TIPS FOR SUCCESSFUL SHOULDER TREATMENT. In Service Training 16 th May 2014

Transcription

1 TIPS FOR SUCCESSFUL SHOULDER TREATMENT In Service Training 16 th May 2014

2 Training day aims to address: Controversies of impingement syndrome diagnosis Controversies of MRI/USS imaging Clinical diagnosis of impingement syndrome Examination of the shoulder Treatment options

3 1. Controversies surrounding the diagnosis of subacromial impingement syndrome How would you explain subacromial pain syndrome to your patients?

4 Controversies surrounding the diagnosis of subacromial impingement syndrome Acromial irritation driven model ( Neer 1972) Motor control model ( Vincenzino 2008) Rotator cuff tendonopathy model (McCreesh and Lewis 2013)

5 Rotator cuff dynamic stability is what matters

6 What maintains functional stability Static restraint: Ø Capsulo-ligamentous ØConcavity-compression ØLabrum Dynamic restraints ØRotator cuff ØScapular stabilisers ØDeltoid/Long head of biceps

7 Local system Mechanoreceptors in capsuloligamentous structure influence muscle recruitment Cuff needs to be active through range Lax patients have a 4/5 x higher injury rates

8 Subacromial impingement syndrome: Current Theories ( Vincenzino 2008)

9 2. Controversies surrounding MRI /USS imaging of rotator cuff pathology Incidence of PTT / FTT was present in greater than 50% of Asymptomatic subjects aged greater than 50 years (Sher et al 1995, Milgrom et al 1995)

10 Controversies surrounding MRI /USS imaging of rotator cuff pathology Current scanners have increased power and resolution 51 asymptomatic males aged abnormalities were found in 90% of participants ( Girish et al 2011) Treatment should be based on clinical NOT on imaging findings Do not feed patients fears and anxiety re:repair

11 3. Clinical Diagnosis of shoulder impingement syndrome Do you have a strategy to approach a clinical diagnosis and guide treatment?

12 Clinical Diagnosis of shoulder impingement syndrome 70% decision making comes from the subjective: Pain location and mechanism, age, co- morbidites and mechanism of injury Structural incompetence Dynamic weakness Compromise due to stiffness / laxity Compromise due to biology Studies have failed to adequately define the condition

13 Impingement syndrome classification based on site of encroachment (Cools et al 2012) EXTERNAL: Soft tissue encroachment Hu head and sub-acromial arch. INTERNAL: Soft tissue encroachment Hu head and glenoid rim.

14 Impingement syndrome classification based on mechanism of problem (Cools et al 2012) PRIMARY ACJ arthropathy Gtr tuberosity # R.C. tendonopathy SECONDARY R.C. tendonopathy Scapular dyskinesis GHJ stiffness GHJ instability Biceps tendonopathy SLAP GIRD Thx kyphosis/ Cx lordosis

15 Impingement syndrome: Physical examination ( Hegedus 2012) Physical examination tests to make a pathognomonic diagnosis cannot be unequivocally recommended Len Funk Orthopaedic surgeon shoulder tests EMG studies of full and empty can tests in 15 asymptomatic subjects is not specific for activation of supraspinatus. EC = 9 other shoulder muscles equally activated to S.spin FC = 8 other shoulder muscles equally activated to S.spin

16 Impingement syndrome: Physical examination (Michener et al 2009) Diagnostic accuracy of 5 tests of impingement: Neer, H-Kennedy, painful arc, empty can and ext rotation resistance test N = 55 patients with shoulder pain examined in an orthopaedic setting by ortho surgeon and physio). Clinical diagnosis was then correlated to arthroscopy findings. Combination of 3+/5 tests may help rule in, whereas less than 3/5 may help rule out RULE IN: Painful arc, ER resistance, Empty can RULE out: Painful arc, ER resistance test, Neer

17 Rotator Cuff Reflex loop Pre-setting Translation control Feed forward / feedback Proprioception Cuff works to stabilise head in the opposite direction to forces

18 Tendonopathy 4 Primary changes Cellular activation or degeneration Increase proteoglycans Collagen disruption Neural and vascular in growth

19 4. Physical examination

20 Scapula dyskinesis

21 Scapula dyskinesis Impingement Serratus Anterior Upper Trapezius Upward rotation Posterior tilt Switch on cuff and re-assess dyskinesis

22 Impingement physical examination Aggs: lat reaching, overhead, ER at 90 abduction, HF with IR Painful arc Jobe full and empty can Hawkins Kennedy Neer s sign External rotation resistance

23 Biceps tendonopathy / SLAP Aggs: winding window, flexion with reaching, opening jars, shoulder rotation, Yergason s Speed s Pain through external rotation Palpation LHB O Brian s Biceps load II

24 Shoulder pain modification procedures (Lewis 2009) Cervical / thoracic spine Scapular assistance Scapular repositioning Humeral head repositioning Kinetic chain 90% patients will get better with rehab if onset insidious and pain reduced with modification procedures

25 Treatment exercise Know your pathology (reactive or degenerative / settle LHB tendonopathy before rehab cuff) Assessment becomes treatment Set system up for success Switch on Warm up through range Then drill Be realistic cuff pathology 3/12 cuff tear 6-9/12

26 Treatment of a reactive tendon / bursitis Relative rest (decrease tendon load) Gentle movement (2/10 inc in VAS) Do not overload tendon no theraband / weights No high load or eccentric ex Pain relief (cervical spine, isometric, paracetamol ) Taping Injection if rehab limited Ibuprofen

27 Treatment of degenerative cuff tear, tendonopathy or impingement syndrome Set up system for success: Unload and reduce pain Optimise scapular positional / postural component Restore functional shoulder ROM Address central dysfunction Whole body system adequate trunk,hip ROM Warm-up through range GHJ and Scap:Thx co-ordination Kinetic chain Specific exercise: Address scapular / rotator cuff strength Functional rehab

28 Treatment manual therapy Cervical spine (Vincenzino et al 2008 McClatchie et al 2009) Thoracic spine stiffness Scapular passive mobility / neural tension GHJ stiffness Neuophysiological release of overactive / short muscle groups

29 Treatment Yellow Flags Acknowledge Summarise and paraphrase Address Pathological beliefs

30 Treatment exercise Optimise sensory input Easier if exercises are: proprioceptive dynamic functional external rotation load closed-chain kinetic chain facilitate scapular neutral

31 Treatment exercise Load tendon to functionally relevant levels High load Eccentric / fast / high weights / ply- ometrics Allow 48 hours between drills to allow for recovery and adaption

32 Treatment exercise Exercise works Majority of patients get better Manual therapy effective Realistic timescales

33 REFERENCES Cools et al (2012) Screening the athlete s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. Br J of Sports Med 42: Hegedus (2012) Which clinical tests provide the most value when examining the shoulder. Br J of Sports Med 46: Sher (1995) JBJS 77A Girish (2011) Ultrasound of the shoulder. Asymptomatic findings in men. American J of Roentgenology Lewis (2009) Rotator cuff tendonopathy / subacromial impingement syndrome: is it time for a new method of assessment? Br J of Sports Med 43 (4) McClatchie 2009 Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Manual Therapy 14 (4)