Rehabilitation of impingement injury stage 2
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Rotator cuff injuries are a common cause of shoulder pain in people of all age groups.
Often, a history of repetitive overhead activities involving the arms or a history of trauma preceding clinical onset of symptoms is present in younger individuals. However, older individuals may present with gradual onset of shoulder pain without a clear history of predisposing factors.
The shoulder complex is comprised of the sternoclavicular joint, acromioclavicular joint, glenohumeral joint, and scapulothoracic joint. These joints work together to permit normal shoulder motion.
The scapula, with its glenoid cup, interacts with the humeral head. This relationship is essential for normal shoulder biomechanics in everyday activities. The scapula glides along the chest wall as it goes through normal shoulder movements.
The shoulder is a ball-and-socket joint, although the glenoid fossa (cup) is flat. In addition, the surface area of the glenoid is much smaller than that of the humeral head (25-30%). The cartilaginous labrum increases the surface area of contact for the humeral head.
These components provide shoulder mobility with limited stability.
Static stabilizers include the bony structures, labrum, glenohumeral ligaments, and joint capsule. The limited contact area of the glenoid with the humeral head as well as its flattened architecture also provides little stability.
The rotator cuff is comprised of four muscles, as follows: the supraspinatus, infraspinatus, subscapularis, and teres minor. The supraspinatus is the principle supporting and movement muscle of the shoulder. The primary function of the rotator cuff muscles is to stabilize the glenohumeral joint so that the larger shoulder movers (eg, deltoid, latissimus dorsi) can carry out their function without significant motion of the humeral head in the glenoid. Increased movement of the humeral head results in “shearing” across the joint and leads to humeral head migration and impingement on the rotator cuff muscles and tendons.
The rotator cuff muscles assist with some shoulder motion; however, the main function is to provide stability to the joint by compressing the humeral head on the glenoid.
The supraspinatus provides shoulder abduction (moving the arm away from the body) by keeping the humeral head centered on the glenoid, with the middle deltoid acting as the primary mover. The infraspinatus and teres minor muscles help with external rotation of the shoulder and also provide an downward pulling of the humeral head, leading to its centering during overhead activity. The subscapularis muscle also helps with this centering but also acts with the pectoralis muscles and latissimus dorsi as an internal rotator of the shoulder.
Weakness of the rotator cuff muscles results in increasing loads on the stabilizers of the shoulder. This can result in stretching of the capsule, which results in shoulder laxity and increased demands on the already weak rotator cuff muscles. Humeral head migration may occur with capsule laxity and leads to rotator cuff impingement and pain.
Pain, weakness, and loss of shoulder motion are common symptoms reported with rotator cuff pathology. Pain is often felt over the anterolateral part of the shoulder and is aggravated by overhead activities. Night pain is a frequent symptom, especially when the patient lies on the affected shoulder.
Symptoms may be relatively acute, either following an injury or associated with a known repetitive overuse activity.
In elderly patients, symptoms often are insidious and with no specific injury. Repetitive motion can be associated with the symptoms.
Patients with rotator cuff tears tend to have a decrease in glenohumeral motion and an increase in scapulothoracic motion during active shoulder elevation.
Decreased active elevation with normal passive ROM is usually observed in rotator cuff tears as a result of pain and weakness. When both active and passive ROM are decreased similarly, this usually suggests onset of adhesive capsulitis.
The impingement syndrome associated with rotator cuff injuries tends to cause pain with elevation ranging from 60-120 degrees when the rotator cuff tendons are compressed against the anterior acromion and coracoacromial ligament.
Several primary causes of rotator cuff pathology have been described, including age-related degeneration, compromised microvascular supply, and outlet impingement. Secondary factors (eg, glenohumeral instability) also appear to be related to rotator cuff injuries.
Increased degenerative changes are observed in athletes and workers who perform overhead motions.
The rotator cuff is surrounded by the coracoacromial arch, which comprises the supraspinatus outlet and consists of the acromion, coracoacromial ligament, and coracoid process.
The shape of the acromion has been implicated in rotator cuff pathology. Different conformities of the acromion- whether it's flat or hook-shaped- may play a significant role in rotator cuff pathology.
The rotator cuff contacts the coracoacromial arch undersurface in the normal shoulder.
Rotator cuff abrasions and fiber failure occur when repeated and excessive compression from humeral head migration is present.
This occurs secondary to underlying muscular imbalance and loss of rotator cuff depressor effects.
Most people with ligamentous laxity are functionally stable. In patients with inherent shoulder or generalized laxity, instability may develop with minimal or no injury.
Stability may be lost if the shoulder becomes deconditioned. As a result, a vicious self-perpetuating cycle of instability, less use, more muscle weakness, and more instability is present.
These patients frequently have relative rotator cuff muscle weakness, particularly the external rotators and scapular stabilizers.
Subtle instability patterns may contribute to impingement development.
MRI is the imaging standard for diagnosing injuries to the rotator cuff.
Ultrasound may also be used to evaluate the rotator cuff. This test can be used to characterize the extent of the rotator cuff tear and visualize biceps tendon dislocation. It is less sensitive for detecting partial-thickness tears and ruptures of the biceps tendon.
Pain control and inflammation reduction are initially required to allow progression of healing and initiation of an active rehabilitation program. This can be accomplished with a combination of relative rest, icing (20 min, 3-4 times per day), and acetaminophen or an NSAID.
Corticosteroid injection can be considered.
For partial tears and for focal tendinopathy, the treatment of choice is ultrasound guided percutaneous needle tenotomy with platelet-rich plasma. The needle tenotomy can also be used to remove small bone spurs that are contributing to the impingement.
A physical therapy program is useful for attaining full pain-free range of motion.
When strength is restored, continue a maintenance program for fitness and prevention of reinjury.
Indications for operative treatment of rotator cuff disease include partial-thickness or full-thickness tears in an active individual who does not improve pain and/or function within 3-6 months with a supervised rehabilitation program. An acromioplasty is usually performed in the presence of a type II (curved) or type III (hooked) acromion with an associated rotator cuff tear.
NSAIDs are frequently used. Good clinical studies justifying routine NSAID use currently are not available.
When treatment is delayed in rotator cuff injuries and shoulder discomfort persists, the patient can develop stiffness of the glenohumeral joint, which is called adhesive capsulitis. The chance of developing adhesive capsulitis can be minimized through prompt diagnosis of painful problems in the shoulder, such as rotator cuff injuries, and the institution of early shoulder ROM as part of the rehabilitation program.
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