Tendinosis & Subacromial Impingement Syndrome

1. Tendinosis & Subacromial Impingement Syndrome Gene Desepoli, LMT, D.C.

2. 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!

3. “He who treats the site of pain is lost. - Karel Lewit

4. 7 Joints of the Shoulder Region 1. Glenohumeral 2. Subdeltoid (false joint) 3. Acromioclavicluar 4. Scapulothoracic (false joint) 5. Sternoclavicular 6. Costosternal 7. Costovertebral

5. The 7 Joints of the Shoulder Region

6. Bony Anatomy Review • Scapula

7. Bony Anatomy Review • Humerus

8. Soft Tissue Review

9. Soft Tissue Review

10. 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 !!!!

11. 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!

12. Rotator Cuff

13. 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

14. Rotator Cuff • Supraspinatus…………Abduction • Infraspinatus…………..External rotation • Teres Minor……………External rotation • Subscapularis…………Internal rotation

15. Rotator Cuff: Supraspinatus • Abduction • Passes under acromion process • Most commonly injured or torn • “Suitcase muscle”

16. 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)

17. Rotator Cuff - Infraspinatus • External rotation • Pulls humerus downward with abduction • Eccentric contraction

18. Rotator Cuff – Teres Minor • External rotation • Pulls humerus downward with abduction

19. Rotator Cuff - Subscapularis • Internal Rotation • Adduction • Stabilizes humerus • Pulls humerus downward w/ abduction • Eccentric contraction

20. Glenohumeral Joint • Designed for flexibility at the expense of stability • Static stabilizers – capsule and ligaments • Dynamic stabilizers – rotator cuff muscles

21. Posture and the Glenohumeral Joint

22. 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)

23. 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

24. Capsular Support Capsule loose Capsule taut

25. 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

26. Biomechanics of Abduction of the Humerus

27. 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!

28. 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!

29. Biomechanics of Abduction External rotation of the humerus occurs due to untwisting of the capsule Tight internal rotators my prevent this!

30. Impingement (pinching) • Bones: acromion and greater tubercle • Soft tissue: supraspinatus tendon & subacromial bursa

31. 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.

32. Coracoacromial Arch • An additional site of impingement

33. 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.

34. Scapulohumeral Rhythm

35. Deltoid Muscle

36. 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

37. Abduction of Humerus • Infraspinatus & Teres Minor

38. Force Coupling

39. The Painful Arc • There is pain during abduction in the range from 45-60 to 120 degrees.

40. 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

41. Progression of Rotator Cuff Tears Tight pectoral muscles  Round shoulders  Impingement  Supraspinatus Tendonosis/ Tendonitis  Calcific Tendonitis  Rotator cuff tear !!

42. Surgery may be preventable. • The real heroes and competent level of massage therapy deals with early recognition and prevention.

43. 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

44. Tendonitis / Tendonosis

45. Tendonitis / Tendonosis • Causes overuse poor body mechanics • Pathology muscle cell damage (tearing, irritation) microinflammation fibroblasts microscarring

46. 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

47. 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.

48. Rotator Cuff Tendinosis • Supraspinatus: pinpoint pain at greater tubercle painful active abduction painful passive adduction stretch

49. Rotator Cuff Tendinosis • Infraspinatus & Teres Minor: pinpoint pain at greater tubercle painful active external rotation painful passive internal rotation stretch

50. Rotator Cuff Tendinosis • Subscapularis: pinpoint pain at lesser tubercle painful active internal rotation painful passive external rotation stretch