Clinical Exam and Treatment of RC Injuries

symptoms associated with rotator cuff tendinopathy

pain associated with OH activityes, pain pattern consistent with typical tendinopathies and their stages, suprapinatus/infraspinatus/teres minor pain

pain associated with OH activities

repetitive lifting for non-OH athletes, more specifically in OH athletes

pain at cocking phase

internal impingement

pain at release/deceleration in posterior shoulder

infraspinatus/teres minor due to tensile overload

pain at release/deceleration in superior/anterior shoulder

supraspinatus tensile overload

supraspinatus tendinopathy will present with

pain over greater tubercle - just under acromion

infraspinatus tendinopathy will present with

pain posteriorly, just below posterior edge of acromion

special tests for supraspinatus tendon/external impingement

painful arc (60-120) during active shoulder elevation (with or without weight), positive suprapinatus test/empty can test, positive hawkins-kennedy test

supraspinatus test/empty can test

resisted scap abduction wiht palm down and then again with thumb down - if thumb down is more painful then test is positive

hawkins kennedy test

bring pt into passive 90 degrees flexion at shoulder and elbow, then have them IR, repeat with less or more horizontal abduction - brings supraspinatus closer to cracoacromial arch - pain is a positive test

special tests for infraspinatus tendon/internal impingement

positive impingement test/neer test, internal impingement test/posterior shoulder pain

neer test/positive impingement test

passively bring arm to endrange flexion and apply overpressure leading with thumb, repeat with IR - pain posterior is internal impingement, pain anteriolaterally is external impingement

internal impingement test/posterior shoulder pain

passive shoulder ER causing pain, then redo movement while stabilizing anterior-posterior shoulder decreasing anterior translation - decreased pain with stabilization is a positive test

pain with resisted 90 deg scap abduction

supraspinatus

pain with resisted ER with arm along body

infraspinatus and teres minor

pain with resisted IR with arm along body

subscpularis

ability to isolate action of any shoulder muscles is limited

pain reproduction can occur with several movements, determine relative amount of pain and location for each movement

additional shoulder tests to guide treatment of RC

modified scapular assistance test, scapular reposition test

item cluster for subacromial pain syndrome/impingement

neer impingement, jobe/empty can, hawkins kennedy, painful arc with elevation, pain/weakness with resisted ER (3/5 is a good indicator)

complete pathoanatomical diagnosis with exam evaluating

impairments with activity/overuse, posture, limited shoulder ROM, scapular dyskinesia, RC, GHJ excessive ROM/hypermobility, total body approach

posture effect on RC

pec major/minor tightness, posterior shoulder/trunk muscle weakness, neck and lumbar spine stabilization

limited shoulder ROM is most likely in a

noncapsular pattern, with likely normal ER range of motion - commonly due to avoiding end range activities from pain or progressive loss of range

GHJ hypomoblity typically presents with

decreased flexion/abduction reflective of inferior capsule tightness, decreased IR and horizontal adduction reflexctive of posterior shoulder tightness

lat dorsi muscle shortening

could limit shoulder range of motion - heavy arch to elevate arm

scapular dyskinesia and RC injury

weakness of SA, LT and MT, tightness of pec minor

treatmetn of acute/subacute rotator cuff tendinpathy

activity mangement and relative rest, avoid repetitive OH activities, avoid/modify activites that aggravate conditions, modify sleeping position, reduce pain and inflammation - support arm whenever possible

treatment of subacute/chronic stages of RC tendinopathy

tissue re-loading with progressive resistance of isometrics to isotonics, progress ROM, load mag and type over time, rotator cuff exercise progression, activity management continues throughout with return to full function

important to emphasize what with progressive functional gains for RC tendinopathy

end range

rotator cuff exercise progression begins with

isometrics - arm along side with painfree ER/IR/ABD, use towel under humerus

isotonics for RC exercise program

weights and elastic resistance - starts below 45 deg, then progress to 90, then full range, tubing along side with goal of 60 deg abducted, manual resistance in ER

neuromuscular rehab for RC tendionpathy

manual resistance and tubing PNF exercises

plyometrics for RC

rebounder

exercise for supraspinatus

full can with weight

exercise for infra/teres minor

sidelying or standing ER, prone ER at 90

exercise for subscap

IR at 0 and 90 degrees abducted, diagonally

rhythmic stabilization

strengthen RC to increase centralization of RC - perform in any motion/direction/point in range, vary speed, force, contact (eyes closed or open)

adress related impairments and contributing factors

posture, GHJ hypomobility, ACJ/SCJ hypomobility, GHJ jypermobility

stretching exercises including posterior shoulder

AAROM in flexion with pulley and T-bar, ER along the body, place towel under arm for flexion to reduce fulcrum

best stretch for pec minor tightness

doorway stretch and rotate trunk away

cortisone injections for RC

politely advise against when offered to the patient, no benefit of injection over conservative treatment