Shoulder

repetitive compression or rubbing of the tendons (mainly supraspinatus) under coraco-acromial arch i.e. subacromial space during abduction -> conjoint tendon slides under coraco-acromial arch abduction approaches 90 deg -> subacromial space narrows internal rotation -> narrower, external rotation -> wider naturally, at 90 deg abduction -> arm externally rotates to increase the space activities with repeated int. and ext. rotation (window cleaning, wall painting) -> compression, rubbing, friction of the tendon -> impingement syndrome Impingement Position -> abduction, slight flexion, internal rotation Site of impingment -> critical area of diminished vascularity in the supraspinatus tendon about 1 cm proximal to its insertion into the greater tuberosity Intrinsic factors degeneration of the tendon (age-related, cell-mediated) changes in the presence of highly sulphated glycosaminoglycans changes in the collagen composition with loading. Changes in vascularity All these changes -> rotator cuff dysfunction -> upward displacement of the humeral head -> subsequent extrinsic compression. Extrinsic factors spurs growing down the coracoacromial ligament a laterally sloping acromion osteoarthritic thickening of the acromioclavicular joint Effects friction -> tendinitis (edema, swelling) -> usually self-limiting prolonged / repetitive -> minute tears -> scarring, fibrocartilaginous metaplasia, calcification in the tendon healing -> vascular reaction -> local congestion -> narrowing of the space -> further impingement slow healing / sudden strain -> microscopic tear extends -> partial / full thickness tear -> loss of abduction large tears -> disturbed shoulder mechanics -> osteoarthritis of the glenohumeral joint Clinical features typically those of a Rotator Cuff Syndrome Subsequent progress depends on the stage of the disorder, the age of the patient and the vigour of the healing response 3 patterns subacute tendinitis chronic tendinitis cuff disruption Subacute tendinitis (painful arc syndrome) anterior shoulder pain after vigorous/unaccustomed activity tenderness along the anterior edge of acromion (easily elicited on extension) often reversible, relieves spontaneously by activity modification Chronic tendinitis recurrent attacks of subacute tendinitis pain relieves with rest, anti-inflammatory treatment recurs with more demanding activity pain is worse at night, patient cannot lie on the affected side pain restricts even simple activities like hair grooming, dressing signs of bicipital tendinitis (tenderness in the bicipital groove, crepitus on moving tendon) Most advanced stage is progressive fibrosis and cuff disruption. Patient gives history of refractory shoulder pain, increasing stiffness and weakness. ...

Phase I (1-2 weeks) passive of active-assisted ROM exercises in pain-free ranges improve or maintain motion provide gentle stress for healing collagen tissue optimize subacromial gliding mechanism phase I ROM -> forward elevation and external rotation, hold for 10 seconds, 10 times each, 2 times daily. both exercises should be pain free phase II ROM -> extension, internal rotation, cross-body adduction, hold for 10 seconds, 10 times each, 2-4 times daily phase I strengthening exercises (using elastic bands / free weights) -> external rotation, internal rotation, flexion, extension Phase II (2-4 weeks) pain and inflammation has resolved, ROM & strength improved sleeper stretch -> hold for 10 seconds, 5 times wall stretch & stretch behind the head phase II strengthening (after reaching level 3 resistance in all phase I strengthening exercises) -> abduction and forward elevation to 45 degrees & external rotation at 45 degrees total arm strengthening with biceps and triceps exercises scapular strengthening exercises -> horizontal abduction with scapular retraction, external rotation with elastic resistance Phase III ROM should be full and pain-free athletes will progress to higher-level exercises involving functional combination movements in more provocative positions Phase IV Athletes should continue with the rotator cuff, deltoid, and scapular exercises with a bias toward sport-specific positions

This comprises of at least four conditions supraspinatus impingement and tendinitis tears of the rotator cuff acute calcific tendinitis biceps tendinitis and/or rupture. Symptoms pain and/or weakness during certain movements of the shoulder. Pain may have started recently, sometimes quite suddenly, after a particular type of exertion; the patient may know precisely which movements now reignite the pain and which to avoid. Rotator cuff pain over the front and lateral aspect of the shoulder during activities with the arm abducted and medially rotated may be present even with the arm at rest tenderness is felt at the anterior edge of the acromion. site association in front along the delto-pectoral boundary biceps tendon over the top of the shoulder acromio-clavicular pathology at the back along the scapular border cervical spine Rotator Cuff Anatomy The rotator cuff comprises the lateral portions of the infraspinatus, teres minor, supraspinatus and subscapularis muscles and their conjoint tendon which is inserted into the greater and lesser tuberosity of the humerus. ...