Rotator cuff tendinopathy

Question 1

what are the 4 rotator cuff muscles?

Answer 1

-supraspinatus
-infraspinatus
-subscapularis
-teres minor

Question 2

what is the anterior cuff vs the posterior cuff?

Answer 2

• subs cap - anterior cuff - biggest RC muscle
  -infraspinatus, supraspinatus and teres minor make up the posterior cuff

Question 3

what other muscle gives the shoulder some anterior support?

Answer 3

the long head of biceps muscle

Question 4

in shoulder flexion met, are the anterior or posterior cuff muscles working?

Answer 4

• flexion - posterior cuff muscles are working

Question 5

in shoulder extension, are anterior or posterior cuff muscles working?

Answer 5

anterior cuff muscles are working during extension

Question 6

how is the function of a tendon in the lower limb different to a tendon in the lower limb for eg, the achilles tendon?

Answer 6

• the tendons in the lower limbs are like springs, also the body weight is the load
  -upper limb tendons are not as reactive as lower limb tendons, they absorb energy and compressive forces swell as controlling friction and shear

Question 7

what does tendon pathology occur with?

Answer 7

it occurs with a change in load or function

Question 8

what are the 3 phases of tendinopathy?

Answer 8

-reactive tendinopathy
-tendon dysrepair
-degenerated tendon

Question 9

what is 66-85% of ALL shoulder complaints down to?

Answer 9

rotator cuff related shoulder pain (RCRSP)

Question 10

what is rotator cuff related shoulder pain?

Answer 10

• pain & weakness in the shoulder, most commonly associated with elevation (flex/abduction) and external rotation due to excessive load on the RC tissues

Question 11

what is the most common age for rotator cuff related shoulder pain?

Answer 11

those aged 40+

Question 12

what are extrinsic mechanisms that are related to rotator cuff pathology?

Answer 12

-those with originate external to the tendon that cause compression or shear

Question 13

what are intrinsic mechanisms in relation to rotator cuff pathology?

Answer 13

-those which originate within the tendon eg degenerative processes associated with aging

Question 14

what are some examples of intrinsic risk factors that could cause rotator cuff pathology?

Answer 14

-male sex
-menopause
-genetics
-systemic inflammatory or autoimmune conditions
-diabetes
-increased BMI
-increased adiposity
-structural or biomechanical abnormalities

Question 15

what are examples of extrinsic risk factors related to rotator cuff pathology?

Answer 15

• change in load (over or under) applied to the tendons eg training amount, activity levels, repeated overhead activity
  -change in muscle;e activity of the shoulder and scapular muscles
• smoking
  -alcohol

Question 16

upon subjective exam, what are signs and symptoms of rotator cuff related shoulder pain?

Answer 16

-pain in super/lateral and anterior shoulder
-pain worse with overhead activity
-pain worse with compression eg night pain (laying on shoulder)
-pain at rest

Question 17

what are signs and symptoms of RCRSP during physical examination?

Answer 17

-pain with shoulder mats
-painful arc - between 70-120 degrees ( abduction - arm is at heaviest at these angles)
-pain & weakness when testing RC in neutral and through range
-special tests will all reproduce pain
-pain on palpation of cuff +/- tendon

Question 18

what is the full can test?

Answer 18

• test used to assess the function of the supraspinatus muscle and tendon of the shoulder complex
  -patient flexes arm to 90 degrees and externally rotates the arm with thumbs pointing up and physio should apply a downward force
  -positive test -pain and or weakness

Question 19

what is the empty can test?

Answer 19

• assesses for lesions in supraspinatus muscle and tendon
  -patient flexes arms to 90 degrees and internally rotate arms with thumbs down
  -physio applies a downward resistance
  -positive test = patients pain is reproduced and or weakness

Question 20

Describe the painful arc

Answer 20

• arc is a test during ROM assessment - active abduction
  -onset of pain between 70-120 degrees due to poor RC control- could be due to the fact that at this point the arm is the heaviest etc

Question 21

what is Neers test?

Answer 21

• the physio should stabilise the patients scapula with 1 hand while passively flexing the arm while it is internally rotated
  -if the patient reports pain in this position, then the result of the test is positive

Question 22

what is Hawkin’s Kennedy test?

Answer 22

-shoulder is placed in 90 degrees of forward flexion & bending the elbow
-the shoulder is forcibly internally rotated
-positive if pain is reproduced

Question 23

what is the belly press test?

Answer 23

• a test used to isolate the subscapularis muscle and assess for a tear or dysfunction
  -patient sits or stands with the elbow flexed to 90 degrees, with the palm of the hand on the upper abdomen, patient is asked to press the palm of the hand against the abdomen, through shoulder internal rotation
  -positive test is there is compensation with wrist flexion, shoulder adduction and shoulder extension

Question 24

what is the problem with RCRSP special tests?

Answer 24

they are not specific

Question 25

how is RCRSP managed?

Answer 25

-patient education -setting realistic goals -address anxiety and fear of moving -reviewing baseline activity and modify -lifestyle modification - eg weight, alcohol, smoking

Question 26

how would a physio manage acute reactive tendinopathy?

Answer 26

-offload tendon by altering activity - ie keep exercise that is not pain provoking -reduce pain - eg manual therapy, short course NSAIDS -exercise should be non-provocative - gradual load of RC through range and avoiding heavy loading exercise initially

Question 27

how should chronic tendon disrepair in RC be managed with exercise?

Answer 27

-combination of isometric, concentric, eccentric - add range, low weight and high reps -functional positions -heavy slow resistance has shown no additional benefit to date - upper limb

Question 28

other than exercise, how can chronic RC tendon disrepair be managed?

Answer 28

-manual therapy if any joint stiffness -stretch any tight muscles

Question 29

what are important characteristics with a RC tear of someone aged less than 40?

Answer 29

-traumatic -increased risk with overhead or contact sports -respond very well to surgery -long road to recovery -account for less than 10% of RC tears

Question 30

what are characteristics of RC tears for older population?

Answer 30

-greater than 40 years -degenerative -end stage of tendinopathy -can reach 30% of population of 60+ years -can be pain free but will be weak

Question 31

upon subjective, what are signs / symptoms of a rotator cuff tear?

Answer 31

- history of trauma or fall if older - no trauma - but difficulties to do ADLs eg changing -inability to lift arm -pain at rest, at night or with activity -heaviness and weakness -loss of function

Question 32

upon an physical exam, what are the signs and symptoms of a rotator cuff tear?

Answer 32

-wasting at scapula and deltoid -positive break tests -pain with resisted tests -often have near full PROM but limited in AROM -acute tears can be stiffer

Question 33

what are examples of important tests for rotator cuff tears?

Answer 33

- break test - need to demonstrate that the muscle is intact -drop arm -lag sign -belly press -Oxford scale

Question 34

Describe a rupture of the long head of biceps and important points about it

Answer 34

- can be a complete or partial tear -most common in older people -often happens with low or no trauma -patient will report sharp pain with a mvt -will have associated bruising -popeye sign

Question 35

what does the conservative management of long head biceps rupture involve?

Answer 35

-relative rest and avoid aggregating exercises -working the cuff muscles -education on load management -can regain full function and pain free mat

Question 36

Describe calcific tendinitis?

Answer 36

- a build up of Ca2+ in the rotator cuff -calcium builds up in the tendon and it can cause a build up of pressure in tendon -severe pain and sudden in onset -pain at rest and night -seen in ages 30-50, rare in 70+ -more common in females than males

Question 37

how is calcific tendinitis managed?

Answer 37

-NSAIDS -surgical removal of Ca2+