Common Shoulder Pathologies Tendonitis

Question 1

Tendonitis is

Answer 1

This is an overuse injury that causes inflammation to the tendons involved in repetitive movements.

Question 2

Tendonitis 3 main indications;

Answer 2

℗ on Length ℗ on Strength ℗ on Palp

Question 3

Tendonitis Etiology:

Answer 3

Tendonitis in the shoulder commonly occurs with the tendons of the rotator cuff muscles and biceps brachii. These tendons are prone to tendonitis with sports that require repetitive upper limb movement and maximal muscle contraction – swimming, any throwing sport, volleyball, golf, tennis, etc. These tendons also become inflamed with occupations that require repetitive movements (RSI) – dry walling, painters, etc.

Question 4

Tendonitis Sand S

Answer 4

• Sleep disturbance if guest sleeps on affected side
• Soft tissue swelling, atrophy, redness, etc.
• Pain with palpation of the tendon(s)

Question 5

The presentation of pain may vary depending on the grade of Tendonitis

Answer 5

Grade 1 = ℗ only after activity.
Grade 2 = ℗ at the beginning of activity and after. Alleviates during activity.
Grade 3 = ℗ at the beginning, during and after activity. Pain may restrict activity.
Grade 4 = ℗ w/ ADLs and continues to get worse.

Question 6

Tendonitis
Supraspinatus (p.303 - Management of Common MSK Disorders –Kessler, Randolph)

Answer 6

• Dynamic ligament and is therefore being constantly challenged to maintain stability and congruency of the joint
• Repetitive movements and strain through:
  i. ) Sports or other activities (abduction and flexion)
  ii. ) Postural changes (kyphosis) causing the RC to undergo fatigue stress from constant use
• Poor vascularity to the rotator cuff especially the supraspinatus and infraspinatus muscles. Hypovascularity > poor nutrition & repair > degenerative changes> inflammation > scar tissue > calcification > tear
• Age, overuse, abuse
• may lead to Impingement Syndrome, bursitis, or adhesive capsulitis

Question 7

Tendonitis

Supraspinatus CI and precautions

Answer 7

• Calcific tendonitis to the supraspinatus tendon
• Anti-inflammatory medications
  *Note: Calcific tendonitis – this occurs in the later stages of rotator cuff tendonitis (esp. in the supraspinatus tendon).
  • Fibroblasts change to chondrocytes and calcified deposits fill up the intercellular spaces of tendons causing an increase in size.
  • As the tendon grows bigger, this may lead to impingement under the acromial arch.
  • This condition is now thought to be a self-healing mechanism.
  • The deposits are eventually reabsorbed.
  • During this time there is increased circulation, inflammation, swelling and pain; may lead to complications like tendon rupture.
  • Bursitis may commence if the calcium deposits rupture into the bursa.
  • Calcific tendonitis is confirmed with an x-ray.

Question 8

Tendonitis
Supraspinatus
Referral pain

Answer 8

-lat brachial region (supraspinatus)

Question 9

Tendonitis
Supraspinatus
Special Tests

Answer 9

Supraspinatus
AROM ↓ ABD, ℗ arc
PROM ↓ ABD/ADD, ℗ arc
RROM ↓ ABD/ possible wknss

1. ℗ainful Arc w ABD AROM – present; ABD = supraspin
2. Drop Arm Test (+) supraspinatus
3. Empty Can Test (aka Supraspinatus strength test) (+) supraspinatus

Question 10

Empty Can Test (aka Supraspinatus strength test) (+) supraspinatus

Answer 10

What does this test for? Supraspinatus Tendonitis, strain, or weakness

What is the position and procedure?
PT: seated. Arm abducted to 90, horiz adduct to 30, full Int Rot
Ther: RROM into adduction, via pressure at the wrist.

What is a positive test/sign?
Positive: Pain along supraspinatus or weakness

Question 11

Drop Arm Test (+) supraspinatus

Answer 11

What does this test for? Rotator Cuff Tear, esp. Supraspinatus

What is the position and procedure?
Ther: PROM Abduct PTs arm to 90.
Pt: slowly adducts arm to starting point

What is a positive test/sign?
Positive: Unable to move arm smoothly & slowly d/t pain

Differential diagnosis tool:
MMT SITS group

Question 12

Tendonitis
Bicipital (p.309 - Mgmt of Common MSK Disorders –Kessler, Randolph)

Answer 12

• The biceps acts as a humeral stabilizer and elbow decelerator; repetitive movements and strain to the tendon may be seen in some sports &/or certain occupations and activities
• Compression of the biceps tendon in the groove
• Tenosynovitis may develop (inflammation of the fluid-filled sheath (synovium) surrounding tendon
• Inflammation may attach tendon to groove decreasing the gliding motion
• Continual cortisone injections may cause weakening of the tendon therefore if repetitive movements continue a rupture of the biceps long head may occur (usually proximal to distal)
• If the transverse humeral ligament is torn or if the bicipital groove is compromised – subluxation of tendon out of groove

Question 13

Tendonitis
Bicipital
Precautions and contraindications:

Answer 13

• Tenosynovitis of the bicipital tendon

- Anti-inflammatory medications

Question 14

Tendonitis
Bicipital
Referral pain

Answer 14

-ant brachial region to the insertion of the biceps (bicipital, never supraspinatus)

Question 15

Special Tests Biceps Tendonitis

Answer 15

AROM           ↓ FLX, EXT
PROM           ↓ EXT
RROM           ↓ FLX/EXT possible wknss
1. Yergason’s Test (+) biceps
2. Speed’s Test (+) biceps

Question 16

Yergason’s Test (+) biceps

Answer 16

What does this test for? Stability of biceps tendon in bicipital groove

What is the position and procedure? PT: Elbow flexed to 90, forearm pronated. Ther. stabilizes elbow against thorax & applies resistance while PT. actively supinates, extends elbow & ext rots humerus

What is a positive test/sign? Positive: Pain & sensation of tendon popping out of bicipital groove, due to loss of integrity of transverse humeral ligament

Differential diagnosis :
If pain presents at biceps T, cont’ to Speed’s Test

Question 17

Speed’s Test (+) biceps

Answer 17

What does this test for? Bicipital Tendonitis

What is the position and procedure? PT: elbow extended, forearm supinated & shoulder flexed to 90 deg.
Ther: RROM to shoulder FLX via pressure at wrist.

What is a positive test/sign? Positive: Pain in bicipital groove

Question 18

Tendonitis Treatment planning

Acute = Or flare up

Answer 18

o Rest and ice (if RSI ice on breaks) 5min- CBAN (use barrier to remove burn. Ice drip can irritate free nerve endings)
o Massage and other manual techniques to help: with inflammation, reduce hypertonicity in affected muscles, maintain available PF ROM, manage and decrease pain, decrease problems in compensatory areas, decrease muscle atrophy

Question 19

Tendonitis Treatment planning Subacute =

Answer 19

o Heat to make tissues pliable
o Friction therapy to break adhesion formation creating mobility (late subacute) – reasoning for this is that there will not likely be spontaneous resolution poor blood flow and continued stress to the tendon leads to poor maturation continual tearing of the scar tissue.
o RROM, stretch &/or fascial line tensions to realign fibres (“)
o Create functional scarring(“)
o Massage techniques to help increase circulation to the shoulder
o Ice post treatment to manage inflammation and pain

Question 20

Tendonitis Treatment planning Chronic =

Answer 20

o Fascial techniques to treat restrictions
o Continue friction therapy if needed
o Joint mobes to mobilize hypomobile joints (Inf glides for ABD)
o Stretch to maintain new length of functional scar
o RROM to help realign fibres and return strength
o Contrast hydrotherapy application to help circulation and decrease edema in the shoulder

Question 21

Cross Fiber Frictions

•Tendons without a sheath

Answer 21

• Painful scar in the tendon body or at the periosteal insertion
• Frictions applied directly over the site of the lesion
• Minimal tensile tension in tendons

Question 22

Cross Fiber Frictions

Tenosynovitis (with a sheath)

Answer 22

• Roughening of the gliding surfaces of both the tendons and the sheath gives rise to pain and sometimes crepitus suggesting roughening if the gliding surfaces
• Tendon and its sheath must be put under tension (maximum LONGITUDINAL stretch) during massage so that the tendon forms an immobile base against the tendon

Question 23

Cross Fiber Frictions

Technique

Answer 23

• Reinforced finger or thumb -No lubricant is used
• Preparatory techniques such as lymphatic drainage, effleurage, petrissage and fascial or connective tissue techniques are used to prepare the tissue beforehand
• Stroking is directed perpendicular (Minute circular movements may also be used) to the tissue fiber orientation of the structure being evaluated or treated
• Superficial tissues are moved over the underlying structures by keeping the hand or fingers in firm contact with the skin
• Begins with the initial gentle transverse movements that gradually bear more deeply and continue for 5-15 minutes , Generally – 90 sec gentle; 90 sec moderate; 90 sec deep
• Rate is about 2-3 cycles per second
• Initial dose of 2-3 minutes is adequate to assess the response to treatment – analgesic effects can be achieved from this brief application
• Continue within client’s pain tolerance; after 1-2 min the analgesic effect should occur and wil be less tender – if not then discontinue. Therapist gradually increases pressure to the client’s
new tolerance
• After frictions repetitive effleurage to increase local circulation
• Application of ice after frictions
• Followed by active movement in minor muscular tears; by passive movement in ligamentous tears; and by avoidance of painful activity in tendinous lesions

Question 24

Cross Fiber Frictions

Contraindications

Answer 24

• 21 Days after cortical steroid injections
• Bacterial and rheumatoid-type tendinitis, tenosynovitis, and tenovaginitis
• Calcification and ossification of soft tissues
• Disorders of nerve structures (i.e. carpal tunnel syndrome)
• Skin problems
• Hematoma
• Acute bursitis

Question 25

tendinitis REMEX and homecare:

Answer 25

o Educate guest of noxious activities or factors o Stretch shortened muscles ( if supra probably wkness so no stretch) o Strengthen weak muscles

Question 26

tendinitis REMEX example;

Answer 26

Grade 1-2 self distraction (ADHESIVE CAP, AC SEP, IMPING) – sitting with the backrest of a chair in the axilla (padded). Let arm drop and provide slight distraction (use a weight if needed)