur, arthroscopic surgery is usually successful in restoring them to their pre-injury level of activity.
Shoulder dislocation
Nonathletes have a 30% recurrence risk with nonoperative treatment, and athletes have an 82% recurrence risk with nonoperative treatment.27
If the dislocation was the patient's first, recurrence rates with nonoperative treatment depend on age, as follows:
- Patients aged 1-10 years have a 100% recurrence rate.
- Patients aged 11-20 years have a 27-95% recurrence rate.
- Patients aged 21-30 years have a 40-79% recurrence rate.
- Patients aged 31-40 years have a 40-72% recurrence rate.
- Patients aged 41-50 years have a 0-24% recurrence rate
Complication of shoulder dislocation include the following:
- Bankart lesions in 80-89% of patients
- Anterior capsular insufficiency in 74% of patients
- Hill-Sachs lesions in 67% of patients
- Inferior glenoid labral tears in 51% of patients
- Glenohumeral ligament insufficiency in 50% of patients
- Partial or complete rotator cuff tears in 13% of patients
- Dysplastic glenoid in 13% of patients
- Biceps tendon lesions in 12% of patients
- Brachial plexus injuries in 11% of patients
- Posterior glenoid labral tear in 11% of patients
- Axillary nerve injuries in 8-10% of patients
- SLAP lesions in 8% of patients
- Partial subscapularis tear in 8% of patients
- Loose bodies in 5% of patients
Shoulder separation
Prognosis is dependent on type of injury. Course of recovery is often prolonged if surgery was required.
• Type I and II injuries usually have good to excellent results with return to full function in 1-3 weeks. Some individuals may have persistent pain or dysfunction. A small percent may need eventual surgery for degenerative disease of AC joint.
• Type III injuries usually return to full function in 6-12 weeks. Most patients treated conservatively have excellent functional outcome. Younger patients and heavy laborers may need surgery to prevent muscle fatigue and discomfort and difficulty lifting due to the displacement. Type III injuries may develop impingement symptoms, muscle discomfort and neurovascular symptoms. Late surgery may be required. Surgical outcomes can be acceptable in more than 90% if treated appropriately.
• Type IV, V, and VI generally require surgery and return to play depends on healing and restoration of near normal strength.
complications of shoulder separation
- Loss of reduction of the clavicle (does not stay in proper position)
- Clavicle fracture
- Infection
- Painful scar
- Deltoid/Trapezius muscle detachment
Frozen shoulder
- Most cases will resolve on their own or with physiotherapy over a 1-3 year period, however it is a slow recovery process
- Most patients who have a frozen shoulder will have slight limitations in shoulder motion, even years after the condition resolves. However, this limit in motion is minimal, and often only noticed when performing a careful physical examination. The vast majority of patients who develop a frozen shoulder will recover their functional motion with therapy and stretching alone
· Treatment with therapy and NSAIDs will usually return the motion and function of the shoulder within a year. Even if left untreated, the frozen shoulder can get better by itself in 18 - 24 months.
· Even if surgery restores motion, you must continue physical therapy for several weeks or months afterward to prevent the frozen shoulder from returning. Treatment may fail if you cannot tolerate physical therapy.
Possible Complications
- Stiffness and pain continue even with therapy
- The arm can break if the shoulder is moved forcefully during surgery
BURSITIES
The condition may respond well to treatment, or it may develop into a chronic condition if the underlying cause cannot be corrected.
Possible Complications
- Chronic bursitis may occur.
- Too many steroid injections over a short period of time can cause injury to the surrounding tendons.
PCL 4 - MUSCLES OF THE SHOULDER
ANTERIOR AXIOAPPENDICULAR MUSCLES
PECTORALIS MAJOR
1. Proximal Attachment
Clavicular head: anterior surface of medial half of clavicle Sternocostal head: anterior surface of sternum, superior six costal cartilages, aponeurosis of external oblique muscle
2. Distal Attachment
Lateral lip of intertubercular sulcus of humerus
3. Innervation
Lateral and medial pectoral nerves; clavicular head (C5, C6), sternocostal head (C7, C8, T1)
4. Main Action
Adducts and medially rotates humerus; draws scapula anteriorly and inferiorly
Acting alone, clavicular head flexes humerus and sternocostal head extends it from the flexed position
PECTORALIS MINOR
1. Proximal Attachment
3rd-5th ribs near their costal cartilages
2. Distal Attachment
Medial border and superior surface of coracoid process of scapula
3. Innervation
Medial pectoral nerve (C8, T1)
4. Main Action
Stabilizes scapula by drawing it inferiorly and anteriorly against thoracic wall
SUBCLAVIUS
1. Proximal Attachment
Junction of 1st rib and its costal cartilage
2. Distal Attachment
Inferior surface of middle third of clavicle
3. Innervation
Nerve to subclavius (C5, C6)
4. Main Action
Anchors and depresses clavicle
SERRATUS ANTERIOR
1. Proximal Attachment
External surfaces of lateral parts of 1st-8th ribs
2. Distal Attachment
Anterior surface of medial border of scapula
3. Innervation
Long thoracic nerve (C5, C6, C7)
4. Main Action
Protracts scapula and holds it against thoracic wall; rotates scapula
POSTERIOR AXIOAPPENDICULAR MUSCLES
i.Superficial posterior axioappendicular (extrinsic shoulder) muscles
TRAPEZIUS
1. Proximal Attachment
Medial third of superior nuchal line; external occipital protuberance; nuchal ligament; spinous processes of C7-T12 vertebrae
2. Distal Attachment
Lateral third of clavicle; acromion and spine of scapula
3. Innervation
Spinal accessory nerve (CN XI) (motor fibers) and C3, C4 spinal nerves (pain and proprioceptive fibers)
4. Main Action
Descending part elevates; ascending part depresses; and middle part (or all parts together) retracts scapula; descending and ascending parts act together to rotate glenoid cavity superiorly
LATISSIMUS DORSI
1. Proximal Attachment
Spinous processes of inferior 6 thoracic vertebrae, thoracolumbar fascia, iliac crest, and inferior 3 or 4 ribs
2. Distal Attachment
Floor of intertubercular sulcus of humerus
3. Innervation
Thoracodorsal nerve (C6, C7, C8)
4. Main Action
Extends, adducts, and medially rotates humerus; raises body toward arms during climbing
ii. Deep posterior axioappendicular (extrinsic shoulder) muscles
LEVATOR SCAPULAE
1. Proximal Attachment
Posterior tubercles of transverse processes of C1-C4 vertebrae
2. Distal Attachment
Medial border of scapula superior to root of scapular spine
3. Innervation
Dorsal scapular (C5) and cervical (C3, C4) nerves
4. Main Action
Elevates scapula and tilts its glenoid cavity inferiorly by rotating scapula
RHOMBOID MINOR AND MAJOR
1. Proximal Attachment
Minor: nuchal ligament; spinous processes of C7 and T1 vertebrae
Major: spinous processes of T2-T5 vertebrae
2. Distal Attachment
Minor: smooth triangular area at medial end of scapular spine
Major: medial border of scapula from level of spine to inferior angle
3. Innervation
Dorsal scapular nerve (C4, C5)
4. Main Action
Retract scapula and rotate it to depress glenoid cavity; fix scapula to thoracic wall
SCAPULOHUMERAL (INTRINSIC SHOULDER) MUSCLES
DELTOID
1. Proximal Attachment
Lateral third of clavicle; acromion and spine of scapula
2. Distal Attachment
Deltoid tuberosity of humerus
3. Innervation
Axillary nerve (C5, C6)
4. Main Action
Clavicular (anterior) part: flexes and medially rotates arm
Acromial (middle) part: abducts arm
Spinal (posterior) part: extends and laterally rotates arm
SUPRASPINATUS
1. Proximal Attachment
Supraspinous fossa of scapula
2. Distal Attachment
Superior facet of greater tubercle of humerus
3. Innervation
Suprascapular nerve (C4, C5, C6)
4. Main Action
Initiates and assists deltoid in abduction of arm and acts with rotator cuff musclesb
INFRASPINATUS
1. Proximal Attachment
Infraspinous fossa of scapula
2. Distal Attachment
Middle facet of greater tubercle of humerus
3. Innervation
Suprascapular nerve (C5, C6)
4. Main Action
Laterally rotates arm; and acts with rotator cuff musclesb
TERES MINOR
1. Proximal Attachment
Middle part of lateral border of scapula
2. Distal Attachment
Inferior facet of greater tubercle of humerus
3. Ineervation
Axillary nerve (C5, C6)
4. Main Action
Laterally rotates arm; and acts with rotator cuff musclesb
TERES MAJOR
1. Proximal Attachment
Posterior surface of inferior angle of scapula
2. Distal Attachment
Medial lip of intertubercular sulcus of humerus
3. Innervation
Lower subscapular nerve (C5, C6)
4. Main Action
Adducts and medially rotates arm
SUBSCAPULARIS
1. Proximal Attachment
Subscapular fossa (most of anterior surface of scapula)
2. Distal Attachment
Lesser tubercle of humerus
3. Innervation
Upper and lower subscapular nerves (C5, C6, C7)
4. Main Action
Medially rotates arm; as part of rotator cuff, helps hold head of humerus in glenoid cavity
SOURCE : Moore K., Dalley A., Agur A., Clinically Oriented Anatomy, 6th ed. Baltimore, Lippincot Williams and Wilkin, 2010
PECTORALIS MAJOR
1. Proximal Attachment
Clavicular head: anterior surface of medial half of clavicle Sternocostal head: anterior surface of sternum, superior six costal cartilages, aponeurosis of external oblique muscle
2. Distal Attachment
Lateral lip of intertubercular sulcus of humerus
3. Innervation
Lateral and medial pectoral nerves; clavicular head (C5, C6), sternocostal head (C7, C8, T1)
4. Main Action
Adducts and medially rotates humerus; draws scapula anteriorly and inferiorly
Acting alone, clavicular head flexes humerus and sternocostal head extends it from the flexed position
PECTORALIS MINOR
1. Proximal Attachment
3rd-5th ribs near their costal cartilages
2. Distal Attachment
Medial border and superior surface of coracoid process of scapula
3. Innervation
Medial pectoral nerve (C8, T1)
4. Main Action
Stabilizes scapula by drawing it inferiorly and anteriorly against thoracic wall
SUBCLAVIUS
1. Proximal Attachment
Junction of 1st rib and its costal cartilage
2. Distal Attachment
Inferior surface of middle third of clavicle
3. Innervation
Nerve to subclavius (C5, C6)
4. Main Action
Anchors and depresses clavicle
SERRATUS ANTERIOR
1. Proximal Attachment
External surfaces of lateral parts of 1st-8th ribs
2. Distal Attachment
Anterior surface of medial border of scapula
3. Innervation
Long thoracic nerve (C5, C6, C7)
4. Main Action
Protracts scapula and holds it against thoracic wall; rotates scapula
POSTERIOR AXIOAPPENDICULAR MUSCLES
i.Superficial posterior axioappendicular (extrinsic shoulder) muscles
TRAPEZIUS
1. Proximal Attachment
Medial third of superior nuchal line; external occipital protuberance; nuchal ligament; spinous processes of C7-T12 vertebrae
2. Distal Attachment
Lateral third of clavicle; acromion and spine of scapula
3. Innervation
Spinal accessory nerve (CN XI) (motor fibers) and C3, C4 spinal nerves (pain and proprioceptive fibers)
4. Main Action
Descending part elevates; ascending part depresses; and middle part (or all parts together) retracts scapula; descending and ascending parts act together to rotate glenoid cavity superiorly
LATISSIMUS DORSI
1. Proximal Attachment
Spinous processes of inferior 6 thoracic vertebrae, thoracolumbar fascia, iliac crest, and inferior 3 or 4 ribs
2. Distal Attachment
Floor of intertubercular sulcus of humerus
3. Innervation
Thoracodorsal nerve (C6, C7, C8)
4. Main Action
Extends, adducts, and medially rotates humerus; raises body toward arms during climbing
ii. Deep posterior axioappendicular (extrinsic shoulder) muscles
LEVATOR SCAPULAE
1. Proximal Attachment
Posterior tubercles of transverse processes of C1-C4 vertebrae
2. Distal Attachment
Medial border of scapula superior to root of scapular spine
3. Innervation
Dorsal scapular (C5) and cervical (C3, C4) nerves
4. Main Action
Elevates scapula and tilts its glenoid cavity inferiorly by rotating scapula
RHOMBOID MINOR AND MAJOR
1. Proximal Attachment
Minor: nuchal ligament; spinous processes of C7 and T1 vertebrae
Major: spinous processes of T2-T5 vertebrae
2. Distal Attachment
Minor: smooth triangular area at medial end of scapular spine
Major: medial border of scapula from level of spine to inferior angle
3. Innervation
Dorsal scapular nerve (C4, C5)
4. Main Action
Retract scapula and rotate it to depress glenoid cavity; fix scapula to thoracic wall
SCAPULOHUMERAL (INTRINSIC SHOULDER) MUSCLES
DELTOID
1. Proximal Attachment
Lateral third of clavicle; acromion and spine of scapula
2. Distal Attachment
Deltoid tuberosity of humerus
3. Innervation
Axillary nerve (C5, C6)
4. Main Action
Clavicular (anterior) part: flexes and medially rotates arm
Acromial (middle) part: abducts arm
Spinal (posterior) part: extends and laterally rotates arm
SUPRASPINATUS
1. Proximal Attachment
Supraspinous fossa of scapula
2. Distal Attachment
Superior facet of greater tubercle of humerus
3. Innervation
Suprascapular nerve (C4, C5, C6)
4. Main Action
Initiates and assists deltoid in abduction of arm and acts with rotator cuff musclesb
INFRASPINATUS
1. Proximal Attachment
Infraspinous fossa of scapula
2. Distal Attachment
Middle facet of greater tubercle of humerus
3. Innervation
Suprascapular nerve (C5, C6)
4. Main Action
Laterally rotates arm; and acts with rotator cuff musclesb
TERES MINOR
1. Proximal Attachment
Middle part of lateral border of scapula
2. Distal Attachment
Inferior facet of greater tubercle of humerus
3. Ineervation
Axillary nerve (C5, C6)
4. Main Action
Laterally rotates arm; and acts with rotator cuff musclesb
TERES MAJOR
1. Proximal Attachment
Posterior surface of inferior angle of scapula
2. Distal Attachment
Medial lip of intertubercular sulcus of humerus
3. Innervation
Lower subscapular nerve (C5, C6)
4. Main Action
Adducts and medially rotates arm
SUBSCAPULARIS
1. Proximal Attachment
Subscapular fossa (most of anterior surface of scapula)
2. Distal Attachment
Lesser tubercle of humerus
3. Innervation
Upper and lower subscapular nerves (C5, C6, C7)
4. Main Action
Medially rotates arm; as part of rotator cuff, helps hold head of humerus in glenoid cavity
SOURCE : Moore K., Dalley A., Agur A., Clinically Oriented Anatomy, 6th ed. Baltimore, Lippincot Williams and Wilkin, 2010
PCL 4 - Anatomy of the Shoulder (Gurki)
There are three main joints in the shoulder girdle, these are:
Glenohumeral Joint (GHJ)
Acromioclavicular Joint (ACJ)
Sternoclavicular Joint (SCJ)
It is also important to consider another “joint” which is important in shoulder movement:
Scapulothoracic Joint
The Scapula (or shoulder blade)
This bone is quite complex and is an attachment site for numerous muscles which support movement and stabilisation of the shoulder. It overlies the 2nd – 7th ribs, is tilted forwards by an angle of 30°, and is encased by 17 muscles which provide control and stabilisation against the thoracic wall (the ribcage). This is sometimes referred to as the “Scapulothoracic Joint” although it is not technically an actual joint.
The Clavicle (or collar bone)
The clavicle is an S-shaped bone and is the main connection between the upper arm and the rest of the axial skeleton. The clavicle is also an important site for muscle attachments including:
Pectoralis Major
Trapezius
Sternoclaedomastoid
Sternohyoid
Subclavius
The Glenohumeral Joint (shoulder ball and socket joint)
The Glenohumeral Joint is a ball and socket joint which provides a large proportion of the movement at the shoulder girdle.
The head of the humerus articulates with the glenoid fossa of the scapula – hence the name. The head of the humerus is, however, quite large in comparison to the fossa, resulting in only one third to one half of the head being in contact with the fossa at any one time. The humerus is further supported by the glenoid labrum – a ring of fibrous cartilage which extends the fossa slightly making it wider and deeper (almost like if you have a deeper bowl, you can fit more in it!).
Both articulating surfaces are covered with articular cartilage which is a hard, shiny cartilage which protects the bone underneath.
The Acromioclavicular Joint
The Acromioclavicular Joint (ACJ) is formed by the lateral end of the clavicle articulating with the medial aspect of the anterior acromium.
The ACJ is important in transmitting forces through the upper limb and shoulder to the axial skeleton. The ACJ has minimal mobility due to its supporting ligaments:
Acromioclavicular Ligament which is composed of strong superior (top) and inferior (bottom) ligaments, and weak anterior (front) and posterior (back) ligaments restricting anterior-posterior (forwards and backwards) movement of the clavicle on the acromion
Coracoclavicular Ligament is composed of the Conoid and Trapezoid ligaments. It forms a strong heavy band to prevent vertical movement.
The Sternoclavicular Joint
The Sternoclavicular Joint occurs at the sternal end of the clavicle, the cartilage of the first rib, and the upper and lateral parts of the manubrium sterni (the upper part of the sternum, or breastbone).
It is the only joint that truly links the upper extremity to the axial skeleton, via the clavicles. The Sternoclavicular Joint functions in all movements of the upper limbs, and is particularly important in throwing and thrusting movements.
The Scapulothoracic Joint
This joint relies entirely on the surrounding musculature for its control. The main muscles which control this joint are:
Serratus Anterior which holds the medial (inside) angle of the scapula against the chest wall.
Trapezius which rotates and elevates the scapula with elevation (lifting up) of the upper arm.
Note that during elevation the Glenohumeral Joint rotates 2° for every 1° of scapulothoracic rotation
The Shoulder Girdle
The anatomy of the shoulder girdle consists of several bony joints, or “articulations”, which connect the upper limbs to the rest of the skeleton and provide a large range of movement.
The three bones which form the shoulder girdle are the clavicle, the scapula and the humerus. The most important aspect of the shoulder is the large range of movement that it permits, which is central to many activities of daily living.
Glenohumeral Joint (GHJ)
Acromioclavicular Joint (ACJ)
Sternoclavicular Joint (SCJ)
It is also important to consider another “joint” which is important in shoulder movement:
Scapulothoracic Joint
The Scapula (or shoulder blade)
This bone is quite complex and is an attachment site for numerous muscles which support movement and stabilisation of the shoulder. It overlies the 2nd – 7th ribs, is tilted forwards by an angle of 30°, and is encased by 17 muscles which provide control and stabilisation against the thoracic wall (the ribcage). This is sometimes referred to as the “Scapulothoracic Joint” although it is not technically an actual joint.
The Clavicle (or collar bone)
The clavicle is an S-shaped bone and is the main connection between the upper arm and the rest of the axial skeleton. The clavicle is also an important site for muscle attachments including:
Pectoralis Major
Trapezius
Sternoclaedomastoid
Sternohyoid
Subclavius
The Glenohumeral Joint (shoulder ball and socket joint)
The Glenohumeral Joint is a ball and socket joint which provides a large proportion of the movement at the shoulder girdle.
The head of the humerus articulates with the glenoid fossa of the scapula – hence the name. The head of the humerus is, however, quite large in comparison to the fossa, resulting in only one third to one half of the head being in contact with the fossa at any one time. The humerus is further supported by the glenoid labrum – a ring of fibrous cartilage which extends the fossa slightly making it wider and deeper (almost like if you have a deeper bowl, you can fit more in it!).
Both articulating surfaces are covered with articular cartilage which is a hard, shiny cartilage which protects the bone underneath.
The Acromioclavicular Joint
The Acromioclavicular Joint (ACJ) is formed by the lateral end of the clavicle articulating with the medial aspect of the anterior acromium.
The ACJ is important in transmitting forces through the upper limb and shoulder to the axial skeleton. The ACJ has minimal mobility due to its supporting ligaments:
Acromioclavicular Ligament which is composed of strong superior (top) and inferior (bottom) ligaments, and weak anterior (front) and posterior (back) ligaments restricting anterior-posterior (forwards and backwards) movement of the clavicle on the acromion
Coracoclavicular Ligament is composed of the Conoid and Trapezoid ligaments. It forms a strong heavy band to prevent vertical movement.
The Sternoclavicular Joint
The Sternoclavicular Joint occurs at the sternal end of the clavicle, the cartilage of the first rib, and the upper and lateral parts of the manubrium sterni (the upper part of the sternum, or breastbone).
It is the only joint that truly links the upper extremity to the axial skeleton, via the clavicles. The Sternoclavicular Joint functions in all movements of the upper limbs, and is particularly important in throwing and thrusting movements.
The Scapulothoracic Joint
This joint relies entirely on the surrounding musculature for its control. The main muscles which control this joint are:
Serratus Anterior which holds the medial (inside) angle of the scapula against the chest wall.
Trapezius which rotates and elevates the scapula with elevation (lifting up) of the upper arm.
Note that during elevation the Glenohumeral Joint rotates 2° for every 1° of scapulothoracic rotation
The Shoulder Girdle
The anatomy of the shoulder girdle consists of several bony joints, or “articulations”, which connect the upper limbs to the rest of the skeleton and provide a large range of movement.
The three bones which form the shoulder girdle are the clavicle, the scapula and the humerus. The most important aspect of the shoulder is the large range of movement that it permits, which is central to many activities of daily living.
PCL 4 Treatment and Management- Non Surgical
- Introduction
- When tendon inflammation or strain is present, non-surgical treatment is usually sufficient.
- Non surgical treatment does not mean that the shoulder injury is neglected, in fact, many patients who follow appropriate treatment and a rehabilitation program can have clinical success without surgery.
- Nonsurgical options help treat the injury and manage pain for minor sprains (clinically called type I and II Acromioclavicular joint injuries), stage 1 rotator cuff impingements, rotator cuff tears and shoulder arthritis.
- Treatment options differ according to location of injury, and the likelihood of successful treatment is affected by the size of rotator cuff tear and duration of presenting signs and symptoms.
- Non-surgical treatments can provide relief of symptoms of a rotator cuff tear in some, but not all, people. While different studies have found different rates of success, about 50% of people who try non-surgical treatments will find relief of symptoms.
- There is no set time frame for overcoming a shoulder impingement without surgery. It may take weeks of ice, anti-inflammatory drugs and exercise to overcome the inflammation and pain. Those who are more proactive in their treatment generally recover more quickly.
PHYSICAL THERAPY ( PHYSIOTHERAPY)
- Often prescribed with medication to alleviate shoulder pain.
- Begins with an assessment of patient's condition
- Helpful in preventing frozen shoulder due to pain, where the patient stops using the shoulder and the muscles seize up,compounding the problem.
- Most important step in treating rotator cuff injury by preventing stress on these muscles.
- This rehabilitation treatment focuses on 2 important aspects of shoulder motion- flexibility and strength.
- For example: Range Of Motion exercises (ROM)
- Pendulum exercises- bend over at the waist letting the affected arm hang down at your side, sway body back and forth using the weight of arm and gravity to form small circles at the surgical shoulder, then move arm counterclockwise and clockwise using this technique.
- Isometric exercises- these strengthen the shoulder muscles
- Stretching exercises- must not increase pain, edema and inflammation. It enables an increased range of motion without compromising ligaments and tendons
- Weight-bearing exercised may begin when full range of motion is attained.
- Personalized to fit each individual's
- cognitive and psychosocial motivation
- understanding of perception of pain
- goal-setting and limitations
- integrating patient back into productive work and social activity
REST AND REHABILITATION
- A person with rotator cuff injury should rest the shoulder and avoid positions/ activities that may strai the muscles.
- It is important not to immobilize the shoulder as it is possible to develop a frozen shoulder.
- At home, general care involves "R.I.C.E." (Rest, Ice, Compression and Elevation)
- Short-term bed rest reduce both inflammation and joint pain, useful when multiple joints are affected.
- Heat therapy
- Use before activities that irritate chronic injuries- strains
- Can be applied at home using heat packs (gel or wheat based), wrapped in a towel
- Applied to injury 15-20 minutes at a time
- Other techniques using warm, damp towels, warm baths and heat rubs can also be easily used at home
- These may not be as effective at warming deeper tissues.
- Other methods of applying heat (http://www.sportsinjuryclinic.net/cybertherapist/general/heat_therapy.php)
- Ultrasound Therapy- produced by mechanical vibration of metal treatment head to generate heat within tissue, may cause an increase in the extensibility of structures such as ligaments, tendons, scar tissue and fibrous joint capsules, reduce pain and muscle spasm.
- TENS- Transcutaneous Electrical Nerve Stimulation (This has been explained in a previous post)
- Interferential stimulation- Uses a medium-frequency of alternating currents to incite tissues of injured muscles and joints, reduces pain, decreases oedema, increasing blood circulation to promote healing in injured tissues.
- Magnetic Field Therapy- Using pulsed or static electromagnetic fields to produce analgesia. (For example, magnetic bracelets purchased from high-street pharmacies.)
- Cold therapy
- reduce pain by numbing nerves around the joints.
- Applied for acute injury (sprain) for no longer than 20 minutes at a time.
MASSAGE THERAPY
- Deep tissue massage is often used in the treatment of soft tissue injuries such as tendonitis.
- Massage therapy relieves pain and increases range of motion while it increases circulation and speeds healing.
- It reduces stress and the production of stress hormone that heighten the perception of pain and contribute to tight muscles (which may cause or increase pain).
- Massage therapy is contradicted if there is swelling of the joint.
PHARMACEUTICAL TREATMENT
- Can be obtained over the counter (Aspirin, Ibuproen, Motrin) or with a doctor's prescription (Cereblex, Relafen)
- NSAIDs (Non-Steroidal Anti Inflammatory Pain Medications) are most commonly prescribed medications
- NSAIDs work to block the effect of an enzyme called cyclooxygenase. This enzyme is critical in your body's production of prostaglandins that cause swelling and pain in a condition such as arthritis or bursitis. Therefore by interfering with cyclooxygenase, you decrease the production of prostaglandins, and decrease pain and swelling associated with these conditions.
- Traditional NSAIDs (Ibuprofen, Motrin, Naproxen) block both COX 1 and COX-2 enzymes. There's a risk of getting stomach ulcers with these drugs because COX-1 (involved in producing the protective gut lining) is inhibited.
- Newer NSAIDs (Cereblex) work against COX-2 allowing COX-1 to function normally. Thus the side effects of stomach ulcers are reduced.
- Anti-inflammatory medications can be taken regularly for a short period of time, and then be used when symptoms of a rotator cuff tear flare-up.
ALTERNATIVE MEDICINE
- Is used in place of conventional medicine
- Cortisone Injections (A steroid with powerful anti-inflammatory properties) such as Cenestone, Kenalog
- Usually there is a limit of 3 injections a year because the overuse of cortisone weakens the tissue structure and may increase risk of tears.
- Side effects: 'cortisone flare' due to crystallization of injected cortisone, leads to brief pain much worse compared to prior injection. Other possible effects are whitening of the skin and infections.
- Joint supplements (Glucosamine and Chondroitin) used for arthritic joints
- The theory is that consuming these supplements may increase the rate of forming new cartilage. However it is not proven to increase the quantity of cartilage precursors in joints.
- Joint Fluid Supplements
- A fluid supplement that acts as a lubricant for the damaged joint.
- Joint injection schedules and duration of relief vary according to the treatment chosen and the individual patient.
- However, these injections do not cure the diseased joint and joint replacement may be needed as the joint worsens with time.
- One common supplement is Hyaluronic Acid injection, which can be effective between 5-13 weeks.
- Acupuncture
- Based on the theory of Chi that circulates throughout the body. The Chi is manipulated using needles placed at Meridian pathways to restore balance to the body.
- Does't repair the tear but it is very useful in treating the inflammation that occurs as a result as well as providing a degree of analgesic relief
- It facilitates the healing process by promoting circulation, relieving nearby muscle tension and interrupting nerve pain signals.
- Naprapathy
- A physical and visual inspection of the musculoskeletal system is made to determine any imbalances.
- When a vertebrae is misaligned, tissues and organs will malfunction throughout the body.
- Naprapaths (Doctors of naprapathy) treat patients with sciatica, tendonitis, sprains and strains.
- Homeopathy
- Many animal, plant, mineral and synthetic substances are used in the remedies.
- An example is Calcium Phosphate to treat rheumatic pains in the shoulder and arm, Iron Phosphate for tearing pain in right shoulder and arm and Ruta g. for wrenching pain in shoulder joint.
COMPLEMENTARY TREATMENTS
- Is used together with conventional medicine, usually to lessen a patient's discomfort following surgery.
- Reiki
- A japanese form of spiritual healing
- The practitioner places his hands in a series of positions over the patient's whole body, not just the affected area.
- A treatment will usually progress with the practitioner moving their hands from one specific position to another, and holding each position for between 3 and 5 minutes. Areas usually covered include the head, back, stomach, knees and feet. Between 12 and 20 positions are used and treatments therefore last for 45-90 minutes. Clients often report feelings of warmth and tingling on areas being treated, even when the hands are not in contact! - There is no scientific evidence available to support the effectiveness of Reiki and especially the presence of the life force energy described in Reiki teachings.
- Kinesiology tape
- There is a method of applying Kinesio tape correctly, and it stems from a holistic practice known as kinesiology.
- A trainer or a therapist certified in the use of Kinesiology tape to helps to apply the tape correctly to your shoulder area.
- Kinesio tape should be applied to your shoulder when your arm is extended fully at 90 degrees.
- Gently press the tape at the top of the shoulder area and unroll it down the length of your arm toward the e elbow. This ensures that the tape will glide along the same direction as your shoulder and arm muscles. Keep your arm extended when patting the Kinesio tape down.
Causes of Rotator Cuff Tendinopathy and Investigations
Causes of Rotator Cuff Tendinopathy
Tendinitis
- When a muscle is stressed due to overuse, microscopic tears occur.
- And because of tears, inflammation occurs as a result of healing.
- However, if the healing is not allowed to occur due to the same activity, inflammation becomes chronic.
- Chronic Inflammation then causes progressive damage to tendons, causing them to be less elastic.
- Hence they become more susceptible to tearing.
Rotator Cuff Tear
- Tears mainly involve supraspinatus tendon.
- Tears can be acute, which are typically present with sudden onset of pain and dysfunction due to trauma.
- Chronic tears are present for longer than 3 months and may be associated with variable degress of weakness and comfort.
- Tears can be of varying in degree.
- Mainly due to overhead motions.*
Impingement Syndrome
- Caused by the impingement of the the 4 muscle tendons under the subacromial space.
- Called so because there’s a space under the arch of the acromion.
- With repetitive pinching with movement, the tendon(s) can get irritated and become inflammed, causing pain.
- Neer described 3 stages of impingement syndrome existing as a continuum eventually leading to rotator cuff tearing.
stage 1 : subacromial oedema and haemorrage present
stage 2 : fibrosis and tendinitis present
stage 3 : rotator cuff failure resulting in partial/complete tearing of tendon
- 2 Types of impingement : External and Internal
- External Impingement : Primary and Secondary
Primary : Impingement is caused by irregular shaping of acromial arch.
: Can be congenital or degenerative changes *.
Secondary : Impingement is caused by poor stabilisation of the scapular, altering
the position of the acromion, making it causing impingements.*
- Internal Impingement : Occurs mainly in athletes
: Under side of rotator cuff gets impinged against the glenoid
labrum , hence causing pain. *
Investigations
X- Rays
- Can only be done to rule out bone dislocation or fracture
- Can also show presence of calcium deposits or bone spurs.
- However they do not show soft tissues in the image
Magnetic Resonance Imaging
- MRI’s use magnetic waves and computers to make detailed images of the interior of the shoulder
- Can show small and even partial tears of tendons.
Athroscopy
- An incision is made on the shoulder, and inserts a small camera into the cut area
- Allows physician to see whether the rotator cuff is torn.
- However, not really done due to it’s invasive nature.
Friday, July 30, 2010
PCL4- Psychosocial factors
PSYCHOLOGICAL REACTIONS ACCOMPANYING ATHLETIC INJURY
EMOTION
-Athletes can be expected to experience a variety of emotional responses upon being injured.
- Athletes may experience feelings of separation, loneliness, guilt and a loss of identity and independence, because they feel that they are no longer vitally contributing to the team and that they are reliant upon others in the rehabilitative process
-The athlete may also experience withdrawal symptoms if they must stop exercising which include depression, increased irritability, decay of personal relationships, anxiety, insomnia, fatigue, and muscle tension
-Emotions such as depression, anger, fear, tension, disgust, anxiety, and panic have been shown to create psychophysiological reactions that contribute to and exacerbate the pain of the injury
-Therefore the emotions experienced by the athlete may further add to the injury
-Problematic emotional reactions occur when symptoms do not resolve or worsen over time, or the severity of the symptoms seems excessive relative to other injured athletes
-Depression is an especially significant warning sign.
- It magnifies other emotional responses and impacts recovery from injury.
| PROBLEMATIC EMOTIONAL REACTIONS (EXAMPLES) | ||
| Persistent Symptoms | Worsening Symptoms | Excessive Symptoms |
| • Alterations of appetite • Sleep disturbance • Irritability | • Alterations of appetite into disordered eating • Sadness into depression • Lack of motivation into apathy • Disengagement into alienation | • Pain behaviors • Excessive anger or rage • Frequent crying or emotional outbursts • Substance abuse |
.
Stress
-If an athlete is injured, stress and anxiety can also become an overwhelming problem during the healing process
-Stress causes attentional changes (e.g., narrowing of attention, general distraction, increased self-consciousness) that interfere with an athlete’s performance
-Stress has been shown to cause increased muscle tension and coordination difficulties which increase the athlete’s risk of injury.
-A serious athlete who identifies herself with a certain sport can be devastated by an injury that takes her out of the game.
-She might fear losing her skills, strength, conditioning, and experience of a season
-She might also fear losing her position.
- Additionally, she is unable to exercise as before due to the limitations of her injury.
-Even though she might now have a lot of time on her hands, she might feel great stress
| Table 1 SELECTED SIGNS AND SYMPTOMS OF STRESS | ||
| Behavioral | Physical | Psychological |
| • Difficulty sleeping • Lack of focus, overwhelmed • Consistently performs better in practice/training than in competition • Substance abuse | • Feeling ill • Cold, clammy hands • Profuse sweating • Headaches • Increased muscle tension • Altered appetite | • Negative self-talk • Uncontrollable intrusive and negative thoughts or images • Inability to concentrate • Self doubt |
As a physician
-A number of factors should be considered when treating injured athletes. These factors include:
• Building trust and rapport with the injured athlete. Injured athletes often experience a range of emotions that make it difficult for athletic care network members to establish rapport and build trust. Listening to the athlete is particularly important, not only to make a medical diagnosis but also to assess and monitor their emotional state.
• Educating the athlete about the injury. Injured athletes must understand and process injury-relevant information, often at a time when they are experiencing emotional upheaval. It is critical that explanations of injuries be presented in terms that the injured athlete can understand. An effective method to assess this understanding is to ask the athlete to provide their interpretation of information given to them.
• Identifying misinformation about the injury. Injured athletes often obtain inaccurate information from a variety of sources (e.g. parents, coaches, teammates, Internet) which may contribute to confusion and emotional upheaval.
• Preparing the athlete and coach (only with athlete’s permission) for the injury recovery process. The injury recovery and rehabilitation process is variable due to characteristics of the injury, treatment provided, presence of complications and psychological issues. Therefore, the athlete and coach should be educated that an injury is best managed on an individualized basis. In addition, coaches should be encouraged to help the injured athlete avoid isolation from the team.
-
• Encouraging the use of specific stress coping skills. Injured athletes can experience considerable stress throughout the injury and rehabilitation process. Psychological as well as physical strategies will enhance the recovery process
Coping strategies
1. Set Appropriate Goals
- SMART
- goal setting can become an incredibly important tool to make sure that the athlete continues to focus on making progress.
- goals will now focus on recovery rather than performance
- will help keep athlete motivated
-By monitoring goals, athlete will also be able to notice small improvements in the rehab of their injury.
-they will feel more confident that they are getting better and improving.
2. Visualization Technique
- visualization is an effective way to reduce or eliminate out-of-control feelings of stress and anxiety
-Visualization is about slowing down and picturing yourself in a time and place where you will be relaxed and peaceful.
-Visualization is a very personalized relaxation technique, and the key to success is coming up with images that will work for you.
- The visualization activity that works for you might involve picturing yourself relaxing in a beach or boat, or it might be an image of yourself standing atop the winner's podium after a tough meet
- This strategy can help ward off extreme anxiety and panic attacks.
3. Accept Responsibility for Your Injury
-What this means is that you accept that now you have an injury and you are the only one that can fully determine your outcome.
-By taking responsibility for your recovery process, you will find a greater sense of control and will quickly progress in recovery, rather than dwelling on the past or blaming the injury on an outside factor.
4.Maintain a Positive Attitude
-To heal quickly you need to be committed to overcoming your injury by showing up for your treatments, working hard, and listening and doing what your doctor and/or athletic trainer recommend.
-You also need to monitor what you are thinking and saying to yourself regarding the injury and the rehab process.
- Your self-talk is important.
-Are your thoughts negative and self-defeating?
-To get the most out of your daily rehab, you need to work hard and maintain a positive attitude. Remain focused on what you need to do.
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