Download Rotator Cuff - Myofascial Trigger Point Therapy Podcast

Tendinosis & Subacromial
Impingement Syndrome
Gene Desepoli, LMT, D.C.
What is the shoulder joint?
• Shoulder joint or shoulder “region?”
• There is an interrelatedness of all moving
parts of the shoulder and dysfunction in
one joint may cause dysfunction and pain
in the others!
“He who treats the site
of pain is lost.
- Karel Lewit
7 Joints of the Shoulder Region
1.
2.
3.
4.
5.
6.
7.
Glenohumeral
Subdeltoid (false joint)
Acromioclavicluar
Scapulothoracic (false joint)
Sternoclavicular
Costosternal
Costovertebral
The 7 Joints of the Shoulder Region
Bony Anatomy Review
• Scapula
Bony Anatomy Review
• Humerus
Soft Tissue Review
Soft Tissue Review
9 Bursae of Shoulder Region
• Only 2 are clinically important:
1. Subacromial (subdeltoid) bursa
susceptible to impingement, esp. if
swollen or inflamed. Frequently
ruptures due to a calcium deposit.
2. Subscapular bursa
between anterior scapula and rib cage
• Note: Bursitis is rarely a primary condition !!!!
Muscle Review
1.
2.
3.
4.
5.
6.
7.
8.
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Levator Scapulae
Upper Trapezius
Serratus Anterior
Biceps brachii
assists abduction when arm is externally rotated.
9. Deltoid: impingement!
Rotator Cuff
Rotator Cuff
• Muscles do not attach
as discreet tendons but
blend to form a
continuous cuff
surrounding the glenoid
head.
• Provides dynamic
stabilization of the joint
due to blending into the
capsule.
• Tendons of rotator cuff
blend with joint capsule
Rotator Cuff
•
•
•
•
Supraspinatus…………Abduction
Infraspinatus…………..External rotation
Teres Minor……………External rotation
Subscapularis…………Internal rotation
Rotator Cuff: Supraspinatus
• Abduction
• Passes under
acromion process
• Most commonly
injured or torn
• “Suitcase muscle”
Hypovascularity of the
Supraspinatus
• Supraspinatus is
considerably
hypovascular with
respect to the other cuff
tendons: “critical zone”
• Tendonitis in this region
correlates to
hypovascualrity (that
progress with age)
Rotator Cuff - Infraspinatus
• External rotation
• Pulls humerus
downward with
abduction
• Eccentric contraction
Rotator Cuff – Teres Minor
• External rotation
• Pulls humerus
downward with
abduction
Rotator Cuff - Subscapularis
• Internal Rotation
• Adduction
• Stabilizes humerus
• Pulls humerus
downward w/ abduction
• Eccentric contraction
Glenohumeral Joint
• Designed for flexibility at the expense of
stability
• Static stabilizers – capsule and ligaments
• Dynamic stabilizers – rotator cuff muscles
Posture and the
Glenohumeral Joint
Glenohumeral Joint
Assuming good, normal posture:
• Gravity’s tendency to pull the humerus
downward is overcome by superior joint capsule
tightness. (vector: pulls humeral head inward for
stability)
• Little or no deltoid or rotator cuff muscular effort
is needed. (even w/ a small weight in the hand)
Glenohumeral Joint
• With thoracic kyphosis (round shoulders):
the rotator cuff must increase tone to
compensate for loss of capsular
stabilization. Round shoulders may even
be a cause of frozen shoulder!!!!
• Increased capsular stress leads to
increased collagen production and
increased fibrosis
Capsular Support
Capsule taut
Capsule loose
Glenohumeral Joint
• With the arm elevated or with round shoulder
posture:
• Tension is lost in sup. joint capsule
• The rotator cuff muscles contract to provide
stabilization. Over time, they fatigue!
• Conditions which compromise stabilization:
1. postural changes
- round shoulders = downward scapular
rotation
2. rotator cuff weakness/ dysfunction / trigger
points
Biomechanics of Abduction of the Humerus
Abduction of Humerus
● Scapula rotates upward (scapulohumeral
rhythm) from upper traps and serratus anterior
● Clavicle elevates & rotates backward
● Upper thoracic vertebrae must extend,
rotate and bend to same side. The
contribution of spinal movement to full
arm elevation is often overlooked!
Abduction
• There is the danger of the greater tubercle
hitting the acromion, subjecting the soft
tissue to repeated trauma!
• The head of the humerus must be guided
into inferior glide / depression to prevent
impingement during abduction (actively or
passively) AND it must externally rotate!
Biomechanics of Abduction
External rotation of
the humerus
occurs due to
untwisting of the
capsule
Tight internal rotators
my prevent this!
Impingement (pinching)
• Bones: acromion and
greater tubercle
• Soft tissue:
supraspinatus tendon
& subacromial bursa
Coracoacromial Ligament
Runs from coracoid process to the acromion.
Important for a/c joint stability
May be a source of impingement
Forms a protective arch over the glenohumeral area
together with the acromion and clavicle (functions as a
secondary restraining arch to prevent superior humeral
head dislocation
Can impinge the supraspinatus tendon and subdeltoid
bursa.
Coracoacromial Arch
• An additional site of
impingement
Altered Biomechanics
Impingement is prevented by proper biomechanics and
by the proper placement of the humerus during
abduction.
Causes of impingement therefore can be:
muscle imbalance, trauma, trigger points, weakness,
inhibition, pain, arthritis, capsular tightness, muscle
memory following injury
eg. scapula doesn’t rotate
bursa is swollen and the space is reduced
Shoulder forward shrugging causes impingement.
Scapulohumeral Rhythm
Deltoid Muscle
Muscular Force Couple
• During abduction the humerus must be
properly situated for full pain-free
movement.
• Force coupling occurs to create smooth
pain free movement
eg. trapezius and serratus anterior
rotator cuff muscles with deltoid
Abduction of Humerus
• Infraspinatus & Teres Minor
Force Coupling
The Painful Arc
• There is pain
during
abduction in the
range from 4560 to 120
degrees.
Assessment Tests
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•
•
•
•
•
•
Painful Arc
Hawkins’ Test / Speeds Test +++
Subacromial push button (Dawbarn’s)
Rotator cuff tendonitis assessment
A/C joint tests
Labrum disruption tests
Rotator cuff tears
Progression of Rotator Cuff Tears
Tight pectoral muscles 
Round shoulders 
Impingement 
Supraspinatus Tendonosis/
Tendonitis 
Calcific Tendonitis 
Rotator cuff tear !!
• Surgery may be preventable.
• The real heroes and competent level of
massage therapy deals with early
recognition and prevention.
Corrective exercises
•
•
•
•
•
•
Correct round shoulders/ergonomics
Restore mobility
Eliminate trigger points
Stretch tight muscles
Strengthen weak muscles
Rehabilitate supraspinatus with scaption.
glenoid cavity faces forward, laterally and
superiorly
Tendonitis / Tendonosis
Tendonitis / Tendonosis
• Causes
overuse
poor body mechanics
• Pathology
muscle cell damage (tearing, irritation)
microinflammation
fibroblasts
microscarring
Tendinosis / Tendonitis
• Not a true inflammatory condition
• Cell damage causes fibroblasts to
proliferate
• Creates a disorganized scar
(massage and movement)
• Leads to pain and further micro-tearing
Tendinitis / Tendinosis
• Accurate Assessment!
1. pinpoint pain
2. painful active (resisted) contraction
3. painful passive overstretching
Highly accurate!
Can be applied to any muscle for assessment.
Rotator Cuff Tendinosis
• Supraspinatus:
pinpoint pain at greater tubercle
painful active abduction
painful passive adduction stretch
Rotator Cuff Tendinosis
• Infraspinatus & Teres Minor:
pinpoint pain at greater tubercle
painful active external rotation
painful passive internal rotation stretch
Rotator Cuff Tendinosis
• Subscapularis:
pinpoint pain at lesser tubercle
painful active internal rotation
painful passive external rotation stretch
Treatment of Tendinosis
•
General Massage
•
Remove TrPs which maintain a shortened / tight muscle
• Transverse Friction massage
creates a mobile flexible scar
causes “good damage” to allow healing
• Strengthen muscle / tendon to tolerate more stress
• Full recovery = the patient can perform 3 sets of 10
strong repetitions
• Ice may be needed before and after Tx. to decrease pain