Rotator Cuff Related Shoulder Pain

buckets of shoulder pain

mobility deficits, stability and movement, muscle power/RTC

clinical presentation of RTC syndrome

worse with repetitive overhead activities, mid range pain with active elevation, RTC muscle weakness

types of muscle power deficits (RTC syndrome)

subaromial impingement, RTC tendinopathy/tear, subacromial bursitis, bicipital tendinopathy

how to rule out RTC syndrome

resistive tests are pain free and normal strength, significant loss of PROM

typical history of impingement syndrome

painful arc with elevation and overhead activities, cannot sleep on that shoulder, history of repetitive activities

cause of primary impingement

structural loss of space due to anatomical issues

cause of secondary impingement

due to joint laxity

what is compressed in primary impingement

supraspinatus, subacromial bursa, long head of biceps tendon

locations of primary impingement

coracoacromial arch, anterior 1/3 of acromion, AC joint

neers stages of impingement syndrome

edema and inflammation → fibrosis and tendinitis → bone spur and tendon rupture

symptoms during stage 1 (edema and inflammation) of primary impingement

reversible lesion, TTP: greater tuberosity, painful arc: 60-120, positive impingement, restricted ROM due to inflammation

symptoms during stage 2 (fibrosis and tendinitis) of primary impingement

not reversible by modifying activities, soft tissue crepitus, limited ROM, all signs from stage 1

symptoms during stage 3 (bone spurs and tendon ruptures) of primary impingement

structural changes, more pronounced loss of AROM, weak abduction and ER, biceps tendon involvement, AC joint tenderness

why do we perform MMTs at different points in the range

to see if it is true weakness or pain limiting

circle stability concept

increased laxity in a part of the capsule also stresses the opposite side

consequences of secondary impingement

glenohumeral laxity and superior translation of humeral head, improper positioning of the scapula

how can secondary impingement lead to RTC tendinitis/weakness

glenohumeral laxity → overload of dynamic restraints → RTC tendinopathy

cause of posterior/internal impingement

secondary to anterior laxity from trying to balance the increased anterior translation

exam findings of posterior laxity

posterior pain with anterior apprehension test, positive relocation test

how to determine primary or secondary impingement

secondary more identified with stability tests

function of RTC

assist humeral head depression (prevent migration into deltoid), balance deltoid forces for stability

passive stability structures

scap, humerus, clavicle, ligaments, labrum, capsule

active stability structures

glenohumeral and scapulothoracic muscles

presentation of RTC syndromes

pain with elevation and ER, reduced muscle performance, altered scapulohueral rhythm

mechanisms for RTC pathology

tensile stress, compression, microinstability, scapular dyskinesia

extrinsic causes of RTC tendinopathy

pec muscle length, scapular muscle performance, thoracic spine mobility, GH capsule extensibility

types of partial thickness RTC tears

bursal side and articular side

characteristics of bursal side tears

general population, in neer’s stage 3, from the superior surface on supraspinatus

characteristics of articular side tears

younger athletes, on the undersurface from the humerus

causes of full thickness RTC tears

acute trauma, degenerative

RTC tendinopathy vs RTC syndrome

tendinopathy does not include tears

observation during RTC eval

deformity, atrophy, scapulohumeral rhythm, movement quality, ROM

shoulder vs scapular ROM assessments

scapular is more observation based and cannot really be measured

recommendation for shoulder strength assessment

HHD is better than MMT

neer’s vs hawkins kennedy

neers tests subacromial impingement and hawkins kennedy tests more coracoacromial/AC impingement

function of scapular reposition and assistance tests

scapular contribution to pain

function of drop arm test

rotator cuff pathology

function of empty/full can test

supraspinatus pathology

tests for subacapularis pathology

lift off, belly press, bear hug

non-op treatment of RTC tears

protect from overhead activities, RTC and scapular strengthening, active rehab program

treatment options for failed conservative management of RTC tears

pharmacological, corticosteroid injection, PRP injection, surgery

surgical options for RTC tears

subacromical decompression, RTC repair, stabilization procedure

function op subacromical decompression

addresses primary impingement by partial resection of acromion

typical progression of RTC repair

supraspinatus → infraspinatus → teres minor

goals of RTC repair rehab

maintain integrity of repair, re-estability mobility and normal movement, return to normal activities

typical precautions post RTC repair

no active ER and ABD 4-12 weeks, no passive IR 2-4 weeks

presentation of AC joint sprain

visible deformity, pain over AC joint, disruption to ligaments

presentation of AC joint arthritis

common in weight lifters, pain with OH, horizontal adduction, pushing

special tests for AC joint pathology

cross arm adduction test, AC resisted extension test

thoracic outlet syndrome

compression of brachial plexus or subclavian vessels in interscalene triangle, costoclavicular space, retropectoralis space

symptoms of thoracic outlet syndrome

pain/weakness in shoulder and arm, paresthesia, UE heaviness, edema, color changes

symptoms of LTN palsy

atrophy of serratus anterior, scapular winging, weakness with OH

causes of LTN palsy

repetitive stretch from OH activity, acute trauma/compression

cause of suprascapular neuropathy

compression of suprascapular nerve at suprascapular notch (from ganglion cyst or repetitive OH)

symptoms of suprascapular neuropathy

atrophy of supraspinatus and infraspinatus, posterolateral shoulder pain

cause of axillary nerve injury

glenohumeral dislocation, proximal humerus fracture, direct blow to deltoid

symptoms of axillary nerve injury

atrophy of deltoid and teres minor, numbness at lateral shoulder