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Tendinosis & Subacromial Impingement Syndrome. Gene Desepoli, LMT, D.C. What is the shoulder joint?. Shoulder joint or shoulder “ region ?” There is an interrelatedness of all moving parts of the shoulder and dysfunction in one joint may cause dysfunction and pain in the others!.

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Presentation Transcript
what is the shoulder joint
What is the shoulder joint?
  • Shoulder joint or shoulder “region?”
  • There is an interrelatedness of all moving parts of the shoulder and dysfunction in one joint may cause dysfunction and pain in the others!
7 joints of the shoulder region
7 Joints of the Shoulder Region

1. Glenohumeral

2. Subdeltoid (false joint)

3. Acromioclavicluar

4. Scapulothoracic (false joint)

5. Sternoclavicular

6. Costosternal

7. Costovertebral

9 bursae of shoulder region
9 Bursae of Shoulder Region
  • Only 2 are clinically important:

1. Subacromial (subdeltoid) bursa

susceptible to impingement, esp. if

swollen or inflamed. Frequently

ruptures due to a calcium deposit.

2.Subscapular bursa

between anterior scapula and rib cage

  • Note: Bursitis is rarely a primary condition !!!!
muscle review
Muscle Review

1. Supraspinatus

2. Infraspinatus

3. Teres Minor

4. Subscapularis

5. Levator Scapulae

6. Upper Trapezius

7. Serratus Anterior

8. Biceps brachii

assists abduction when arm is externally rotated.

9. Deltoid: impingement!

rotator cuff
Rotator Cuff
  • Muscles do not attach as discreet tendons but blend to form a continuous cuff surrounding the glenoid head.
  • Provides dynamic stabilization of the joint due to blending into the capsule.
  • Tendons of rotator cuff blend with joint capsule
rotator cuff1
Rotator Cuff
  • Supraspinatus…………Abduction
  • Infraspinatus…………..External rotation
  • Teres Minor……………External rotation
  • Subscapularis…………Internal rotation
rotator cuff supraspinatus
Rotator Cuff: Supraspinatus
  • Abduction
  • Passes under acromion process
  • Most commonly injured or torn
  • “Suitcase muscle”
hypovascularity of the supraspinatus
Hypovascularity of the Supraspinatus
  • Supraspinatus is considerably hypovascular with respect to the other cuff tendons: “critical zone”
  • Tendonitis in this region correlates to hypovascualrity (that progress with age)
rotator cuff infraspinatus
Rotator Cuff - Infraspinatus
  • External rotation
  • Pulls humerus downward with abduction
  • Eccentric contraction
rotator cuff teres minor
Rotator Cuff – Teres Minor
  • External rotation
  • Pulls humerus downward with abduction
rotator cuff subscapularis
Rotator Cuff - Subscapularis
  • Internal Rotation
  • Adduction
  • Stabilizes humerus
  • Pulls humerus downward w/ abduction
  • Eccentric contraction
glenohumeral joint
Glenohumeral Joint
  • Designed for flexibility at the expense of stability
  • Static stabilizers – capsule and ligaments
  • Dynamic stabilizers – rotator cuff muscles
glenohumeral joint1
Glenohumeral Joint

Assuming good, normal posture:

  • Gravity’s tendency to pull the humerus downward is overcome by superior joint capsule tightness. (vector: pulls humeral head inward for stability)
  • Little or no deltoid or rotator cuff muscular effort is needed. (even w/ a small weight in the hand)
glenohumeral joint2
Glenohumeral Joint
  • With thoracic kyphosis (round shoulders): the rotator cuff must increase tone to compensate for loss of capsular stabilization. Round shoulders may even be a cause of frozen shoulder!!!!
  • Increased capsular stress leads to increased collagen production and increased fibrosis
capsular support
Capsular Support

Capsule loose

Capsule taut

glenohumeral joint3
Glenohumeral Joint
  • With the arm elevated or with round shoulder posture:
  • Tension is lost in sup. joint capsule
  • The rotator cuff muscles contract to provide

stabilization. Over time, they fatigue!

  • Conditions which compromise stabilization:

1. postural changes

- round shoulders = downward scapular

rotation

2. rotator cuff weakness/ dysfunction / trigger

points

abduction of humerus
Abduction of Humerus

● Scapula rotates upward (scapulohumeral

rhythm) from upper traps and serratus anterior

● Clavicle elevates & rotates backward

● Upper thoracic vertebrae must extend,

rotate and bend to same side. The

contribution of spinal movement to full

arm elevation is often overlooked!

abduction
Abduction
  • There is the danger of the greater tubercle

hitting the acromion, subjecting the soft

tissue to repeated trauma!

  • The head of the humerus must be guided

into inferior glide / depression to prevent

impingement during abduction (actively or

passively) AND it must externally rotate!

biomechanics of abduction
Biomechanics of Abduction

External rotation of the humerus occurs due to untwisting of the capsule

Tight internal rotators my prevent this!

impingement pinching
Impingement (pinching)
  • Bones: acromion and greater tubercle
  • Soft tissue:

supraspinatus tendon

& subacromial bursa

coracoacromial ligament
Coracoacromial Ligament

Runs from coracoid process to the acromion.

Important for a/c joint stability

May be a source of impingement

Forms a protective arch over the glenohumeral area

together with the acromion and clavicle (functions as a

secondary restraining arch to prevent superior humeral

head dislocation

Can impinge the supraspinatus tendon and subdeltoid

bursa.

coracoacromial arch
Coracoacromial Arch
  • An additional site of impingement
altered biomechanics
Altered Biomechanics

Impingement is prevented by proper biomechanics and by the proper placement of the humerus during abduction.

Causes of impingement therefore can be:

muscle imbalance, trauma, trigger points, weakness, inhibition, pain, arthritis, capsular tightness, muscle memory following injury

eg. scapula doesn’t rotate

bursa is swollen and the space is reduced

Shoulder forward shrugging causes impingement.

muscular force couple
Muscular Force Couple
  • During abduction the humerus must be properly situated for full pain-free movement.
  • Force coupling occurs to create smooth pain free movement

eg. trapezius and serratus anterior

rotator cuff muscles with deltoid

abduction of humerus1
Abduction of Humerus
  • Infraspinatus & Teres Minor
the painful arc
The Painful Arc
  • There is pain during abduction in the range from 45-60 to 120 degrees.
assessment tests
Assessment Tests
  • Painful Arc
  • Hawkins’ Test / Speeds Test +++
  • Subacromial push button (Dawbarn’s)
  • Rotator cuff tendonitis assessment
  • A/C joint tests
  • Labrum disruption tests
  • Rotator cuff tears
progression of rotator cuff tears
Progression of Rotator Cuff Tears

Tight pectoral muscles 

Round shoulders 

Impingement 

Supraspinatus Tendonosis/

Tendonitis 

Calcific Tendonitis 

Rotator cuff tear !!

slide42
Surgery may be preventable.
  • The real heroes and competent level of massage therapy deals with early recognition and prevention.
corrective exercises
Corrective exercises
  • Correct round shoulders/ergonomics
  • Restore mobility
  • Eliminate trigger points
  • Stretch tight muscles
  • Strengthen weak muscles
  • Rehabilitate supraspinatus with scaption.

glenoid cavity faces forward, laterally and

superiorly

tendonitis tendonosis
Tendonitis / Tendonosis
  • Causes

overuse

poor body mechanics

  • Pathology

muscle cell damage (tearing, irritation)

microinflammation

fibroblasts

microscarring

tendinosis tendonitis
Tendinosis / Tendonitis
  • Not a true inflammatory condition
  • Cell damage causes fibroblasts to

proliferate

  • Creates a disorganized scar

(massage and movement)

  • Leads to pain and further micro-tearing
tendinitis tendinosis
Tendinitis / Tendinosis
  • Accurate Assessment!

1. pinpoint pain

2. painful active (resisted) contraction

3. painful passive overstretching

Highly accurate!

Can be applied to any muscle for assessment.

rotator cuff tendinosis
Rotator Cuff Tendinosis
  • Supraspinatus:

pinpoint pain at greater tubercle

painful active abduction

painful passive adduction stretch

rotator cuff tendinosis1
Rotator Cuff Tendinosis
  • Infraspinatus & Teres Minor:

pinpoint pain at greater tubercle

painful active external rotation

painful passive internal rotation stretch

rotator cuff tendinosis2
Rotator Cuff Tendinosis
  • Subscapularis:

pinpoint pain at lesser tubercle

painful active internal rotation

painful passive external rotation stretch

treatment of tendinosis
Treatment of Tendinosis
  • General Massage
  • Remove TrPs which maintain a shortened / tight muscle
  • Transverse Friction massage

creates a mobile flexible scar

causes “good damage” to allow healing

  • Strengthen muscle / tendon to tolerate more stress
  • Full recovery = the patient can perform 3 sets of 10

strong repetitions

  • Ice may be needed before and after Tx. to decrease pain