Osteopathic Considerations in Shoulder Pain. Kristen Brusky DO February 22, 2018

Transcription

1 Osteopathic Considerations in Shoulder Pain Kristen Brusky DO February 22, 2018

2 Overview Importance of pectoral girdle Ligaments, ligaments tensegrity Bones, joints, muscles Neurovasculature Innervation dermatomal and peripheral Myofascial Pain Syndromes It s all connected!

3 3 Bones, 3+1 joints, 17 muscles

4 The 17 muscles are

5 Deltoid Trapezius Infraspinatus Supraspinatus Teres minor Subscapularis Levator scapulae Omohyoid Rhomboid minor Rhomboid major Serratus Anterior Latissimus Teres Major Triceps long head Biceps long, short Coracobrachialis Pectoralis Minor

6 Pectoral Girdle

7 Clavicle

8 Allows Full ABduction

9 Acromioclavicular Joint

10 Scapulocostal (Pseudo) Joint

11 Scapula

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13 Humerus

14

15 Labrum

16 Gilroy Atlas of Anatomy p268

17 Gilroy Atlas of Anatomy p269

18 Gilroy Atlas of Anatomy p273

19 Gilroy Atlas of Anatomy p264

20 Gilroy Atlas of Anatomy p265

21 Gilroy Atlas of Anatomy p273

22 Gilroy Atlas of Anatomy p322

23 Dermatomes

24 Gilroy Atlas of Anatomy p330

25 Gilroy Atlas of Anatomy p327

26 Gilroy Atlas of Anatomy p325

27 Gilroy Atlas of Anatomy p325, 346

28

29

30 To The Extremity and Beyond. Supraspinatus Syndrome Deltoid Syndrome Teres Major Syndrome Scapulocostal Syndrome Thoracic Outlet Syndrome Adhesive Capsulitis

31 Supraspinatus Syndrome (M79.7) Symptom Presentation: exquisite tenderness superior border of the scapula. Pain on ROM and pain referred to the shoulder in a non dermatomal pattern. Mechanics: repetitive overhead trauma, a single injury, or chronic deconditioning of the agonist and antagonist muscle unit.

32 Supraspinatus Syndrome Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function Treatment: Trigger point injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI. Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation

33 Deltoid Syndrome (M79.7) Symptom Presentation: trigger points in both the anterior and posterior deltoid fibers. Mechanics: Flexionextension and lateral motion stretch injuries, repetitive lifting or impact injuries.

34 Deltoid Syndrome Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function Treatment: Trigger point injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI. Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation

35 Teres Major Syndrome (M79.7) Symptom Presentation: trigger points lateral to scapula. Mechanics: Stretch or impact injuries sustained while playing sports or MVAs in addition to falls onto the lateral scapula. Repetitive reaching up and behind

36 Teres Major Syndrome Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function Treatment: Trigger point injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI. Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation

37 Scapulocostal Syndrome (G56.80) Symptom Presentation: Unilateral pain and paresthesias at medial scapula. Referred pain from deltoid to dorsal hand. Decreased scapula ROM. Mechanics: repetitive reaching backward to retrieve items causing overuse of scapular stabilization muscles.

38 Scapulocostal Syndrome Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function Travelling Salesman s Shoulder Treatment: Trigger point injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI. Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation

39 Gilroy Atlas of Anatomy p333

40 What If no improvement after TPI? tight muscles overstretched muscles weakness of other surrounding muscles cross pattern imbalance primary hypermobility of joint additional injury

41 Thoracic Outlet Syndrome (G54.0) Symptom Presentation: ache or paresthesias at neck with radiation into the shoulder Mechanics: compression of the neurovascular bundle due to cervical rib, hypertonicity of anterior and middle scalenes, somatic dysfunction of the clavicle or upper ribs, abnormal insertion of the pectoralis minor

42 Thoracic Outlet Syndrome Special tests Adson s (compression between the scalenes), Wright s (compression under the pectoralis minor), Military posture (compression between clavicle and 1 st rib). Treatment OMT, PT, OT, gabapentin, carbamazepine (SE: aplastic anemia), pregabalin, baclofen, nerve block

43 Gilroy Atlas of Anatomy p336

44 Gilroy Atlas of Anatomy p316

45 Adhesive Capsulitis (M75.00) Symptom Presentation: aching anterior shoulder, grating/ popping and decreased PROM/ AROM typically after prolonged immobility and age over 40 years. Pain affects sleep. Worse with abduction, internal and external rotation. Extension is typically preserved. Mechanics: formation of fibrous adhesions.

46 Two Categories Within Shoulder Rotator Cuff Tendinopathy Subdeltoid Bursitis Biceps Tendinopathy Other Diseases Stroke Diabetes Myocardial Infarction Reflex Sympathetic Dystrophy

47 Adhesive Capsulitis Prevention is the best treatment option; early mobilization after shoulder injury. Treatment NSAIDs, COX-2 inhibitors, PT, rest, heat, corticosteroid injection, NSAIDs, rest, heat; OMT Spencer technique, GH joint, upper thoracic

48 The 1 Connection.Fascia

49 Think about the fascia

50 Gilroy Atlas of Anatomy p330, 331

51 3 Bones, 3+1 joints, 17 muscles

52 Pectoral Girdle

53

54 To know all of a bone in its entirety would close both ends of an eternity. A. T. Still MD

55

56 Resources Abbasi, D. & Keener, J. Biceps Tendonitis. Retrieved from Armstrong, A. D. & Hubbard, M. C. (2016) Essentials of Musculoskeletal Care 5 th Ed. Rosemont, IL: American Academy of Orthopedic Surgeons Chung, K. W. & Chung, H. M. (2008) BRS Gross Anatomy 6 th Ed. Baltimore, MD: Lippincott Williams & Wilkins. DeStefano, L (2011) Greenman s Principles of Manual Medicine 4 th Ed. Baltimore, MD: Lippincott Williams & Wilkins. DiGiovanna, E. L., Schiowitz, S. and Dowling, D. J. (2005) An Osteopathic Approach to Diagnosis and Treatment 3 rd Ed. Baltimore, MD: Lippincott Williams & Wilkins. Gilroy, A. M., MacPherson, B. R. and Ross, L. M. (2008) Atlas of Anatomy. New York, NY: Thieme Medical Publishers, Inc. Magee, D. J. (2014) Orthopedic Physical Assessment 6 th Ed. St. Louis, MO: Elsevier. Moore, K. L. & Dalley, A. F. (1999) Clinically Oriented Anatomy 4 th Ed. Baltimore, MD: Lippincott Williams & Wilkins. Myers, T. W. (2009) Anatomy Trains 2 nd Ed. China: Elsevier. Savarese, R. G. (2003) OMT Review 3 rd Ed. OMT Review. Simons, D. G., Travell, J. G. and Simons, L. S. (1999) Myofascial Pain and Dysfunction The Trigger Point Manual 2 nd Ed. Baltimore, MD: Williams & Wilkins. Waldman, S. D. (2012) Atlas of Common Pain Syndromes 3 rd Ed. Philadelphia, PA: Elsevier.