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Regional rheumatic pain syndromes Regional rheumatic pain syndromes Postižení měkkých tkání • Zánětlivé změny kloubních i mimokloubních struktur • Entesitidy – záněty úponů šlach nebo vazů do kostí • Bursitidy – rameno, loket, koleno • Tendinitidy – nejčastěji šlachy flexorů • Tendovaginitidy – zánět šlachy i šlachové pochvy • Kapsulitidy – zánět pouzdra – rameno Regional rheumatic pain syndromes • Inflammatory changes of joint ´s and extraarticular structures Localised: • Enthesopathy • Tendinitis • Bursitis • Carpal tunel syndrome • Rotator cuff injuries Regional rheumatic pain syndromes Systemic: Fibromyalgia Inflammation of Achille´s tendon and TC joint Carpal tunel syndrome • Result of oedema and inflammation of structures in carpal tunel – pressure to n. medianus • Pain: – Goes to I. – III. fingers,forarm, elbow and arm – Worsening during the night Periartritis humeroscapularis • Tendinitis and enthesopathy of rotator cuff • Bursitisda – of subdeltoid bursa – of subacromial bursa • Capsulitis of shoulder joint – Retraction of capsula- „Frozen shoulder “ The rotator cuff is made up of muscles and tendons. It holds the top of the upper arm into the shoulder joint (socket). The rotator cuff is made up of four muscles. The muscles include the supraspinatus, infraspinatus, teres minor, and subscapularis. The tendons attach the muscles to four shoulder bones: the shoulder blade (scapula), the upper arm bone (humerus), and the collarbone (clavicle.) The tendons are broad, measuring approximately 5 centimeters in width, and form a cuff encapsulating the articular surface of the top of the humerus. Anatomy Rotator Cuff Injuries Tendinitis: Tendons in your rotator cuff can become inflamed due to overuse or overload, especially in athletes who perform a lot of overhead activities. In some people, the space where the rotator cuff resides can be narrowed due to the shape of different shoulder bones, including the outside end of the collarbone or shoulder blade. Bursitis: The fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and inflamed. Strain or tear: Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear. Rotator Cuff Tear • A ripping of one or more of the tendons • Result when a sudden eccentric force applied to the rotator cuff resulting in failure of the tendon. • Uncommon under the age of 40 but strains do occur. • In the population over 40 years of age, supraspinatus tears occur and less commonly, infraspinatus tears. Tears in the subscapularis tendon are uncommon and are often the result of a shoulder dislocation. Rotator Cuff Injuries Causes • Repetitive stress: Repetitive overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers and tennis players. It's also common among people in the building trades, such as painters and carpenters • Impingement: Falls or incorrect throwing techniques or arm movements and weak shoulder muscles may cause the arm bone to move up and trap the tendon. This may also happen in persons who over-train or have a sudden change in arm or shoulder activity. Normal wear and tear: The rotator cuff tendons can degenerate due to ages (starting around the age of 40) . This can cause a breakdown of fibrous protein (collagen) in the cuff's tendons and muscles. • Calcium deposits: Calcium may deposit in the tendons due to decreased oxygen and poor blood supply. These deposits may cause irritation and inflammation Causes • Poor posture: When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones, including your collarbone, especially during overhead activities, such as throwing. • Falling: Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle. • Lifting or Pulling: Lifting an object that's too heavy, or doing so improperly (especially overhead) can strain or tear your tendons or muscles. Pulling something, such as an archery bow of too heavy poundage, may cause an injury. Common in sports such as: • • • • • • • Baseball Tennis Football Weight Lifting Skiing Swimming Racquetball Symptoms • Pain in the shoulder or arm , especially with arm movement (reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side. • Radiation of the pain to the upper, lateral arm • Pain at night • You may not be able to move your arm well, especially away from your body. • Your shoulder may feel weak, numb, or tingly. • Loss of shoulder range of motion • Inclination to keep your shoulder inactive • Lying or sleeping on the affected shoulder also can be painful Physical Examination The physical examiner must detect the torn muscle by isolating the muscles through manual testing. Perform following with patient seated: • • • • • • • External rotation - with elbow at right angles and held into side, turn the arm outwards as far as possible. Internal rotation - with elbow held into side, raise arm as far as possible up patient's back. Internal rotation with 90° forward flexion - support elbow and shoulder with elbow at right angles pointing vertically downwards and palm facing backwards, turn the forearm as far backwards as possible. Forward flexion - start with arm at patient's side and lift arm forwards and upwards as far as possible. Extension-with arm by the patient's side, lift the arm back wards as far as possible. Abduction-with arm at patient's side, lift arm away from the body as far as possible, continuing past the horizontal by allowing the shoulder to externally rotate, bringing the hand behind the head. Adduction-draw the arm across the anterior chest wall as far as possible. Diagnosis Diagnosis is usually made after a physical examination, often by a sports medicine physician. X rays are also sometimes used in diagnosis as well as an arthrogram. However, the arthrogram is an invasive procedure and may be painful afterwards. For this reason, magnetic resonance imaging (MRI) is preferred to determine tendon tears as it also shows greater detail than the arthrogram. Diagnosis Continued • Arthrogram: A test done by injecting dye into the shoulder joint and then taking x-rays. Areas where the dye leaks out indicate a tear in the tendons. • Magnetic Resonance Imaging (MRI) Scan: A special radiological test that uses magnetic waves to create pictures of an area, including bines, muscles, and tendons. • Ultrasound: An ultrasound is a test that looks inside your body. Sound waves are used to show pictures of your muscles and tissues on a TV-like screen Diagnosis Continued • Arthrogram: A test done by injecting dye into the shoulder joint and then taking x-rays. Areas where the dye leaks out indicate a tear in the tendons. • Magnetic Resonance Imaging (MRI) Scan: A special radiological test that uses magnetic waves to create pictures of an area, including bines, muscles, and tendons. • Ultrasound: An ultrasound is a test that looks inside your body. Sound waves are used to show pictures of your muscles and tissues on a TV-like screen Treatment Initial Care: Treatment will depend on your symptoms and the length of time you have them. Your caregiver may want you to limit activity on your affected shoulder to decrease stress on the tendon. This may help prevent further damage, decrease pain, and promote tendon heal. The primary treatment is resting the shoulder and, for minor tears and inflammation, applying ice packs. You may need to wear a sling to keep the shoulder from moving. Medicines: Anti-inflammatory medications may also be prescribed. As Rehabilitation Rehabilitation is crucial to restore the rotator cuff strength. The length of recovery depends of the severity of the tear. Rehabilitation can be divided into three phases: Phase I: Pain control: Use of non-steriodal antiflammatory agents, cryotherapy, protection of the injured tissue through the use of a sling or shoulder immobilizer. Exercises such as the pendulum can be performed. This is important for preservation of strength, which will speed recovery time. Phase II: 5 to 7 days after injury: In an overuse problem, this phase begins when pain diminishes. Range of motion is fully restored. Progressive resistive exercises are initiated to establish normal strength. Some examples of exercises are rotator cuff strengthening and strengthening of the scapular stabilizers. Restoration of strength and mobility of the shoulder is vital to allow for a successful return to sports.