Download 1 What is the Rotator Cuff Bony Anatomy

What is the Rotator Cuff
Understanding the Shoulder:
Injuries and Rehab Concepts
Presented by
Jennifer Hoffarth, MPT
•
•
•
•
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
• Biceps not technically part of the RTCbut often implicated and significant
cause of anterior shoulder pain
Bony Anatomy
Humeral head
Glenoid fossa
Sternoclavicular joint
Scapulothoracic joint-scapula lies
flush against thoracic spine/ribs
• Acromioclavicular joint
•
•
•
•
1
Glenohumeral Joint
• Where the largest range of motion
(ROM) is generated from
• Humeral head is large in
comparison to glenoid (ice cream
cone theory)
• Labrum helps stabilize the joint and
keep humeral head seated in joint
Acromioclavicular Joint
• Allows scapula to glide
forward/backward and rotate
• The AC joint is often a part of
shoulder pain
– Implicated with ROM over 80-90
degrees
Sternoclavicular Joint
• Where the sternum and clavicle join
• A small disc also is present at this
joint
• The clavicle needs to elevate and
spin posteriorly during normal
flexion/elevation of the arm
• Motion at this joint needs to be
assessed
2
Scapulothoracic Joint
• Scapula rides along the thoracic
spine
• Muscles in this area provide the
stability at this joint (trapezius,
rhomboids, serratus anterior,
levator, etc.)
• Weakness of these muscles
(proximal weakness) will effect
strength at shoulder on down
Subacromial Joint
• Provided by the acromialclavicular
joint and by the ligaments (superior
aspect of joint
• Inferiorly by the humeral head
• Normal subacromial space(714mm)
Cervical & Thoracic Spine
• Also need to assess these areas
• Posture of thoracic spine affects
position of the scapula and the
position of the humeral head
– Humeral head forward
– Posture needs to be addressed as part
of treatment- especially with the
exercises
• Thoracic extension is necessary for
full elevation of the shoulder as
well.
– Need to assess for this especially in
our older patients.
– Movement of thoracic spine all the
way to T6 necessary for normal
movement of shoulder
3
What Other Muscles Impact the
RTC/Shoulder
•
•
•
•
•
•
•
•
Deltoid
Pec major and minor
Latisimuss dorsi
Trapezius
Rhomboid major and minor
Serratus anterior
Levator
Teres major
Other Areas of Concern
• The capsule-helps stabilize the
humeral head
• Bursa of the shoulder
• The labrum
Our job is to figure out what is
exactly causing the problem!
4
Three Phases of Shoulder
Elevation
• Phase I—0-60 degrees- increases
supraspinatus activity- which
compresses humeral head and the
subscapularis works to depress the
humeral head
• Phase II—(motion 60-140 degrees)
considered the critical phase-need
full ER for this portion
– Scapula begins to rotate
– Important to have scapular
stabilization during this phase
Scapulohumeral Rhythm
• Phase III—( motion from 140-180
degrees) the soft tissue impacts
this portion of motion
– Will see if they have “tight” shoulder
will “move as one”, usually extends
through the thoracic spine to make up
for this tightness
2:1 motion
120 degrees comes from humeral
head
60 degrees at the scapula
5
What Affects Scapulohumeral
Rhythm
• Soft tissue flexibility
• Poor posture
• Proximal or distal muscle weakness
• It is not just the movement of the
shoulder it is the quality of the
movement. It is important to watch
them actively elevate or abduct the
arm. Look at scapular position with
the arms in various positions. Look
for winging of the scapula during
these movements.
Why Does the Shoulder Hurt
• The shoulder is the most
“moveable” joint in the body.
• It is this flexibility/motion that sets
the shoulder up for significant
problems.
• When do we not use our arms?
• Poor blood supply to tissues of the
shoulder.
• Sleeping position often is
aggravating to the pain
• Our activities throughout our
lifetime often catch up with us later
in life.
• Time spent performing static
activities, such as computer work.
6
Examination of the Shoulder
• Subjective
–
–
–
–
What activities cause the pain
Where does it hurt
When did it start (from injury or over time)
When does it hurt
•
•
•
•
Rest
With activity
Time of day
Does it effect your sleep
• How does it hurt
– Diffuse
– Sharp
– Popping
– Burning pain
– Catching sensation
Objective Assessment
• Does the patient have a previous
history of injury to this shoulder.
• Occupation—what does the patient
do for a living or what activities
does he/she do at home or what
sports/leisure activities
• Pain level—at rest and with activity
• Any neck pain along with the
shoulder pain?
• AROM-quality and quantity
– At what point in motion do they start
to experience pain
• PROM• Strength Assessment
• Scapulohumeral Rhythm
– Position of scapula ( 3 positions)
• Palpation
7
– Posture--is there anterior translation
of the humeral head?
– Swelling
• Observation
– Do they hold the arm at the side
– Do they cradle the arm
– Do they use it to take there shirt off
– Do they have a hard time reaching
behind their back
– Muscular atrophy
– Bony anatomy
Palpation
• Peripheral Joint Scan—assess
briefly the cervical and thoracic
spine
– Pain in shoulder referred to C4 and C5
dermatomes
• C4-look closely at SC/AC joints
• C5-common to have pain throughout this
dermatome with shoulder pain the more
the severe pain may radiate further into
the C5 dermatome
•
•
•
•
AC joint
SC joint
Spine of the Scapula
Greater/Lesser tubercle
– Lesser tubercle with ER
– Greater tubercle with IR
– Coracoid process
8
• Subscapularis Tendon
– Arm resting at side, slide lateral off
the coracoid and before the bicipital
groove—close relation to the biceps
tendon
• Supraspinatus Tendon
– noted in slight extension, max IR and
slight abduction
• Infraspinatus Tendon
– Shoulder flexion to 80 degrees
– Slight adduction and ER
– Identify spine of scapula and resist ER
to know that you are there
Special Tests
• Distraction/Pull Test
– Resisted abduction with arm at side, if
painful-• Repeated with distraction force
• If worse with distraction-tendonitis
• If better with distraction-bursitis
Belly Press Test
• Hand against lower abdomen
– Have patient hold hand to this area as
you try to pull them away
– If painful implicates the superior fibers
the subscapularis
9
Lift Off Sign
• Have patient hold there hand
against the small of their back or at
the sacrum, have them lift just
slightly away
– If positive implicates the inferior fibers
of the subscapularis
• Speeds Test
• O’Briens Test
– Positive if pain greater in IR than with ER
and resistance
– Deep pain indicates SLAP lesion, superior
pain indicates AC joint pathology
• Yergasons
– Indicates bicipital tendonitis or tear of
transverse ligament
• AC Shear
– Indicates involvement of the AC joint, either
arthritic changes or ligament involvement
• Hawkins Kennedy
– Impingement of supraspinatus
• Neer Impingement
– Impingement of supraspintus or LHB
• Coracoid Impingement
– Indicates LHB or subscapularis with medial pain,
lateral pain indicates supraspinatus
• Sulcus at 0 degrees/90 degrees
– Laxity at 0 degrees indicates superior
glenohumeral ligament
Laxity at 90 degrees indicates inferior
glenohumeral complex
• Crossover Impingement
–
–
–
–
Anterior pain—subscapularis or LHB
Lateral pain supraspinatus
Superior pain AC joint
Posterior pain infraspinatus, post. capsule, teres
10
Resistive Tests
(learned from IAOM)
• ERLS
– Have patient hold position as you first
let go at wrist then at the elbow
• Part one indicates the infraspinatus
• Part two indicates the supraspinatus
• Positive sign is when there is a drop
greater than 5 degrees,
• Pain with resisted abduction/ER
– supraspinatus
• Pain with resisted ER only
– Infraspinatus
• Pain with resisted IR only
– Subscapularis
• Pain with resisted Add/ER
– Teres minor
• Pain with resisted Add/IR
– Lat, pec major, teres major
Diagonoses We See
• Impingement
– Acromion types I, II and III
– GHJ instability
– Scapulothoracic instability/weakness
– Shortening of posterior capsule-slides
humeral head forward, painful
anterior structures
• Bursitis
– Bursa is densely innervated compared
to the other structures
– Bursa can be compartmentalized—
therefore injections not always helpful
11
• RTC tears
– Can be traumatic or occur over times
• Small tears vs. large tears
• Tendonitis
• Selective hypomobilities-restrictions
in only one or two directions
• Ligamentous Instability
– Can lead to nerve damage
• Frozen Shoulders/Adhesive Capsulitis
– Limitation of ER greater than abduction and
IR
– Idiopathic usually, typically between 40 and
60 years old, 70% female
– More often dominant arm
– Not uncommon to one shoulder and later the
other
– Can take up to 2 years to improve
– Freezing, frozen and thawing stages
– Can lead to bony lesions
– Bankart lesions
– Muscle tears
– The laxity can lead to impingement as
well
• Long thoracic—serratus
• Suprascapular nerve (supra and
infraspinatus)
12
• Tendonitis
– Any of the tendons can become
inflamed following injury or unknown
cause
• It is important to differentiate what
is causing the pain to allow you to
guide your treatment plan. Usually
it is more than one structure that is
causing the pain. Good assessment
will help you better guide your
treatment and rehab plans.
Treatment Options
• Modalities
– US
– phonophoresis
– Iontophoresis
– CP
– Estim
– Use of therapuetic pool
•
•
•
•
•
•
•
Passive stretching
AAROM/AROM
Manual techniques to gain ROM
Joint mobilization
STM
Cross Friction massage
Self stretching
13
Cross Friction/Self stretch
Techniques
• Supraspinatus
– Transverse friction-arm held slightly
behind the back
– Self stretch—arm flexed to slightly
above/below 90 degrees
• Subscapularis
– Transverse Friction-supine head of
bed or head elevated- inferior to
superior
– Self stretch
• At doorway
• With broomstick, arm abducted to 90
degrees, maximal ER with assistance of
broomstick or dowel
• Infraspinatus
– Transverse Friction-on stomach,
propped on elbows, one thumb on top
of each other, inferior to superior
– Self stretch-as noted for
supraspinatus-just need to vary
position slightly
• Biceps
– Transverse friction-similar to
subscapularis position—make sure
thumb is in bicipital groove, passive
slight ER, release and repeat
– Self stretch—standing-shoulder
extension, full pronation, elbow
extension-
14
Exercises
• Shoulder IR, ER, adduction and
extension
• Prone over ball or on bed: extension,
horizontal abduction, rows, active
scaption if tolerated,
• Corner “pushout”
• Seated chair pushups
• Scaption/empty can if done with good
form
Thank You!!
15