New Treatment of Rotator Cuff Injury

The Ultimate Rotator Cuff Training Guide

The Ultimate Rotator Cuff Training Guide is the most comprehensive manual available on the market today with A to Z information on injury, anatomy, clinically proven exercises, and step-by-step training techniques to alleviate & prevent these all too common shoulder injuries! It is packed full of over 40 descriptions and pictures of detailed exercises. Reveals 12 proven exercises you should be doing for your rotator cuff. Includes tips on how to avoid injury associated with risky traditional lifting exercises. Discover how poor posture and your own anatomy may lead to injury. Reduce the chances that rotator cuff tendonitis will sideline you or your clients. Immediate access to a proven 6 week rotator cuff training program for inflamed shoulders. Straightforward training outline for people with healthy shoulders. Finally learn how to end pain related to rotator cuff tendonitis/bursitis. Avoid surgery with a proven blueprint for fixing your shoulder injuries Read more here...

The Ultimate Rotator Cuff Training Guide Summary

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Rotator cuff muscles Fig 665

Four muscles comprise the rotator cuff the supraspinatus, subscapularis, infraspinatus and teres minor. The supraspinatus has its origin on the posterior superior scapula, superior to the scapular spine. It passes under the acromion, through the supraspinatus fossa, and inserts on the greater tuberosity. The supraspinatus is active during the entire range of scapular plane abduction, and a suprascapular nerve block results in a loss of abduction torque of approximately 50 39,40 . The supraspinatus muscle can abduct the joint without the action of the deltoid. Fig. 6.6.5 Rotator cuff muscles viewed from the side with the anterior aspect to the right. The humeral head has been removed. Fig. 6.6.5 Rotator cuff muscles viewed from the side with the anterior aspect to the right. The humeral head has been removed. The subscapularis muscle arises from the anterior scapula and is the only muscle to insert on the lesser tuberosity. It is the sole component of the anterior rotator cuff and...

Rotator cuff tendinitis

Rotator cuff tendinitis is one of the most common injuries at all activity levels in sports with repetitive overhead motions 168 . The classical signs and symptoms of this pathology include crepitus and point tender pain at the anterior and lateral aspects of the shoulder with overhead motion and are relieved with the arm at the side. Two separate etiologies exist for these symptoms. Symptoms in athletes under 35 years of age are usually due to subclinical or mildly overt instability of the glenohumeral joint due to anteroinferior or anterosu-perior capsular and labral deficiencies 169 . These rotator cuff injuries have been termed 'secondary tensile overload injuries' since muscular weakness and imbalance lead to capsular and labral deficiencies 170,171 . Treatment should therefore begin with evaluation of flexibility and strength deficits and proceed to evaluation of the directional instability and include tests for competence of all rotator cuff muscles. Conservative treatment...

Rotator cuff lesions and tendon trauma Rotator cuff lesions

Partial Rotator Cuff Tear Symptoms

The rotator cuff muscles and their respective tendinous insertions to the humerus are considered the primary dynamic stabilizers of the glenohumeral joint and are extensively loaded during overhead and contact sports 117 . The rotator cuff of well-conditioned athletes stabilizes the joint successfully without injury. However, where the demands placed on the rotator cuff are increased beyond its capabilities, injury may result. These injuries can progress from inflammation to microtears to partial and full-thickness tears. Improper throwing mechanics, muscle fatigue and glenohumeral instability increase the loads on the rotator cuff and can result in a cycle of degeneration that causes mechanical impingement, collagen tensile failure, and further rotator cuff dysfunction 118,119 . Athletes involved in overhead sports commonly experience injury to the rotator cuff through repetitive microtrauma, while the mechanism of injury in those participating in contact sports includes blunt force...

Radiological considerations

The rounded humeral head articulates with a rather flat glenoid to maximize the possible range of movement at the joint. The stability of the joint is maintained by the cartilage of the glenoid labrum, ligaments, and the tendons of the rotator cuff. The rotator cuff is Ultrasound in experienced hands is a valuable tool for assessment of the shoulder, especially for rotator cuff tears. It may be more sensitive than plain radiography for some calcifications. It is often easier to obtain than magnetic resonance imaging (MRI), although it cannot image the glenohumeral joint. MRI can show all the joint structures, including the rotator cuff, and will be required if there is concern regarding areas not seen well on ultrasound, if ultrasound is equivocal, or if ultrasound expertise is not available. For recurrent dislocations, accurate imaging of the bony gle-noid and labrum, the capsule and glenohumeral ligaments, as well as the rotator cuff is needed. Cross-sectional imaging (MRI or CT)...

Sumant G Krishnan John M Tokish and Richard J Hawkins

Impingement Rotator cuff Instability Physical examination of the injured shoulder for some has unfortunately become somewhat of a lost art because of the difficulty of the examination itself, the subtleties of the normal athletic shoulder that often make comparison to the opposite side unreliable, and the ever-increasing reliance on magnetic resonance imaging (MRI) for definitive diagnosis. As helpful a tool as the MRI is, it is of concern that completely asymptomatic shoulders demonstrate pathology that might be erroneously attributed to an athlete with symptoms. Sher et al1 demonstrated a 34 rate of tears of the rotator cuff in painless volunteers. Miniaci et al2 showed that 79 of asymptomatic professional baseball pitch ers had abnormalities of the glenoid labrum. Furthermore, partial-thickness rotator cuff tears, a diagnosis common to the throwing and overhead shoulder, may be missed by MRI as much as 44 of the time.3 Hence, even with the technologic advances available, we remain...

Assessmentinterpretation

Subacromial bursitis (subdeltoid bursitis) can be exacerbated by a direct blow over the shoulder, which compresses the acromion process into the rotator cuff or into the humeral head. Overuse of the shoulder joint in an abducted and internally rotated position (i.e., in the front crawl stroke in swimming) could inflame the bursa.

Results And Outcomes

Shoulder pain in the throwing athlete was at one time attributed to subacromial impingement, even though we now know that this is a rare entity in the young population. Tibone et al35 were the first to report the lack of success treating throwers with chronic overuse disorders by acromioplasty. Only 43 of the patients (including just 4 of 14 pitchers) returned to their preoperative level of competition following surgery. Acromio-plasty alone was used with unflattering results by Kvitne et al.4 Andrews et al36 treated athletes with debridement of both rotator cuff and labral pathology, resulting in a 76 return to same level sport. Payne et al22 reported on debridement of partial-thickness rotator cuff tears, noting decreased return to competition when instability was present in addition to a tear. The patients with a history of an insidious onset of symptoms were much less likely to return to their preinjury sports level (45 ), and this probably represents the patients with true...

Clinical Features And Evaluation

Rotator cuff disease presentation varies depending on the cause and classification of the cuff pathology. Cuff pathology ranges from traumatic rotator cuff tears, articular side partial thickness tears associated with internal impingement in a thrower or overhead athlete, or a classic impingement process with an insidious onset resulting from repetitive overhead activities, each with vastly different presentations. The presentation of a patient with a traumatic tear will relate the onset of symptoms to a specific traumatic event, and often the high-energy nature of the mechanism causes other injuries to the shoulder or other parts of the body. Often this is the result of abrupt force on the arm, as when trying to support oneself during a fall. An overhead athlete or thrower with articular side rotator cuff tendon pathology will describe a gradual onset of weakness and pain associated with throwing, often at the beginning of a season or as a result of a more strenuous training regimen....

Weakness Associated Shoulder Pain

Pain in the upper extremity often limits therapy and function and interferes with sleep, so it requires immediate attention. Indiscriminate traction on a paretic arm and shoulder during bed mobilization and transfers can start the pain. In the shoulder, some level of pain has been noted in up to 75 of patients by approximately 2 months after a hemispheric stroke. Subluxation of 1 or more cm, found in 50 -85 of hemiplegic patients, may contribute, though studies have not always shown this relationship. Glenohumeral subluxation is lessened by a variety of slings, but these do not necessarily prevent shoulder pain.121 Sources of pain include biceps tendonitis, capsulitis, rotator cuff impingement or tear, myofascial pain, brachial plexopathy, suprascapsular neuropathy, heterotopic osssification, osteoporosis and fractures, contractures, flaccidity or spasticity, overuse, degenerative joint disease, and RSD. Most patients have inflammation of the rotator cuff tendons and subacromial...

Glenohumeral Joint Big Picture

The glenohumeral joint allows for a considerable amount of range of motion more than any other joint in the body. The glenohumeral joint is a ball-and-socket synovial joint that produces a great deal of freedom, including flexion and extension, abduction and adduction, and medial and lateral rotation of the humerus. Because of the large range of motion in the gleno-humeral joint it must depend upon ligaments and muscles for structural support. To minimize friction, bursae (synovial sacs) are positioned between the rotator cuff muscles and the joint capsule.

Muscles Of The Posterior Compartment Of The

V Biceps tendinopathy is a condition that results most frequently in painful sensations in the anterior region of the shoulder. The long head of the biceps is often irritated by overhead motions and excessive or repetitive lifting, resulting in inflammation of the tendon and the peripheral structures. The pain is most frequently described as occurring between the greater and lesser tubercles of the humerus in the intertubercular groove, where the long head travels. The condition is exacerbated by the actions of the biceps (e.g., shoulder flexion, elbow flexion, and supination) and is frequently confused with pathologies of the rotator cuff.

Proprioception and joint kinematics

Rotator cuff and biceps muscles are required for normal shoulder function. According to Gowan and his associates 52 , two groups of muscles control the shoulder during the pitching motion in professional baseball pitchers. The first group of muscles demonstrates increased electromyographic activity during the early and late cocking phase and decreased activity during the acceleration phase. This group of muscles positions the arm for the delivery of the pitch. The second group of muscles demonstrates increased elec-tromyographic activity during the acceleration phase of the pitch. Using the same measurement technique, Glousman and coworkers 45 showed changes in the electromyographic pattern in baseball pitchers with chronic anterior instability of the glenohumeral joint. Alteration of the normal neuromuscular balance in patients with anterior instability can cause changes in joint kinematics that can lead to repetitive microtrauma of the glenohumeral joint.

Biceps tendon ruptures

Treatment of isolated ruptures of the biceps tendon has been separated into two groups based on age. In young and active patients that are particularly involved in overhead sport, weight-lifting or jobs requiring forceful supination, a sudden overload of this tendon may result in an isolated rupture. Physical examination and ultrasonography of the biceps can isolate the rupture site while MRI should be used to examine the status of the rotator cuff. An early repair is recommended 133 for patients with high functional expectations. Combined biceps tendon and rotator cuff tears. Patients over the age of 50 and physically inactive usually have a prior history of shoulder problems and treatment. Ruptures in this group usually occur within the bicipi-tal groove and are caused by attrition. In addition, they will have signs of rotator cuff tears or impingement. Therefore, simple observation for 4 weeks may be the treatment of choice resulting in the immediate pain resolving, almost normal...

Other common problems

To traumatization of various structures and inferior subluxation can lead to injuries, including tendons, capsule or peripheral nerves and plexus. It is important to keep the shoulder correctly positioned to prevent subluxation by orthotic management. Hemi-plegic shoulder pain in stroke may be due to adhesive capsulitis (50 ), shoulder subluxation (44 ), rotator cuff tears (22 ), and shoulder-hand syndrome (16 ) 121 . The etiology of shoulder-hand syndrome with pain of the shoulder or arm and edema of the hand and arm is controversial many authors consider it a form of reflex sympathetic dystrophy complex regional pain syndrome, probably initiated by mechanisms mentioned above. Management includes positioning, orthotic management, physical therapy including steps for reduction of edema, and analgetics. In more severe cases intermediate dosage treatment with oral prednisone is effective 122 .

Tests for Weakness Jobes Test

Full Can Test

These are three signs that have been shown to be reliable and efficient alternatives to more traditional rotator cuff testing.14 The external rotation lag sign is performed by placing a patient in 20 degrees of elevation, 90 degrees of elbow flexion and near maximal external rotation. A patient who cannot maintain this position (even with a 5-degree lag) has a positive test suggesting a supraspinatus or infraspinatus tear.14 The drop sign (or hornblower's sign) is evaluated much the same way, except that This test, described by Codman,5,15 attempts to palpate a rent through the deltoid in a patient with a supraspinatus tear. Palpation is accomplished in a relaxed patient at Codman's point, just anterior to the anterolateral border of the acromion with the dorsum of the hand on the buttock. Wolf et al16 have reported on the diagnostic accuracy of this test, noting a sensitivity of 95.7 , a specificity of 96.8 , and a diagnostic accuracy of 96.3 for a rotator cuff tear. It should be...

Bilateral Stance On Unstable Surface

Single Leg Stance Foam

In the upper extremity, it is common to see patients who present with tightness in the anterior structures, such as the pec-toralis musculature, and consequently exhibiting a protracted, forward head posture. This can lead to several shoulder pathologies, such as impingement due to the protracted and anteriorly tilted scapular position.43 Furthermore, the authors believe that loss of internal rotation (IR) in most throwers is due to posterior rotator cuff tightness and osseous Figure 11-9 Rhythmic stabilization to promote cocontraction of the rotator cuff. Figure 11-9 Rhythmic stabilization to promote cocontraction of the rotator cuff. Dynamic stabilization exercises for the upper extremity also begin with baseline proprioception and kinesthesia drills to maximize the athlete's awareness of joint position and movement in space. In addition to joint repositioning and closed kinetic chain drills, rhythmic stabilizations are incorporated to facilitate cocontraction of the rotator cuff...

Ruptur Thympanic Membran Cruris

Vibratori Coppia Gif

The movements of the shoulder occur at the glenohumeral, thoracoscapular, acromioclavicular, and sternoclavicular joints. The glenohumeral joint is a ball-and-socket joint. In contrast to the hip joint, which is also a ball-and-socket joint, in the glenohumeral joint the humerus sits in the very shallow glenoid socket. Therefore, the function of the joint depends on the muscles surrounding the socket for stability. These muscles and their tendons form the rotator cuff of the shoulder. For this reason, many shoulder problems are muscular, not bone or joint related, in origin. Special tests are necessary to determine specific diagnoses. The impingement syndrome, tears of the rotator cuff, and bicipital tendinitis are common. The examinations for these conditions are described in this section. The impingement syndrome, also known as rotator cuff tendinitis, is usually secondary to sports trauma. Irritation of the avascular portion of the supraspinatus tendon progresses to an inflammatory...

Joseph Yu and William E Garrett Jr

Calf Muscle Tear Ultrasound

Ruptures of the medial head of the gastrocnemius muscle have been documented in patients ranging from adolescents to the elderly. The incidence is greatest in the middle-aged, as reported by Millar,3 who reported a mean age of 42 years for men and 46 for women, which suggests a degenerative process analogous to a rupture of the long head of the biceps, the rotator cuff of the shoulder, the Achilles tendon, or the attachment of the rectus femoris.4 Ruptures to the medial head of the gastrocnemius are nearly nonexistent in young tennis players with the same stresses.5 This injury seems to be most common in men.

Surgical Technique Biceps Tenodesis

Is debrided with a motorized shaver back to a stable rim on the superior labrum (Fig. 24-7). The arthroscope is then removed from the posterior portal and directed into the subacromial space through the same skin incision. A lateral acromial working portal is localized first with a spinal needle and then established under direct visualization. The subacromial space is evaluated, and, if needed, a decompression or rotator cuff repair can be performed. Care must be taken to avoid cutting the previously placed sutures transfixing the biceps tendon. The biceps sutures

Patellar Instability Or Maltracking

Femoral Neck Stress Response

SYMPTOMS Gradual onset of diffuse exercise-induced pain or ache around the proximal part of the patellar tendon. It is common in middle-aged runners and recreational athletes in racket sports. AETIOLOGY Tendinosis is defined from histopatho-logical findings as a free tendon condition with altered collagen structure, thickening of the tendon, re-vascularisation and increased cellularity. It can be looked upon as an active halt in an early healing stage and is an ongoing process, not a degenerative condition. The condition may or may not be symptomatic. A majority of complete Achilles tendon and rotator cuff ruptures show these changes. It is most often localised at the proximal, central and posterior part of the patellar tendon. CLINICAL FINDINGS There is localised tenderness on palpation over the tendon, which often is thicker than the other side. There may be inflammatory signs with redness and increased temperature. Compare to the other side.

Hidden Home Exercises

Ankle Exercises After Surgery

Person to use 70 to 80 per cent of their maximal oxygen uptake, equivalent to running for 45 minutes at a good pace. Cleaning windows manually is excellent rotator cuff training after shoulder injuries vacuum cleaning requires core stability and posture washing dishes in warm water is excellent for a healed radius fracture. There are many, many other examples running up and down stairs, standing on one leg on a wobble board while brushing your teeth, stretching out in the shower, cutting the hedges, mowing the lawn, walking or jogging the dog, jumping off the bus one stop away from the office, using stairs instead of lifts. We neglect many of these things (if we can) during the week, then we spend money and energy on a one-hour run on a treadmill and gym training. Who needs a gym if there is a garden to attend to Who needs exercise if you are running after three small children all day or taking the dog out once a day Internal impingement syndrome Multi-directional instability...

Relevant Anatomy And Biomechanics

Accurate diagnosis and effective treatment of rotator cuff disease relies on an appreciation of shoulder anatomy and bio mechanics. Structures that contribute to normal function will also influence pathologic conditions of the rotator cuff. An awareness of the discerning features of a patient's history and physical examination, and an understanding of potential contributions from surrounding structures will assist in developing a differential diagnosis and formulating an effective treatment plan. The rotator cuff is formed from the coalescence of the tendinous insertions of the subscapularis, supraspinatus, infra-spinatus, and teres minor muscles into one continuous band near their insertions on the greater and lesser tuberosities of the proximal humerus. This arrangement suggests that the muscles of the cuff function in concert. In fact, the name rotator cuff may be a misnomer the major function of the rotator cuff is to depress and stabilize the humeral head, effectively compressing...

Treatment Options

Nonoperative treatment of disorders of the long head of the biceps is usually directed by the treatment for concomitant rotator cuff disease. Initially ice, rest, and anti-inflammatory medications in conjunction with a well-supervised physical therapy program should be prescribed. Athletic activity that incites shoulder pain should be temporarily curtailed. Patients who fail a trial of rest and physical therapy may require a sub-acromial steroid injection to help control the inflammation. Injections can also be given in the glenohumeral joint or directly into the tendon sheath. During the acute phase of inflammation, physical therapy begins with range-of-motion exercises of the shoulder before moving on to strengthening of periscapular musculature. The serratus anterior and trapezius muscles help create a stable platform for the scapula. Strengthening exercises can gradually progress to repetitive eccentric loading of the biceps to build endurance in preparation for strenuous...

Provocative Tests to Reproduce Pain

Subacromial impingement and 85 sensitive for rotator cuff tearing but has poor specificity.7,8 Hawkins Sign This test is performed by placing the arm in 90 degrees of forward flexion, with the elbow flexed 90 degrees. The examiner then internally rotates the arm maximally (Fig. 16-5). A positive test is signified by production of pain. This test has been shown to reflect contact between rotator cuff and the coracoacromial ligament.5 It has been shown to have a sensitivity of 92 for subacromial impingement and 88 for rotator cuff tearing.8 Like the Neer sign, however, this test is not very specific for these conditions. One should be mindful that subacromial impingement syndrome may be associated with a tear of the rotator cuff. Because rotator cuffs are often painful, any workup for impingement should include testing for a tear of the cuff. Although these tests are usually looking for weakness, any impingement examination should include an evaluation of the cuff.

Magnetic Resonance Imaging

Signal-to-noise ratio about 2 cm or more from the surface coil. When using a plane circular surface coil, the nail plate must be placed against the coil to offer the maximum signal close to the superficial layers of the nail unit. The hand is placed above the head in a supine or prone position with the coil fixed on the centre of the gantry. Full cooperation of the patient and efficient mechanical support with adhesive bandages are necessary. Some patients with painful shoulders (rotator cuff tears, multiple tendon calcifications) or frozen shoulder cannot maintain this position during the entire examination. For study of the toes, the position is more comfortable the patient lies supine with the feet in the gantry. In all cases perfect immobility of the distal phalanx is necessary to avoid movement artefacts, which are particularly disturbing with high spatial resolution. For this reason, children younger than 6 years should not be examined in this manner. Routine examination...

Suture Passing Instruments

The Spectrum set is a cannulated set of curved or straight trocars used to pierce tissue and deliver suture using a manual wheeling mechanism (Fig. 17-11). It is most useful for labral repairs or capsular plications. It may also be useful in side-to-side rotator cuff repairs. The cuff stitch is a device with a sharp trocar tip and a needle eye used to pass suture (Fig. 17-12). It has a concave side and convex side. This instrument allows the user to pass a stitch through soft tissue and retrieve it with a grasper. Applications include soft tissue-to-soft tissue repair such as in a side-to-side rotator cuff repair or the passage of suture from suture anchors through soft tissue such as in a labral or rotator cuff repair. The one technical obstacle is to understand how to load and unload the instrument. The instrument is loaded and unloaded on the same side. For example, if it is loaded through the convex side, it should be unloaded with a grasper from the convex side. Otherwise, the...

Postoperative Rehabilitation

During the first 3 weeks after surgery (phase I), the patient wears the sling full-time except when participating in therapy. Passive range of motion, submaximal isometric, and scapular stabilization exercises are performed. Between weeks 3 and 6 (phase II), passive and active-assisted range of motion exercises are advanced, and specific strengthening exercises are initiated. Between weeks 6 and 12 (phase III), additional strengthening exercises are added and advanced. After week 12 (phase IV), gym exercises such as bench presses, lat pull-downs, and military presses are initiated. An interval-throwing program may be started at week 16. Rotator cuff strengthening and scapular stabilization exercises are continued throughout the program.

Postoperative Rehabilation

The third phase begins at 3 months following surgery and continues until maximal improvement is achieved. Full range of motion is a goal during this period. Strengthening is progressed from isometrics, to light resistive bands, to weights ranging from 1 to 5 pounds. In addition to rotator cuff muscles, it is important to strengthen scapular stabilizers and the deltoid. We recommend that strengthening work be performed only three times per week to avoid cuff tendonitis.

Pain Secondary to Instability

Duces posterior pain that is relieved by a posteriorly directed force on the humerus, and again recreated by removing the pressure and allowing the humerus to slide forward, then a diagnosis of internal impingement and or posterosuperior labral pathology may be considered. Paley et al26 demonstrated contact of the undersurface of the rotator cuff and the posterosuperior glenoid in the relocation position in 100 of patients undergoing arthroscopy for internal impingement. It should be noted that this test is differentiated from a standard apprehension test, which is a measure of instability and described later.

Symptomsclinical picture

Examination usually reveals normal range of motion and normal strength of the rotator cuff muscles. Neer's and Hawkins' impingement tests are usually negative. Maximal abduction and external rotation (an extreme apprehension test) results in pain posterior in the glenohumeral joint, not to be confused with a positive apprehension test, in which the discomfort is felt anteriorly. Instability tests may be positive. SLAP tests may be positive.

Suprascapular nerve entrapment

Since its first description by Kopell in 1959 179 , several authors have reported suprascapular nerve entrapment in association with transverse ligament anomalies 180 , trauma 181 , fractures of the scapula 182 , anterior shoulder dislocations 183 and rotator cuff ruptures 184 . The mechanism of injury occurs at the suprascapular notch secondary to the 'sling' effect 185 . The 'sling effect' involves the kinking of the suprascapular nerve against the suprascapular notch under the transverse scapular ligament during forceful throwing.

Rehabilitation after overuse injuries

Both range of motion (ROM), muscle strength and other functional qualities (neuro-muscular control, endurance, proprioception, etc.) are reduced. Most patients have elongation of anterior structures (capsule and ligaments) with hypermobil-ity in external rotation and posterior tightness with limited internal rotation. Weakening of the rotator cuff and the scapulothoracic muscle is also common. These findings are guidelines for the following rehabilitation program 203,204 . The rate of progression through the following protocol may vary according to the type of injury, sport and individual factors (age, health, tissue response, etc.). During the entire rehabilitation period it is important to keep training the uninjured parts of the body.

Ligament dynamization

The glenohumeral ligaments and capsule are relatively lax in the midranges of joint rotation and seem to function only at the end ranges to limit excessive translations and prevent further rotation of the humerus with respect to the scapula 18,26,33,37 . Studies have demonstrated that the rotator cuff tendons attach directly to the various capsuloligamentous components 38 . Therefore, it is possible that the glenohumeral capsule and ligaments may be loaded during contraction of the rotator cuff muscles.

Rationale For The Differentialdirected Approach

The initial pathologic differential in the athlete's shoulder is formed from two important pieces of information (1) the athlete's age and (2) the athlete's chief complaint. One simple example of this is the 60-year-old male tennis player with shoulder pain. Certainly the diagnosis is not guaranteed with such limited information, but the astute clinician has a working differential from the very start. Throughout the examination, the clinician has certain findings that he or she is expecting may be positive. In this example, impingement signs with associated weakness with supraspinatus testing would strongly suggest a rotator cuff tear. At the same time, features of the examination that focus on subtle glenohumeral instability might be less emphasized. This format emphasizes attention to a set of expected findings and makes the diagnosis that much more specific. The first step in the differential-directed approach is to understand how pathologies present as chief complaints, so that...

Impingement Syndrome

Impingement syndrome is also known as rotator cuff tendonitis and supraspinatus tendonitis. The causes of impingement syndrome can be classified as intrinsic or extrinsic causes. Intrinsic causes of impingement include derangement of the acromion causing damage and irritation to the supraspinatus tendon. Diagnostic imaging is also useful in diagnosing rotator cuff impingement. The gold standard is an MRI of the shoulder with oblique coronal and oblique sagittal planes. An increased signal on the surface of the cuff may indicate tendonitis or a partial tear. During the acute phase the use of NSAIDs or a subacromial injection may be necessary. This followed by physical therapy for rotator cuff strengthening and scapular stabilization exercises. Once the athlete has completed the acute phase of physical therapy (PT), he or she transitions into the maintenance phase. Surgical intervention is rarely indicated for impingement syndrome. Some surgical procedures that are used to treat this...

Bicipital Tendonitis

Biceps tendonitis is an inflammation of the long head tendon of the biceps. This disorder can result from impingement as it passes through the humeral bicipital groove and inserts on the superior aspect of the labrum of the glenohumeral joint or as an isolated inflammatory injury. Bicipital tendonitis can also be a secondary injury as a result of compensation to other disorders such as labral tears, intra-articular pathology and rotator cuff pathology. Bicipital tendonitis is more common in overhead athletes such as baseball pitchers, swimmers, and tennis player and can be the result of overuse syndrome of the shoulder, which is also common in gymnasts and rowing kayaking athletes. Trauma may cause direct injury to the tendon as the arm is moved into excessive abduction and external rotation. after unsuccessful rehabilitation or when rotator cuff injury is suspected.

Labral Tears

The labrum is located on the periphery of the glenoid fossa and is a fibrocartilaginous structure that serves to deepen the glenoid. Tendons of the rotator cuff muscles and the biceps insert on the labrum therefore, any instability or tear of the labrum can be accompanied by biceps tendon or rotator cuff pathology.

Baseball

Abducted, externally rotated humerus. Posterior capsular contracture, common in the pitching shoulder, acts to further lever the humerus anteriorly. With time, repetitive stretching of this structure may lead to chronic laxity and plastic deformation. In an attempt to maintain stability, the dynamic stabilizers of the rotator cuff must compensate, rendering them vulnerable to fatigue and discoordination, eventually resulting in more damage to ligamentous restraints and recurrent instability. Most cases of instability related overuse can be treated with a program of active rest and supervised rehabilitation focusing on strengthening of the rotator cuff musculature and scapular stabilizers. Posterior capsular stretching can aid in reduction of anterior translational forces. This cool down phase should be continued through the initial stages of pain and inflammation, with commencement of a staged throwing program only after restoring strength, normal kinematics, and painless motion....

Clinical Evaluation

On physical examination, the patient should be inspected for symmetry of both upper extremities. A ruptured long head of the biceps can result in the classic Popeye deformity in which the muscle of the long head of the biceps is retracted distally leaving a characteristic bulge in the distal arm (Fig. 24-2). Strength and range of motion of both shoulders should be documented. Changes in range of motion are variable and are often in conjunction with rotator cuff disease. Impingement as well as stability testing must be included in the examination. Direct palpation of the biceps tendon can sometimes be difficult. The bicipital groove faces anteriorly when the arm is in slight internal rotation. Pain consistent with biceps tendonopathy will move laterally as the arm is externally rotated. Biceps pain can sometimes be elicited with shoulder extension and internal rotation. Differential injections may also be useful in diagnosing biceps disorders. An injection into the subacromial space...

Histopathology

In contrast to acute muscle injuries, the pathologic findings in most tendon injuries are consistent with tendinosis, a degenerative condition of the tendon, and not a tendinitis involving inflammation, as was formerly believed. Healthy tendon contains parallel bundles of tightly packed collagen fibers, with little extracellular matrix (ground substance) and no fibroblasts or myofibroblasts. In contrast, symptomatic tendons contain disorganized collagen fibers, increased mucoid ground substance, prominent capillary proliferation, and increased numbers of fibroblasts and myofibroblasts (Khan et al., 1999). Histopathologic examination is notably devoid of inflammatory cells. Animal models have also suggested that inflammatory cells are absent by 1 week after induced overuse injury (Zamora and Marini, 1988). These findings are present in the most common tendon injuries, including the patella, Achilles, rotator cuff, and extensor carpi radialis brevis tendons, and have important...

Imaging Studies

Besides rotator cuff injuries, MRI studies are particularly useful for possible cruciate ligament, complete lateral collateral ligament (LCL), and meniscal tears in the knee for potential surgical candidates. Although expensive, MRI shows soft tissue destruction long before plain radiographs. Bone scans also are costly and are nonspecific but demonstrate RA changes before radiographs.

Dynamic Stabilizers

There are many muscles that cross the hip joint, including the rectus femoris and hamstrings, but the major dynamic stabilizers of the hip include the glutei (minimus, medius, and maximus), iliopsoas, iliacus, psoas major, adductors, iliotibial band with the tensor fasciae latae, and deep musculature (pectineus, piriformis, superior and inferior gemellus, and obturator internus and externus). These deep muscles of the hip are thought to be the rotator cuff' muscles of the hip and have a role in fine-tuning hip motions.

Axillary Borders

Muscles of the glenohumeral joint (posterior view). B. Lateral view of the rotator cuff muscles supporting the glenohumeral joint. C. Muscles of the glenohumeral joint (anterior view). Figure 30-3 A. Muscles of the glenohumeral joint (posterior view). B. Lateral view of the rotator cuff muscles supporting the glenohumeral joint. C. Muscles of the glenohumeral joint (anterior view).

Biceps tendinitis

The long head of the biceps muscle extends intra-articularly under the acromion through the rotator cuff to its insertion on the superior rim of the glenoid. Bicipital tendinitis is produced by the same mechanisms that initiate impingement symptoms in rotator cuff injuries and can inflame the tendon in its subacro-mial location 158 . This condition can also be caused by subluxation of the tendon out of the bicipital groove on the proximal humerus due to rupture of the transverse ligament (see section on 'Biceps tendon instabil-p. 7i6).

Matrix Augmentation

Collectively, these clinical results correspond to the preclinical performance of this extracellular matrix in cellular studies, animal models, and biomechani-cal testing. Mechanical testing of a variety of extracellular matrices by Barber et al.20 showed that the suture pullout strength was higher (157 to 229 N) for this type of material than all other materials tested. The inherent mechanical properties and suture purchase offered by the matrix should aid in the intraoperative and preliminary postoperative reinforcement of the primary repair prior to graft incorporation. The initial strength properties of an acellular dermal matrix construct were also statistically equivalent to palmaris longus tendon grafts in a biomechanical study of medial collateral ligament elbow reconstruction.21 This acellular human dermal graft has repeatedly reflected regenerative tissue properties, a lack of inflammation, and cellular incorporation in a variety of canine, porcine, and rat models as well as...

Shoulder Instability

Patellofemoral Instability Exercises

Shoulder laxity has been traditionally associated with the female athlete. Hormonal factors such as progesterone, estrogen, and relaxin11 as well as decreased upper extremity muscle mass12 have all been implicated. Yet there has been much debate as to whether these gender-specific differences contribute to injury patterns. The shoulder is a complex, highly mobile structure. In order to accommodate for extremes in motion, there is a delicate dynamic between normal and pathologic. The glenohumeral joint is inherently unstable. Relative to the glenoid, the humeral head is very large, providing only a small contact surface area for bony support. Thus, the joint relies heavily on balanced contraction of rotator cuff musculature, coordinated scapulotho-racic motion, and the integrity of the soft tissues. It has been proposed that the female athlete is predisposed to atraumatic or multidirectional shoulder instability due to laxity of capsu-loligamentous constraints. McFarland et al13 and...

Shoulder Anatomy

Nerves The Rotator Cuff

At the most lateral edge of the scapular spine, the acromial process is formed. This serves as a site of origin for the deltoid muscle and receives attachment of the coracoacromial ligament, an important structure in the development of shoulder impingement. Several different types of acromial morphology have been identified that represent varying levels of severity of compromise to the supraspinatus outlet. The acromion also is a frequent site of osteophyte formation further adding to rotator cuff impingement. In the anatomical position, the proximal humerus is retroverted an average of 30 when compared to the humeral condyle alignment. A humeral neck to shaft angle of 130 is also found. The lesser tuberosity of the proximal humerus serves as the site of insertion for the subscapularis muscle with the rotator cuff tendon inserting into the greater tuberosity. Between these tuberosities in the groove rests the biceps tendon. Here the long head of the biceps passes to the superior...

Muscular Support

Any muscle that crosses the glenohumeral joint and produces a compressive force between the head of the humerus and the glenoid cavity will produce muscle stability (Figure 30-7D). Muscle stability is best exemplified by the rotator cuff muscles, which provide support to all sides, except the inferior aspect of the glenohumeral joint. In addition to the support of the rotator cuff musculature, the long head of the biceps brachii and deltoid muscles assist in the support of the glenohumeral joint Figure 30-7 A. Glenohumeral joint. B. Joint capsule of the glenohumeral joint. C. Rotator cuff with associated bursae. D. Rotator cuff from a lateral degree. Rotator cuff muscles

Relevant Anatomy

Walch et al6 first described internal impingement as intra-articular contact between the posterosuperior rotator cuff (infraspinatus) and posterior glenoid labrum at maximal shoulder abduction and external rotation in tennis players. Anatomic lesions associated with internal impingement include injury to the articular surface of the rotator cuff (especially the infra-spinatus tendon in throwers and the supraspinatus tendon in tennis players), posterior and superior labrum, and anterior capsular structures. Posterior capsular thickening and contracture have also been reported as common findings11 (Box 23-2). Injury to the posterosuperior rotator cuff (infraspinatus) due to direct abutment against the glenoid and labrum with the shoulder in abduction and external rotation The biomechanical etiology for injury to these structures is controversial. Two possible causes have been reported, although neither is universally accepted. The most prevalent theory has been termed rotational...

Injection Tests

We normally perform this injection from the back using the posterior lateral angle of the acromion as a landmark, although an anterior approach was originally described by Neer (Fig. 1622). The area is prepped sterilely, and 5 mL of 1 lidocaine and 5 mL of 0.25 Marcaine are placed in the subacromial space by advancing the needle directly under the acromion anteriorly and slightly medially. Care must be taken in the exceptionally large individual that the needle be long enough to reach the anterior one third of the subacromial area since the pathology exists anteriorly. Alternatively, lateral and anterior injections can be placed in the subacromial space. Once an adequate amount of time has passed (usually 5 minutes), re-examination of the patient is performed. We inquire about any resting relief that the patient experiences with the injection. Next, we ask the patient to move the arm into positions that caused pain before the injection to see whether he or she obtained relief. This...

Pathophysiology

It is important to realize that the symptoms of primary impingement originate from the rotator cuff, in particular the supraspinatus tendon, even though in most cases it is caused by structures next to the tendon. Neer's classification of primary impingement depends primarily on the condition of the rotator cuff (Table 6.6.2) 75 . There are several reasons why the anterior part of the subacromial space can get overcrowded. Neer divided these into outlet and non-outlet causes, the first being changes in the coracoacromial arch impinging on the rotator cuff, and the latter being changes in the subacromial bursa or the tendon itself.

Practical Concepts

Suture Hooks

Arm position plays an important role in rotator cuff and labral repairs. For rotator cuff repairs, the arm position is varied with some abduction and internal external rotation to place the greater tuberosity beneath the lateral portal to allow a 90-degree angle of entry into the tuberosity (Fig. 17-15). For labral repairs, the arm is positioned in mild external rotation prior to tying knots to avoid constraining the joint. Suture management is perhaps the most complex and difficult concept to successfully achieve. Anchors need to be placed in a logical progression, and the sutures need to be tied at specific intervals to avoid tangling suture. Judicious use of accessory and working portals helps to minimize tangles. For example, in a rotator cuff repair, we place all the anchors first and group all the sutures in separate clamps in the anterior portal. Sutures are sequentially passed through the rotator cuff from anterior to posterior. Once all sutures are passed, they are...

Disabled Athletes

Athletes with spinal cord injuries have their own set of medical concerns. For example, shoulder injuries and carpal tunnel syndrome are very common among the wheelchair-dependent population. Exercises that strengthen the rotator cuff and scapular stabilizers should be initiated early. Also, paralyzed athletes can accumulate fluid in the immobilized extremities during physical activity, which diminishes cardiac return and cardiac output. These individuals should be advised to use compressive garments during exercise. Paraplegic athletes with high thoracic injuries (above the T6 neurological level) have problems regulating body temperature and should be advised to avoid exposure to severe environments. There are also skin issues of potential concern, such as pressure sores, and persistent fungal infections which must be identified and addressed.

Surgery

A standard posterior arthroscopic portal is used to inspect the articular surfaces, labral rim, rotator interval and biceps, rotator cuff articular side, and the axillary pouch. Placing the arthro-scope into the anterior portal will also facilitate improved visualization of the posterior labrum, the posterior band of the inferior glenohumeral ligament, and the posterior capsule. In classic MDI, there are few anatomic lesions. The most commonly encountered finding is a voluminous axillary recess, the classically defined entity in MDI.

Muscle Sources

We recommend that the examiner begin by asking the patient during which activities and in what position he or she is weak. As so many athletes are involved in year-round strength training, they are often very sensitive to changes in their lifting abilities and will often present early and with subtle findings. The examiner must use enough force to overcome the tested muscle. We use a standard approach to the muscular examination36 as shown in Table 16-3 (as well as the rotator cuff tests employed as previously described).

Implants

These refer to materials left in situ to maintain the repair. For arthroscopic shoulder surgery, these include suture and suture anchors. Most suture that we use is nonabsorbable, braided multifilament suture. Generally, no. 2 suture is used for rotator cuff repairs and 2-0 suture is used for labral repairs. Some new suture types such as FiberWire (Arthrex, Naples, FL) confer greater failure strength. Capsular plications may also be done with no. 1 or 0 polydiaxone suture. Anchors are either bioabsorbable or metal. Either type may be used, although we prefer metal for rotator cuff repairs. Larger 5.0-mm anchors are used to repair the rotator cuff and smaller 2.8-mm to 3.5-mm anchors are used for glenohumeral repairs.

Clinical Features

Primary bicipital tendonitis, where there is isolated inflammation of the long head of the biceps with no identifiable inciting cause, is rare. In younger athletes, biceps inflammation is usually caused by repeated microtrauma from overuse activities. The development of subacromial impingement is a more common scenario, which can be potentiated by weak periscapu-lar musculature that fatigues with repetitive use. Rotator cuff muscle fatigue results in an elevation of the humeral head further potentiating the impingement. In older patients, degenerative changes of the biceps are frequently associated with impingement and rotator cuff disease. Many times the cause of biceps inflammation is multifactorial. The long head of the biceps is surrounded by a synovial extension of the glenohumeral joint, and the development of an inflammatory process can be directly related to the structures in proximity. Inflammatory tenosynovitis almost always occurs with concomitant rotator cuff disease as...

Chief Complaint

These are difficult decisions that can be successfully made only with a thorough understanding of the athlete's chief complaint and how it relates to the rest of his or her history. For example, a chief complaint of pain in the shoulder may intimidate a novice examiner because there are so many possibilities. This assumption would be compounded if the examiner went from the chief complaint of pain directly to an MRI that showed AC degenerative changes, a partial-thickness undersurface tear of the rotator cuff, and a patulous capsule. However, if that same examiner seeks to gain a thorough understanding of the chief complaint, he or she might ask where exactly is the pain, when does it hurt, and how is the pain produced. These simple questions might reveal an athlete who has pain on the top of the shoulder with a bench press and is tender to palpation of the AC joint, leading to an initial suspicion of AC pathology. In contrast, the patient might say the shoulder hurts at the back when...

SLAP lesions

Although uncommon, these lesions may be a source of significant disability since they are difficult to diagnose. Labral tears are frequently associated with other pathology such as instability and rotator cuff tears therefore these entities need to be ruled out 138 . The most common complaint from patients is overhead pain and a 'popping or clicking' sensation. These symptoms are non-specific and the history may be more consistent with a diagnosis of impingement syndrome, biceps tendinitis or glenohumeral instability. However, patients may also complain of pain while attempting forward flexion with the arm supinated.

Shoulder impingement

2 secondary impingement, in which the rotator cuff is subject to microtrauma or overuse during motion, because of glenohumeral instability and 3 internal impingement, in which the undersurface of the rotator cuff collides with the superior rim of the glenoid. This is probably a natural phenomenon, but becomes symptomatic in the athlete, because the collision happens repetitively and with great force.

Indications

There are only very few randomized, placebo-controlled studies concerning the effect of local corticosteroids and chronic tendon injuries, but some effect has been recognized in the treatment of tennis elbow 74,75 , rotator cuff tendinitis 76 and plantar fasciitis 72 . Often the effect has been of short duration. Newer randomized, doubleblind, placebo-controlled studies 76a,76b have shown a significant effect of ultrasound-guided peri-tendinous injection of long-acting corticosteroids in athletes with the most severe ultrasonography-verified jumper's knee or Achilles tendinopathy. Despite having had symptoms for an average of i1 , years 50 of the athletes were free of symptoms after 3 months but only 20 were free of symptoms after 6 months. The increased tendon diameter and the edema evaluated by ultrasonography were highly significantly reduced every week for the first 4 weeks following an injection despite the fact that the tendons were never totally normalized...

Case story 662

A 27-year-old weight lifter gradually developed anterior pain in his left shoulder, extending out anterolateral in the arm. He had pain when weight-lifting, but also in his daily life, lifting shopping bags, during sleep, or working with the arm above horizontal. There were few degrees reduction in flexion, but otherwise normal movements of the shoulder. He had good power in all rotator cuff muscles, but pain when abducting with power against resistance. Neer's and Hawkins' tests were positive, as was the acromioclavicular joint compression test. There was tenderness of the AC-joint. The shoulder was stable.

Bursitis

Bursitis of the shoulder refers to inflammation of the subacromial bursa. Inflammation of this bursa is generally secondary to shoulder impingement, and therefore both the signs and symptoms and the treatment are similar 158 . Rotator cuff strengthening and stretching exercises may reduce the symptoms. With return of the cuff's normal function, there is greater room under the acromial arch, and less impingement and irritation occur.

Basic examination

Acromioclavicular Compression Test

The general impression of the shoulder contours gives valuable information Is this a muscular or a slight individual Is there atrophy on the affected side of the deltoid (as in axillary nerve palsy), the supraspinatus (as in rotator cuff rupture) or the infraspinatus muscles (as in suprascapular nerve palsy in volleyball players) Is the humeral head in joint (An epulet shoulder is characteristic of acute dislocation.) Is the acromioclavicu-lar joint intact or is the clavicle protruding Test strength of the rotator cuff muscles abduction (in the scapular plane) (Fig. 6.6.6), inwards and outwards rotation (Fig. 6.6.7). A reduced strength can be due to either rotator cuff rupture, muscle fatigue (as in suprascapular nerve palsy with infraspinatus atrophy) or pain (which can eventually be eliminated by injection of local analgetics). The movements of the scapula are visualized by watching the patient from behind. Asymmetric movements of scapula during the first sequences of abduction,...

Tendinopathy

Tendon injuries can involve acute overuse tendinopathy, chronic tendinosis, partial-thickness tears, or complete rupture of the tendon. The exact role of NSAIDs in the treatment of tendinopathy remains uncertain. NSAIDs are potentially helpful initially following acute tendon injury, when inflammation is most likely to be present. For tendinopathy of longer duration, use of NSAIDs, although an adjunct to pain control, does not contribute to tendon healing. The exact mechanism of action of corticosteroid injections, such as in the treatment of lateral epicondylosis and rotator cuff ten-dinopathies, is also unclear. Corticosteroid injections bathe the region of tendinosis, alter the chemical composition of the matrix, and may modify nociceptors on nearby structures (Khan and Cook, 2000). NSAIDs and corticosteroids also may have an effect on other biochemical irritants (yet to be defined) that play a role in the generation of tendon pain.

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