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

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.

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

- Increases blood flow, pain tolerance and flexibility, used for chronic injuries.

- 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)

1. 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.
2. TENS- Transcutaneous Electrical Nerve Stimulation (This has been explained in a previous post)
3. 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.
4. Magnetic Field Therapy- Using pulsed or static electromagnetic fields to produce analgesia. (For example, magnetic bracelets purchased from high-street pharmacies.)

• Cold therapy

- cold packs, ice massage, over the counter sprays and ointments

- 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

- Is injected into area of inflammation instead of into the blood stream to limit inflammation of acute rotator cuff tear.

- 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

- Glucosamine is a precursor to a molecule called a glycosaminoglycan that is used in the formation and repair of cartilage whereas chondroitin is the most abundant glycosaminoglycan in cartilage and is responsible for the resiliency of cartilage.

- 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

- For patients whose joint pain does not improve with medication or physical therapy, "joint grease" injections may provide temporary relief.

- 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 healing method that works through the connective tissues (ligaments, tendons, muscles) that is gently manipulated to release tension and restoring balance.

- 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

- Practitioners use highly diluted preparations drugs to treat various conditions (For example, frozen shoulder)

- 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

- Provides shoulder relief, allows area around the muscle to stay flexible, maintaining circulation to speed up healing.

- 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.

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.

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• 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.