CSAT week 10
Page 1: Greater and Lesser Tubercle Actions
Greater Tubercle
Actions:
Abduction
External Rotation
Lesser Tubercle
Action:
Internal Rotation(Source: Kendall et al., 2005)
Page 2: Palpating the SITS
Palpation Technique:
Thumb: Subscapularis
Index Finger: Supraspinatus
Middle Finger: Infraspinatus
Ring Finger: Teres Minor(Source: Magee & Manske, 2021)
Page 3: SITS Tendon Pathologies
Common Issues:
Partial or complete tears
Impingements
Calcification
Affected Populations:
Adults aged 40+
Younger athletes (repetitive overhead activities)
Pain Characteristics:
Described as a "dull ache" often in the anterior/lateral shoulder(Source: Magee & Manske, 2021; Rattray & Ludwig, 2005)
Page 4: Causes of SITS Tendon Pathologies
Pathology Causes:
Wear and tear under the acromion arch
Sports-related trauma or falls
Secondary issues related to shoulder instability(Source: Rattray & Ludwig, 2005)
Page 5: Rotator Cuff Injury Risk Factors
Major Risk Factors:
Advancing Age: Average age of tear repair is 59
Gender: Equally affects both sexes; more common in post-menopausal females
Smoking: Negatively impacts vascularity to tendons
Family History
Posture Problems: E.g., hyperkyphosis decreases acromial-humeral space
Page 6: Long Head of Biceps Pathologies
Injury Causes:
Relates to SITS injury
On the presence of SLAP lesions
Conditions:
LHB Tenosynovitis in the intertubercular sulcus/bicipital groove
Subacromial impingement
Increased wear from transverse humeral ligament injury
Pain Symptoms:
Presenting in anterior shoulder at bicipital groove(Source: Magee & Manske, 2021)
Page 7: Superior Labrum Tears (SLAP Lesions)
Definition:
Superior Labrum tear that runs Anterior to Posterior
Associated Injury:
Injury to long head of Biceps tendon
Causes:
Overhead throwing, falls on an outstretched arm, aging
Pain Characteristics:
Anterior GH pain; more diffuse than LHB injury(Source: Smithuis & Jan Vander Woude, 2021)
Page 8: Inferior Labrum Tears (Bankart Lesions)
Definition:
Tear of anterior/inferior labrum
Causes:
Repeated anterior GH dislocations, overhead athletes, trauma
Detection:
More challenging to assess physically
Pain Symptoms:
Generalized pain
Consequences:
Both lesions can lead to GH joint instability(Source: Smithuis & Jan Vander Woude, 2021)
Page 9: Subacromial Impingement Syndrome
Also Known As:
Subacromial Pain Syndrome
Description:
Inflammation and impingement of structures (tendons, bursae) beneath the coracoacromial arch
Most Affected Structure:
Supraspinatus tendon
Mechanism:
Repetitive compression and microtrauma during arm abduction and rotation
Pain Characteristics:
Presenting at anterior/lateral shoulder
Page 10: Stages of Subacromial Impingement Syndrome
Stage 1:
Under 25 years, acute inflammation, reversible edema
Stage 2:
Ages 35-40, increased friction, fibrous tendinitis, less reversible damage
Stage 3:
Over 40 years, risks of partial/complete tear, osteophyte formation(Source: Gibbons, 2020)
Page 11: Shoulder Bursitis
Description:
Subacromial Bursitis linked with impingement syndrome, common in overhead use
Mechanism:
Bursa irritation from compression by rotator cuff tendons, coracoacromial ligament, and acromion or long head of biceps tendon
Pain Symptoms:
Localized pain at superior lateral GH joint(Source: Visible Body, 2020)
Page 12: Structural Impingement Risk Factors
Key Factors:
Bursa inflammation or thickening
Thickening or tendinitis of SITS tendons
Abnormal acromion shape, spurs, or malunion fractures
Humeral head abnormalities or fractures
AC Joint abnormalities (sprain, degenerative spurs)
Page 13: Functional Impingement Risk Factors
Contributing Issues:
Weakness, inflammation, or imbalance of SITS tendons
Scapular factors due to poor postural adaptations, position, motion restrictions, or neuromuscular control issues
Capsular hyper/hypomobility
Neurological scapular winging(Source: Physiopedia, 2023)
Page 14: Frozen Shoulder (Adhesive Capsulitis)
Characteristics:
Painful condition with significant restriction in active and passive ROM
Tight, inflexible joint capsule
Restricted movements include external rotation and abduction
Affected Population:
Common in individuals aged 40-65; more prevalent in women
Can occur secondary to GH pathology, trauma, or idiopathic causes
Pain Symptoms:
Anterior/lateral shoulder pain that does not extend to the elbow
Page 15: Subjective Data Gathering
Intake Details:
Update health history forms as per CMTO
Consider age-related factors and underlying health conditions
Evaluate impact on ADLs
Document pain location, onset, mechanism of injury, and description
Family history and medications should be recorded
Consider the circle of care and any additional information(Source: Magee & Manske, 2021)
Page 16: Shoulder Pain Descriptors
Type of Pain by Structure:
Cramping, dull, aching: Muscle and ligament/joint capsule pain
Sharp, shooting: Nerve root pain
Deep, nagging, dull: Nerve pain
Sharp, severe, intolerable: Bone pain
Throbbing pain: Fracture and vasculature pain(Source: Wilson, 2023)
Page 17: Pain Severity and Activity Relation
Severity Levels:
Level 1: Pain after activity
Level 2: Pain at start, subsides with warm-up
Level 3: Pain during/after activity, no performance impact
Level 4: Pain during/after that affects performance
Level 5: Pain with ADLs
Level 6: Constant dull ache at rest, no sleep disturbance
Level 7: Dull ache at rest that disturbs sleep
Page 18: Objective Data Collection
Assessment Components:
Vitals
Posture
Gait
ROM
Special Orthopedic Tests (SOTs)
Palpation
Observations (e.g., bruising/swelling, deformity)(Source: Magee & Manske, 2021)
Page 19: Active Range of Motion (AROM) Assessment
AROM Measurement Ranges:
Assess willingness to move
Acromioclavicular painful arc: 180°
Glenohumeral painful arc: 120°
Painful arc observed at 45-60°
Page 20: Passive ROM Assessment
ROM Assessment:
Evaluate joint end range in degrees
End Feel Quality:
Normal
Abnormal:
Empty = restricted by pain
Capsular = may feel like tissue stretch but restriction occurs earlier in ROM and has a thicker quality(Source: Clinical Physio, 2019)
Page 21: Resisted Range of Motion (RROM) Assessment
Assessing Contractile Tissue Issues:
Strong & Pain-Free: No lesion, possible pain on palpation
Strong & Painful: Lesion of muscles/tendons (1st or 2nd degree)
Weak & Painful: Possible fracture with weakness due to inhibition
Weak & Pain-Free: Muscle rupture (3rd degree strain), or nerve involvement(Source: Clinical Physio, 2020)
Page 22: Special Orthopedic Tests for Shoulder
Shoulder Impingement Tests:
Near
Hawkins-Kennedy
Supraspinatus Tear Tests:
Empty Can Test
Drop Arm Test
SLAP Lesions:
Labral Crank
Speed's Test (also evaluates SLAP)
Yergason’s Test (also for transverse humeral ligament)
Arthritic Changes:
Ellman’s Compression Rotation Test
Page 23: Differential Assessment Activity
Activity Description:
Small group work on assigned scenarios
Perform ROM and SOTS of the GH region
Conduct combination of SOTs
Form a clinical impression and communicate findings
Page 24: Treatment of Chronic Supraspinatus Tendon Pathologies & Impingement
Duration:
45-60 minutes
Areas to be Treated:
Upper body positioning for comfort, support posture, access structures
Treatment Goals:
Decrease pain through techniques like effleurage and rhythmical mobilizations
Rest muscle tone in primary and compensatory areas through various techniques
Improve biomechanical motion using fascial techniques and joint play
Page 25: Treatment Goals Continued
Focus Areas for Trigger Points:
Trapezius, levator scapula, SITS muscles, deltoids, pectoralis major/minor, latissimus dorsi, biceps, triceps
Emphasis on lateral border of scapula and external rotators (infraspinatus & teres minor)
Page 26: Treatment Goals Continued
Additional Treatment Goals:
Normalize joint integrity (fascial, cross-fiber friction techniques)
Increase muscle performance with rhythmic mobilization and specific techniques
Example: Cross Fiber Friction of Supraspinatus(Source: International Academy of Orthopedic Medicine, 2015)
Page 27: Glenohumeral Joint Play Examples
Inferior Glide:
Used to increase ROM (abduction and flexion) and decrease pain at the GH joint
Posterior Glide:
Used to increase ROM (internal rotation and flexion) and decrease pain at the GH joint(Source: Edmond, 2017)
Page 28: Trigger Point Pain – Front Shoulder
Affected Muscles:
Infraspinatus
Deltoid
Scalenes
Supraspinatus
Pectoralis
Biceps(Source: Tiggerpoint.net, 2020)
Page 29: Trigger Point Pain – Back Shoulder
Affected Muscles:
Trapezius
Levator Scapulae
Teres Major/Minor
Subscapularis
Triceps(Source: Tiggerpoint.net, 2020)
Page 30: Treatment Cautions & Contraindications
Special Considerations:
Require special consent for chest region documented in charts
No frictions with anti-inflammatory medications (NSAIDs)
Avoid corticosteroid injections for 14-21 days
Proceed with caution if the patient is on pain-relieving medications; consider patient consent(Source: Rattray & Ludwig, 2005)
Page 31: Case Study – Shane the Swimmer
Patient Profile:
20-year-old competitive swimmer with left supraspinatus pain and ongoing impingement
Training 6 days a week with little health history
Reports pain increasing towards the end of training
Goals:
Decrease left shoulder pain
Reduce upper back and chest stiffness
Page 32: Peer Exchange Activity
Treatment Activity:
30-minute treatment sessions in prone and supine positions focusing on back, neck, chest, and arms
Address fascial restrictions and trigger points as discussed
Review SITS anatomy and perform GH joint mobs and rhythmic mobilizations
Incorporate hot hydrotherapy and passive/PNF stretching
Page 33: Static Stretch Examples for Rotator Cuff
Stretches:
Supraspinatus Stretch (using towel or dowel)
Infraspinatus & Teres Minor Stretch
Subscapularis Stretch (using broom handle or towel)(Source: Bradford Family Chiropractic, 2020; Wilk, Hooks, & Macrina, 2023; Sports Injury Clinic, 2011)
Page 34: Strengthening Exercises for Rotator Cuff
Exercises:
Internal Rotation (subscapularis)
External Rotation (infraspinatus, teres minor)
Scapular Squeezes (mid traps, rhomboids)(Source: Sports Injury Clinic, 2023)
Page 35: Exercise Prescription
Prescription Details:
Frequency: 1x day, in the morning after a shower
Intensity: tension, no pain
Duration: 30 seconds
Type: Static triceps stretch with towel
Observe technique and ensure safety; discontinue if pain occurs
Page 36: General Prognosis for Supraspinatus Injury & Impingement
Treatment Schedule:
2-3 times a week for weeks 1-2
1-2 times a week for weeks 3-4
Efficacy of Treatment:
Combined massage with therapeutic exercise is more effective for managing impingement
Outcomes depend on duration of inflammation before treatment
Page 37: Shoulder Pain Mapping
Common Conditions Mapped:
E: Clavicle Injury
F: Brachial Neuritis
G: SCJ Injury
H: ACJ Injury
I: Supraspinatus Acute Tendonitis
J: Heart Attack
K: Mid-Shaft Fracture(Website Reference: shoulder-pain-explained.com)
Page 38: Common Fractures of GH Region
Fracture Types:
Clavicle fracture (most common)
Humerus and scapula fractures (less common)
Causes:
Trauma, falls, car accidents, direct blows to shoulder, sport-related injuries(Source: Unknown Author)
Page 39: Glenohumeral (GH) Dislocation Types
Dislocation Types:
Anterior: Most common, caused by falling on an outstretched arm
Posterior: Less common, high-energy trauma with humerus in flexion and adduction
Inferior: Least common, traumatic falls (motorcycle incidents)(Source: Kisner, Colby, & Borstad, 2018)
Page 40: Acromioclavicular (A/C) Separation Causes
Cause:
Falling on outstretched arm or shoulder
Distal end of clavicle displaces posteriorly and superiorly
Ligaments supporting A/C joint may rupture(Source: Kisner, Colby, & Borstad, 2018)
Page 41: Rotator Cuff (SITS) Strains
Strain Definition:
Injury involving supraspinatus, infraspinatus, teres minor, and subscapularis
Most Commonly Injured:
Supraspinatus (95% of injuries)
Causes:
Trauma, overuse, fall on outstretched hand
Graded Severity:
1: microtear
2: rupture of fibers
3: complete rupture
Symptoms:
Weakness, loss of function, pain influenced by risk factors like age, smoking, and diabetes(Source: Kisner, Colby & Borstad, 2018; Physiopedia, 2023)
Page 42: Assessing Acute GH Injuries
Assessment Steps:
Comprehensive intake and documentation processes
Focused pain-related questions (LORD FICARAH)
Record vitals, posture, and gait observations
Avoid removing slings or supportive braces; AROM may be demonstrated
All other assessments contraindicated; assess compensatory areas(Source: Magee & Manske, 2021; Rattray & Ludwig, 2005)
Page 43: Considerations for Acute GH Injury Assessment
Future Assessments:
Consider evaluating compensating areas for injuries
Assess if injury has been diagnosed by another healthcare provider
Possible rescheduling or referral recommended
Page 44: Signs & Symptoms of Acute Injuries
Common Symptoms:
Snapping or popping noise at injury
Patient describes joint instability and severe pain
Signs of bruising, swelling, or joint deformity
Possible injuries to nerves, bones, or blood vessels in the area(Source: Rattray & Ludwig, 2005)
Page 45: Preparing for Treatment
Patient Communication:
Discuss attire requirements (tank top, buttons) prior to appointment
Consider if patient needs assistance with changing clothes
Page 46: Treatment of Acute GH Pathologies
Treatment Areas:
Neck, unaffected shoulder, arm and hand, and chest (with consent)
Focus of Treatment:
Decrease pain and SNS firing
Reduce edema and maintain ROM in compensating areas
Duration:
30-45 minutes(Source: Andrade, 2014; Rattray & Ludwig, 2005)
Page 47: Positioning for Acute GH Treatment
Positioning Options:
Seated with arm supported or supine (may require assistance)
Side lying position with the affected side up, considering patient’s comfort
Page 48: Draping for Treatment of Acute GH Pathologies
Draping Options:
Working over clothing
Assisted "Toga Style" Drape
Medical gown or tank tops – permission required for moving straps
Involvement of sports bras(Source: Unknown Author)
Page 49: RICE Treatment for Acute GH Pathologies
RICE Principles:
Rest, Ice, Compression, Elevation of the affected area
Consider the weight of ice or gel pack for treatment
Superficial Techniques:
Lymph drainage towards terminus with possible cross-drainage if necessary
Caution advised when treating cervical spine due to protective spasm(Source: Unknown Author)
Page 50: Distal and Compensating Treatment
Distal Treatment Techniques:
Static contact, gentle muscle squeezing for comfort
Compensating Areas:
Treatment within pain tolerance; kneading and muscle squeezing while avoiding pain-inducing techniques(Source: Unknown Author)
Page 51: Treatment Cautions & Contraindications
Avoidances:
Do not remove protective spasms in cases of acute dislocation
Avoid positioning limb as per injury causes
Referrals required for suspected tears
Caution with anti-inflammatory medications and patient consent to treatment(Source: Rattray & Ludwig, 2005)
Page 52: Self-Care Recommendations
Self-Care Instructions:
Rest and ice (with barrier) on affected areas
Immobilization may be needed for 2 weeks in 40+ inactive populations
Incorporate pain-free AROM of unaffected shoulder and neck; caution with neck stretches
Page 53: Complementary Modalities
Additional Treatment Modalities:
Low-level light therapy to promote healing
Acupuncture for reduced inflammation and enhanced healing
Kinesiology taping & bracing to control inflammation and provide stability
Page 54: Treatment Frequency & Expected Outcomes
Frequency Recommendation:
Shorter, more frequent treatments to address inflammation: 2-3 times a week
Progress to 1 treatment per week over time
Outcome Factors:
Patient’s overall health, age, pre-injury activity levels, injury history/severity, compliance with care