Interventions and Interventions and Management of Shoulder Management of Shoulder Rotator Cuff Rotator Cuff - PDF Document

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  1. Outline Outline Interventions and Interventions and Management of Shoulder Management of Shoulder Rotator Cuff Rotator Cuff   EBM EBM   Evidence, pt values, clinical expertise Evidence, pt values, clinical expertise   Management Management   General treatment approach General treatment approach General treatment approach General treatment approach   Specific Interventions Specific Interventions   Judging improvement Judging improvement   Consensus and Controversies Consensus and Controversies   Questions and Answer time… Questions and Answer time… Lori Lori A Michener PhD, PT, ATC, SCS A Michener PhD, PT, ATC, SCS Virginia Commonwealth University Virginia Commonwealth University Medical College of Medical College of Virginia Richmond Richmond, , VA Virginia VA Not what you do, but how you sell it Not what you do, but how you sell it (Scheele J, BMC MSK, 2011; Carroll LJ, J (Scheele J, BMC MSK, 2011; Carroll LJ, J Rheumatol Evidence Based Medicine Evidence Based Medicine Rheumatol, 2009) , 2009)   Expectation of recovery Expectation of recovery   Your expectations for this episode of pain? Your expectations for this episode of pain?   Do you think your injury will get better, Do you think your injury will get better, worse, stay the same? worse, stay the same?   Do o think PT ill help this episode? Do o think PT ill help this episode?   Do you think PT will help this episode? Do you think PT will help this episode?   Any interventions in particular helpful? Any interventions in particular helpful?   Evidence Evidence   Study results Study results - - response of the majority response of the majority   Evidence: ‘first choice’ of treatment Evidence: ‘first choice’ of treatment   Pt not improving Pt not improving– – your pt is in the minority? your pt is in the minority?   Clinical expertise Clinical expertise   Valuable, however should not be used IN Valuable, however should not be used IN PLACE of evidence until evidence used PLACE of evidence until evidence used   “Selective memory” “Selective memory” – – eyewitness to a crime   Patient preference and values Patient preference and values   More important than you think! More important than you think! ** What to do with the answers? ** What to do with the answers? eyewitness to a crime PT PT – – a sales job a sales job – – not ‘what’ you do, but not ‘what’ you do, but how you sell it. how you sell it. Complaint of “Shoulder Symptom” Treatment Categories Treatment Categories Level 1 Screen History (A), Basic PE (B), Red Flags (C) Non-shoulder origin of sx Shoulder origin of sx Impingement Syndrome Instability Adhesive Capsulitis Other e.g, fracture “Too loose” “Too Tight” Specific Phys Exam (D) Level 2 M di Medical Dx “Control” l D Rotator Cuff / Impingement Frozen Shoulder Glenohumeral Instability Level 3 Rehab Dx - Subacromial Space Disorder - Anterior – Superior Shoulder pain High Irritability Moderate Irritability Low Irritability

  2. Systematic Reviews of SAIS/ Systematic Reviews of SAIS/ Sh ( (Hanratty Hanratty CE, 2012, CE, 2012, Littlewood Littlewood C, 2012, C, 2012, Brudvig Kromer Kromer TO, 2009; Kuhn JE, 2009; Ainsworth, 2007; Michener LA, 2004; TO, 2009; Kuhn JE, 2009; Ainsworth, 2007; Michener LA, 2004; Desmeules Desmeules, 2003) • • 9 9- - 16 RCTs 16 RCTs • •   pain & pain &   function / disability: function / disability: • • Exercise Exercise- - stretch & strengthen/ MC stretch & strengthen/ MC • • Exercise + manual therapy to the Exercise + manual therapy to the glenohumeral joint and spine glenohumeral joint and spine • • Home exercise programs Home exercise programs • • Passive treatments: not recommended Passive treatments: not recommended • • US: not effective US: not effective Sh P LN, 2011; P Treatment Approach Treatment Approach – – Evidence Bottom Line Up Front Bottom Line Up Front Evidence- -Based Based: : Brudvig TJ, 2011; TJ, 2011; Marinko Marinko LN, 2011; , 2003)   Unsure (limited or no evidence): Unsure (limited or no evidence):   Scapular taping Scapular taping – –immed   Scapular motor control and stabilization Scapular motor control and stabilization exercise focus exercise focus exercise focus exercise focus   Core stability training Core stability training   Eccentrics focus Eccentrics focus immed. effects only . effects only   Frequency of treatment Frequency of treatment   Progression of treatment Progression of treatment   Dose of exercise and manual therapy Dose of exercise and manual therapy Complaint of “Shoulder Symptom” High Irritability (3/5 to categorize) Moderate Irritability (3/5 to categorize) Low Irritability (3/5 to categorize) Level 1 Screen History (A), Basic PE (B), Red Flags (C) • Mod Pain (4-6/10) • Night or rest pain intermittent • Pain at end ROM •AROM ≈ PROM • Mod Disability •(DASH ASES) (DASH, ASES) • High Pain (> 7/10) • night or rest pain • consistent • Pain before end ROM •AROM < PROM High Disability • High Disability •(DASH, ASES) • Low Pain (< 3/10) • Night or rest pain • none • Min pain with overpressure •AROM equal to PROM PROM • Low Disability •(DASH, ASES) Non-shoulder origin of sx Shoulder origin of sx Specific Phys Exam (D) Level 2 M di Medical Dx l D Rotator Cuff / Impingement Frozen Shoulder Glenohumeral Instability Rx focus: • pain reduction • improve impairments • improve basic functions (self-care, domestic tasks) Rx focus: • pain reduction Rx focus: • restore higher demand functional activities (work demands, recreational and leisure activity) Level 3 Rehab Dx High Irritability Moderate Irritability Low Irritability Ant or General Ant or General Capsular Capsular Laxity Laxity Spine Spine Posture Posture Dose Dose - - Evidence Evidence   High High- -dose ( (Osteras Osteras H, Open Ortho, 2010; H, Open Ortho, 2010; Osteras   Hi Hi- -dose: dose:   pain & function 3, 6 & 12 pain & function 3, 6 & 12 months post months post   High High- -dose: dose:   1 1- -hr session, 9 hr session, 9- -11 exercises, 3 x 30 reps, 11 exercises, 3 x 30 reps, 1000 reps per treatment, aerobic ex 1000 reps per treatment, aerobic ex   Low Low – –dose: dose: 2 x 10 reps/ exercise 2 x 10 reps/ exercise dose vs vs low low- -dose chronic dose chronic imping Osteras H, H, Physiother Physiother Res imping. . Res Int Int, 2010) , 2010) Scapular Ms Scapular Ms Strength Strength RCD / imp. Treatment Treatment Category Ant Ant Sh Tightness Tightness Sh RC Strength RC Strength Post Post Sh Tightness Tightness Sh Scapular Scapular kinematics kinematics Humeral Humeral kinematics kinematics

  3. Clinical Trial of Rehab for Clinical Trial of Rehab for Imping (Tate AR, McClure PW, Young IA, (Tate AR, McClure PW, Young IA, Salvatori Salvatori R, Michener LA. JOSPT, 2009) Imping. . Key Impairments Key Impairments R, Michener LA. JOSPT, 2009) Standardized impairment evidence Standardized impairment evidence- -based Program: Program: – – Exercise Exercise – – Manual therapy: shoulder and spine Manual therapy: shoulder and spine P i d i P i d i – – Patient education Patient education – – Home exercise program Home exercise program Standardized approach for dose, Standardized approach for dose, progression, and frequency progression, and frequency Use this as the framework for Use this as the framework for defining the treatment approach defining the treatment approach based   Tightness Tightness   Weakness Weakness   Scapular Dysfunction Scapular Dysfunction Upper thoracic extension stretch Upper thoracic extension stretch Tightness Tightness Flexibility: Self Stretching Flexibility: Self Stretching Lie on top of a Lie on top of a vertically placed vertically placed towel under the towel under the thoracic spine thoracic spine Shoulders ER Shoulders ER Upper thoracic extension stretch Upper thoracic extension stretch Doorway pectoral stretch Doorway pectoral stretch Crossbody Crossbody stretch stretch Crossbody Crossbody stretch stretch Shoulder flexion stretch Shoulder flexion stretch – – Supine (phase 1) Supine (phase 1)  Shoulder ER stretch Shoulder ER stretch Shoulder IR stretch (towel) Shoulder IR stretch (towel)  standing (phase 2,3) standing (phase 2,3) Crossbody Crossbody and Pec Pec stretch stretch and Shoulder flexion Shoulder flexion stretch stretch

  4. Patient Education: Sleeping Patient Education: Sleeping posture posture Shoulder IR and ER stretch Shoulder IR and ER stretch Strengthening Strengthening and Motor Control and Motor Control Scapular Muscle Scapular Muscle   Upper Trapezius Upper Trapezius   REDUCE activity during arm elevation REDUCE activity during arm elevation   Motor control can help Motor control can help – – mirror, verbal feedback, manual feedback, manual   Exercises with more ‘vertical orientation’ Exercises with more ‘vertical orientation’ increase UT activity increase UT activity   Is it strengthening or motor control? Is it strengthening or motor control? Likely a combination Likely a combination   Rotator Cuff Rotator Cuff S l l S l l   Scapular Muscles Scapular Muscles   Other shoulder muscles Other shoulder muscles – – elevators, etc. mirror, verbal elevators, etc. Scapular Muscle Scapular Muscle   Lower trap and Serratus Lower trap and Serratus   INCREASE muscle activity at the right INCREASE muscle activity at the right time during ROM time during ROM   Lower Trap Lower Trap   LT muscle test, rows, LT muscle test, rows, scaption rows, ‘down and back’ command rows, ‘down and back’ command   Serratus Anterior Serratus Anterior   Forward punch, Forward punch, scaption scaption, knee push plus, supine punch, dynamic hug, plus, supine punch, dynamic hug, push up plus up plus Rotator Cuff Muscle Rotator Cuff Muscle   Exercise to best activate the cuff Exercise to best activate the cuff   IR and ER IR and ER   Shoulder elevation Shoulder elevation – – also hi levels of cuff cuff also hi levels of scaption, lower , lower   Respect pain levels and muscle Respect pain levels and muscle ability to determine start point and ability to determine start point and progression progression , knee push- -up up push- -

  5. ER and IR ER and IR at 0 deg at 0 deg Maintain POSTURE & in non Maintain POSTURE & in non- -painful ROM. painful ROM. Begin with arm at Begin with arm at the side the side P ll P ll Pull away / towards Pull away / towards your abdomen, then your abdomen, then slowly release slowly release / t / t d d Scapular Scapular retraction retraction Scapular Scapular protraction protraction Grasp band with Grasp band with both hands, elbows both hands, elbows bent to 90 bent to 90o o Pinch shoulder Pinch shoulder Pinch shoulder Pinch shoulder blades together blades together Supine to reduce Supine to reduce UT activity UT activity W’s Upper quarter Upper quarter postural postural exercise exercise Active elevation with upper trap Active elevation with upper trap relaxation relaxation Lift your arm without Lift your arm without shrugging shrugging Sitting or Sitting or standing standing g g

  6. Criteria for progression to Phase 2 Criteria for progression to Phase 2 Able to perform 3 sets of 10 reps Able to perform 3 sets of 10 reps with with red non red non- -latex latex or band without substantial pain or band without substantial pain or fatigue fatigue fatigue fatigue Strengthen rotators before Strengthen rotators before progression to shoulder elevation progression to shoulder elevation or Green latex Green latex Scaption Scaption and Flexion and Flexion Shoulder ER and IR Shoulder ER and IR with with abd abd (45 (45o o to 90 Quadruped push up plus (camel) Quadruped push up plus (camel) to 90o o) ) Prone shoulder scapular retraction Prone shoulder scapular retraction “T” and “Y” “T” and “Y” Phase 3 Phase 3 (not everyone will get to Phase 3) (not everyone will get to Phase 3) Progression: Perform Phase 2 (any color Progression: Perform Phase 2 (any color band) for 1 week without an increase in band) for 1 week without an increase in symptoms symptoms Continue exercises from phase 2 with Continue exercises from phase 2 with progression of progression of theraband theraband resistance p p resistance

  7. Forearm prone plank with plus Forearm prone plank with plus Lawn mower pull Lawn mower pull Body blade Body blade 3 x 30 sec bouts 3 x 30 sec bouts Good scapular control! Good scapular control! Start at ~ 60 Start at ~ 60  then 90 ** then 90  Treatment Approach Treatment Approach – – Limited Evidence Limited Evidence Evidence Evidence – – Scapular Dysfunction Scapular Dysfunction   Motor Control: Motor Control:   Mechanistic evidence Mechanistic evidence indicated scapular motion / kinematics and muscle activity motion / kinematics and muscle activity can improve can improve (Roy JS, Man (Roy JS, Man Ther DeMey DeMey K JOSPT 2012; K JOSPT 2012; Baybar Baybar PTJ 1998) DeMey DeMey K, JOSPT, 2012; K, JOSPT, 2012; Baybar Baybar, PTJ, 1998)   Pts reported Pts reported   pain & pain &   function with motor control focus motor control focus   **Limitation: not RCTs **Limitation: not RCTs (Roy JS, Man (Roy JS, Man Ther Ther, 2009; , 2009; Worsley Worsley P, JSES, 2012; Rheumatol Rheumatol, 2012) , 2012)   Unsure (limited or no evidence): Unsure (limited or no evidence):   Scapular motor control ex focus Scapular motor control ex focus   Scapular taping Scapular taping   Core stability training Core stability training   Core stability training Core stability training   Eccentrics focus Eccentrics focus indicated scapular Ther, 2009; , 2009; Worsley PTJ 1998) , PTJ, 1998) function with Worsley P, JSES, 2012; P, JSES, 2012; P, JSES, 2012; Struyf Struyf F, F, Clin Clin Scapular Scapular Control and Mobility and Mobility Control Evidence Evidence – – Scapular Dysfunction Scapular Dysfunction   Scapular Stabilization addition: Scapular Stabilization addition:   Addition of scapular stabilization Addition of scapular stabilization exercises to the ‘standard’ ex program of exercises to the ‘standard’ ex program of stretch and strengthen stretch and strengthen   Improved muscle LT and elevation HHD Improved muscle LT and elevation HHD strength and scapular dyskinesis strength and scapular dyskinesis ( (Baskurt Baskurt Z, J Back MSK Rehab, 2011) Z, J Back MSK Rehab, 2011)

  8. Leukotape Scapular Taping Scapular Taping Core strength Core strength (Hsu, Yin (Hsu, Yin- -Hsin 2005; 2005; Selkowitz Selkowitz DM, JOSPT, 2007) Hsin, 2009; Lewis J, JOSPT, , 2009; Lewis J, JOSPT, DM, JOSPT, 2007) Assess core strength; Assess core strength; can they do the can they do the following and maintain following and maintain upright w/o deviations? upright w/o deviations? – – Single leg stance Single leg stance – – Single leg squat Single leg squat – – Single leg squat with Single leg squat with arm movement (sport or arm movement (sport or work activity) work activity) Elastic tape Effects in pts with SAIS: •  thoracic extension •  GH & scapular motion •  UT &  LT ms activity • Immediate effects only for patient-report Non Non- -thrust Manipulation (Mobs) thrust Manipulation (Mobs) & thrust Manipulations & thrust Manipulations Evidence Evidence – – Manual Therapy Manual Therapy   MT to GH, MT to GH, & & or spine + ex   Better than ex alone to improve function Better than ex alone to improve function (Bang M, 2000; (Bang M, 2000; Bennell Bennell, 2010; Winters, 1999) , 2010; Winters, 1999) or spine + ex vs vs exercise alone exercise alone General categories: General categories: 1 1- -   pain pain  2 2- -   spine motion spine motion  t t- -spine, ??? rationale for treatment ??? spine, ??? rationale for treatment ??? 3 3- - Central mechanisms Central mechanisms via spinal cord to brain level brain level   ne neurophysiological effects of urophysiological effects of manipulation manipulation that can improve ms activity, that can improve ms activity, reduce pain locally and peripherally via reduce pain locally and peripherally via central mechanisms central mechanisms  evidence supports evidence supports  NO NO evidence evidence   motion, motion,   GH GH   GH mobs + ex GH mobs + ex or   No No better outcomes better outcomes (Chen J, 2009; Kachingwe Kachingwe A, 2008) A, 2008)   Better outcomes Better outcomes ( (Senbursa 1998) 1998)   Considering quality of trials and effect sizes… Considering quality of trials and effect sizes… b + b + or GH mobs alone vs. ex GH GH GH mobs alone vs. ex b l b l (Chen J, 2009; Yiasemides Yiasemides R, 2011; R, 2011; via spinal cord to Senbursa, 2011; , 2011; Senbursa Senbursa, 2007; Conroy, , 2007; Conroy, Thoracic PA Thoracic PA glide glide Evidence Evidence – – Manual Therapy Manual Therapy   Spinal manipulation Spinal manipulation   Single Single- -arm arm – – 1 1- -2 2 Rxs upper, middle, lower upper, middle, lower  AROM & patient AROM & patient- -rated outcome Mintken Mintken P 2010; Boyles R 2009) P 2010; Boyles R 2009) Mintken Mintken P, 2010; Boyles R, 2009) P, 2010; Boyles R, 2009)   RCT RCT – – improved outcomes with thoracic improved outcomes with thoracic manipulation & HEP manipulation & HEP (Bergman, 2004; Winters J, 1999)   Spinal manipulation appears to be Spinal manipulation appears to be beneficial. Active ingredient of Manual beneficial. Active ingredient of Manual Therapy package? Therapy package? Seated, pt Seated, pt grasps hands grasps hands behind neck behind neck Make a “ Make a “vee with thumb and with thumb and index finger or index finger or use use pisiform pisiform to apply posterior apply posterior to anterior glide to anterior glide while extending while extending thoracic spine thoracic spine Rxs of t  improve shoulder improve shoulder rated outcome ( (Strunce of t- -spine spine manip manip to to vee” ” Strunce J, 2009; J, 2009; to (Bergman, 2004; Winters J, 1999)

  9. Thrust prone Thrust prone Thoracic Thrust Thoracic Thrust supine supine Spine Exercises/ Spine Exercises/ Self Self- - Mobilizations Mobilizations Mintken Mintken et al upper and mid et al upper and mid – – Supine over a towel Supine over a towel – – Supine over a roller Supine over a roller – – Seated thoracic and Seated thoracic and cervical extension over cervical extension over cervical extension over cervical extension over chair chair GH mob: post glide during elevation GH mob: post glide during elevation (Mulligan MWM) (Mulligan MWM) Posterior capsule Posterior capsule stretch stretch Posterior glide Posterior glide during arm elevation during arm elevation Stabilize scapula Stabilize scapula medially using medially using thenar eminance eminance of one of one hand hand hand hand Use other hand to Use other hand to apply a medially apply a medially directed force directed force 30 seconds x 3 30 seconds x 3 thenar

  10. AC Joint: anterior and inferior glide AC Joint: anterior and inferior glide GH mob / glides: GH mob / glides: Evidence Evidence – – HEP HEP Recruit patients w ith SAI S   Home exercise programs can reduce Home exercise programs can reduce pain and improve function pain and improve function Ludewig Borstad Borstad, , Occup Occup Environ Med, 2003; Walther M JSES, 2004) Environ Med, 2003; Walther M JSES, 2004)   This approach may be appropriate This approach may be appropriate f ti t f ti t for some patients, but likely not all, for some patients, but likely not all, as all patients did not resolve as all patients did not resolve   Consider this approach! Consider this approach! Clinician History and Examination Ludewig & & Treatment Using Evidence-Based Evidence-Based Guidelines b t lik l b t lik l t ll t ll W hat predicts success w ith rehab? W eek 6-8 Discharge exam ( 10 visits or sooner if goals met) 3, 6, 12 Month Outcome Measures Funded by the NATA-REF Predictors of Predictors of “Successful” Outcome “Successful” Outcome Predictors of Predictors of “Successful” Outcome “Successful” Outcome 6 wks 6 wks – – 68% had a ‘successful’ outcome 68% had a ‘successful’ outcome – – 50% DASH 50% DASH   & & GROC GROC – – ‘moderate better’ Age Age- - younger younger Stop sports or ex b/c of shoulder pain Stop sports or ex b/c of shoulder pain Stop sports or ex b/c of shoulder pain Stop sports or ex b/c of shoulder pain Regular exercise 3x/wk Regular exercise 3x/wk Symptoms 0 Symptoms 0- -6 wks 6 wks vs vs 12 wks Shoulder injection Shoulder injection Some college education Some college education No pain at night No pain at night Less loss of active IR Less loss of active IR Less loss of passive flexion or abduction Less loss of passive flexion or abduction ‘moderate better’ Shoulder pain reduced 2/10 pts with Shoulder pain reduced 2/10 pts with scapular reposition test scapular reposition test 12 wks Serratus anterior weakness Serratus anterior weakness What’s else? Predictors of non What’s else? Predictors of non- -success and long and long- -term outcomes… stay tuned! term outcomes… stay tuned! success

  11. RCD Management RCD Management - - Summary   Treatment approach Treatment approach 1. 1. Strengthen /Motor Control Strengthen /Motor Control – – Rotator cuff, scapular, shoulder scapular, shoulder Motor control alone Motor control alone – – unclear of effectiveness 2. 2. Flexibility Flexibility – –post cuff, post cuff, pec 2. 2. Flexibility Flexibility post cuff, post cuff, pec spine spine 3. 3. Scapular Scapular Dysf Dysf – –S Scap cap taping + Motor Control, addition of scapular stabilization exercises addition of scapular stabilization exercises 4. 4. Home exercise program Home exercise program 5. 5. Modalities Modalities – – limited use, only in limited use, only in combination with active treatment combination with active treatment Summary 6. 6. Manual: Spine Manual: Spine OR   Pain, Pain,   joint motion, other neurophysiological joint motion, other neurophysiological effects, ?? biomechanical at spine?? effects, ?? biomechanical at spine??   GH GH – – alone alone - -doesn’t appear effective doesn’t appear effective 7. 7. Use of impairments Use of impairments prn   Guiding Treatment Guiding Treatment Hi Hi M d t M d t L i it bilit L i it bilit   Hi Hi – – Moderate Moderate – – Lo irritability Lo irritability   Dose: Hi reps (dose) Dose: Hi reps (dose)   Evidence 1 Evidence 1st, then if not successful consider other interventions consider other interventions   Pt expectations Pt expectations- - recovery, PT, PT recovery, PT, PT interven   Judge outcome Judge outcome- - pt pt- -report & performance OR combined (GH, spine) combined (GH, spine) Rotator cuff, prn unclear of effectiveness pec minor, minor, lats pec minor, minor, lats lats, CT , CT lats, CT , CT taping + Motor Control, st,then if not successful interven. . report & performance Thank you for your Thank you for your kind attention! kind attention! RCD Management RCD Management Controversy Controversy (weak/ no evidence): (weak/ no evidence):   Guiding treatment Guiding treatment- - irritability? irritability?   Hi dose (reps) Hi dose (reps)   Motor Control Motor Control Motor Control Motor Control   Scapular taping Scapular taping – – only immediate effects immediate effects   Other modalities Other modalities – – ice, acupuncture, etc… acupuncture, etc…   Spine MT Spine MT – – can impair. drive decision drive decision- -making?   Core stability training Core stability training Consensus (evidence): Consensus (evidence):   PT helps the majority PT helps the majority   Exercise Exercise – – stretch, strengthen, MC, HEP strengthen, MC, HEP   Addition of manual Addition of manual Addition of manual Addition of manual therapy to Exercise therapy to Exercise – – Combined or spine Combined or spine   US US – – not effective not effective   HEP may be enough for HEP may be enough for some folks some folks stretch, only ice, can impair. making? Question Question and and Answer Answer Time Time

  12. Rotator Cuff Tendinopathy: Examination 1/28/2013 Rotator Cuff Tendinopathy: Diagnosis Does it matter ? • Guide Intervention – Is “rotator cuff tendinopathy” a  homogeneous group?  – If not how do we subgroup? – If not, how do we subgroup? Consensus and Controversies in  Rehabilitation of Rotator Cuff Disease: Rehabilitation of Rotator Cuff Disease:  Examination • Inform Prognosis Phil McClure PhD, PT mcclure@arcadia.edu Does the classic pathoanatomic model work for rehabilitation? Complaint of “Shoulder Symptom” Orthopaedic Section: Shoulder Guideline Group Level 1 Screen History (A), Basic PE (B), Red Flags (C) Non-shoulder origin of sx Shoulder origin of sx Level 2 Pathoanatomic Pathoanatomic (Med Dx) Specific Phys Exam (D) Diagnostic Classification Scheme • Screening • Pathoanatomic Dx (Medical Dx) • Rehab Dx (Irritability) Glenohumeral Instability Rotator Cuff / Impingement Frozen Shoulder Level 3 Rehab Dx High Irritability (E) Mod Irritability (F) Low Irritability (G) Rotator Cuff Tendinopathy: Examination  Overview • Differential Dx (Pathoanatomic/Medical Dx)  – Be sure we have a problem that we can treat – Puts us in the “ball park” • Identification of Key Impairments (Rehab Dx) – Guides specific rehab treatment  – Weakness( Motor control, inhibition, disuse atrophy, tears) – Mobility (tightness or laxity… shoulder girdle & spine) – Scapular Dysfunction (due to weakness or mobility) – Environmental factors  leading to overuse • Outcome Measures (How do we keep score?) Pathoanatomic Dx vs “Rehab” Dx • Pathoanatomic Dx (Medical Diagnosis) – Pathoanatomic – Primary Tissue Pathology Pathology – Stable over episode of care – Guides general Rx strategy – Informs prognosis – Important for Surgical Decisions • Rehab Diagnosis – Sx Severity / Impairment – “Irritability” • Current intensity – Often changes over episode of care – Guides specific rehab Rx – May inform prognosis McClure 1

  13. Rotator Cuff Tendinopathy: Examination 1/28/2013 Rotator Cuff Tendinopathy: Examination  Differential Diagnosis • Things that may look like RC tendinopathy… but are not – Cervical spine  • Pain location,  ROM, Upper Limb tension test, Spurlings, Traction test – Thoracic Outlet  • Pain location, Upper Limb tension test, palpation brachial plexus @  Erb’s point, Adson’s p – Frozen shoulder • LOM in multiple planes, females, 40‐60 yo – Nerve injury (suprascapular, axillary, long thoracic) • Hx: traction or direct blow, weakness, palpation – Red Flags (Cardiac, Pancoast’s tumor) • Pain location, males > 50, smoking Test Test ULTTa - - LR LR .12 (neg helps r/out) + LR + LR 1.3 Involved Cerv Rot <60 deg .23 (neg helps r/out) 1.8 Distraction Test .62 4.4 (pos help r/in) Spurling’s .58 3.5 (pos help r/in) 2 of 4 .88 3 of 4 6.1 4 of 4 30.3 Wainner et al, Spine 2003 (NCS/EMG as criterion) Pain Location Pain Location Subacromial injection of 1.5 ml of 5% hypertonic saline Subacromial space AC Jt • Anterolateral shoulder pain Anterolateral shoulder pain •Pain above acromion rare • Pain below elbow possible 4/17 •Anterolateral pain in all •Posterior pain 3/10 •No pain above acromion or in supraspinatus muscle / scapular area Hypertonic saline under flouroscopic guidance Stackhouse et al. 2012 JSES Gerber, 98, JSES Cloward, 1959 Annals of Surgery Discogenic pain Brachial plexus entrapment/TOS Special tests Kellgren Clin Sci, 1939 Feinstein JBJS, 1954 Interspinous Ligaments • Elevated Arm Stress Test • ULTT Others • Others Dwyer et al Spine 1990 Direct palpation Adson’s Costoclavicular compression Facet pain Positive test = reproduce chief complaint sx Diagnostic accuracy uncertain because gold standard is lacking McClure 2

  14. Rotator Cuff Tendinopathy: Examination 1/28/2013 Rotator Cuff Tendinopathy: Examination  Differential Diagnosis Rotator Cuff Tendinopathy: Examination  Differential Diagnosis • Things that may look like RC tendinopathy… but are not – Cervical spine  • Pain location,  ROM, Upper Limb tension test, Spurlings, Traction test – Thoracic Outlet  • Pain location, Upper Limb tension test, palpation brachial plexus @  Erb’s point, Adson’s p – Frozen shoulder • LOM in multiple planes, females, 40‐60 yo – Nerve injury (suprascapular, axillary, long thoracic) • Hx: traction or direct blow, weakness, palpation – Red Flags (Cardiac, Pancoast’s tumor) • Pain location, males > 50, smoking • Things that may mimic or accompany RC tendinopathy – Reasons why the patient may not respond well  • Full thickness RC tear  – Age, weakness w/empty can, ER lag signs, Drop Arm • SLAP lesion  – Hx (click pop catch) + multiple tests Hx (click,pop,catch) + multiple tests  – Biceps load, crank test, dynamic shear, Ant Slide, Speed’s • GH Instability – Hx, Apprehension/Relocation test, Sulcus • AC joint – Pain location, palpation, horiz adduction, O’brien’s • Myofascial Trigger Points – Palpation of muscle belly Rotator Cuff Tendinopathy: Examination  Differential Diagnosis Rotator Cuff Tendinopathy: Examination  Differential Diagnosis • Things that may mimic  or accompany RC  tendinopathy • SLAP lesion  – Hx (click,pop,catch) +  l i l multiple tests  – Crank test, Biceps load,  Speed’s, Anterior Slide,  Dynamic shear  • Things that may mimic or  accompany RC tendinopathy • Full thickness RC tear – Age, weakness w/empty can, ER  lag signs, Drop Arm g g , – All 3 tests tend to show : – High specificity – Mod sensitivity – Helpful to r/in – Not as helpful to r/o p Kibler 09, JSES – Dx Accuracy Variable – Specificity: Mod‐High – Sensitivity : Low‐Mod Rotator Cuff Tendinopathy: Examination  Differential Diagnosis Rotator Cuff Tendinopathy: Examination  Differential Diagnosis • • Things that may mimic or  accompany RC tendinopathy • AC joint – Pain location, palpation,  horiz adduction, active  compression (O’brien) – High Specificity – Variable sensitivity Things that may mimic or  accompany RC tendinopathy • GH Instability – Hx, Apprehension/Relocation,  Sulcus – Dx Accuracy – Specificity : High  – (apprehension, not pain) – Sensitivity : Mod – Sulcus? McClure 3

  15. Rotator Cuff Tendinopathy: Examination 1/28/2013 Rotator Cuff Tendinopathy: Examination  Differential Diagnosis Rotator Cuff Tendinopathy: Examination  Differential Diagnosis • Things that may mimic or accompany RC tendinopathy – Reasons why the patient may not respond well  • Full thickness RC tear  – Age, weakness w/empty can, ER lag signs, Drop Arm • SLAP lesion  – Hx (click pop catch) + multiple tests Hx (click,pop,catch) + multiple tests  – Biceps load, crank test, dynamic shear, Ant Slide, Speed’s • GH Instability – Hx, Apprehension/Relocation test, Sulcus • AC joint – Pain location, palpation, horiz adduction • Myofascial Trigger Points – Palpation of muscle belly • Things that may mimic or  accompany RC tendinopathy • Myofascial Trigger Points  – Palpation of muscle belly – Repro CC pain, taut band ??? Do these negatively affect prognosis? Rotator Cuff Tendinopathy: Examination  Differential Diagnosis BJSM 2012 • Rotator Cuff  Tendinopathy  –aka subacromial impingement – Neer’s – Hawkin’s – Jobe’s Empty can (isom resist elev w/IR in plane of scap) – Painful Arc (60‐120 deg) – Isom resist ext rot (Infraspinatus test) – Speed’s – Horizontal adduction – palpation …more than you ever wanted to know about diagnostic accuracy! Diagnostic Accuracy of Clinical Tests for the Different Degrees of  Subacromial Impingement Syndrome     Park et al, JBJS, 2005 Diagnostic Accuracy of Clinical Tests for the Different Degrees  of Subacromial Impingement Syndrome     Park et al, JBJS, 2005 • • • Large Series, n= 359 Physical Exam findings compared with Diagnostic Arthroscopy 8 tests – Neer’s  – Hawkin’s – Painful Arc – Speed’s test – Cross‐body Adduction – Drop Arm test – Supraspinatus (empty‐can position) – Infraspinatus (Arm at side) • High Sensitivity • Negative test helps rule out – Neer’s  H ki ’ – Hawkin’s – Painful Arc • High Specificity • Positive test helps rule in – Speed’s test C b d Add – Cross‐body Adduction – Drop Arm test – Supraspinatus (empty‐can  position) – Infraspinatus (Arm at side) ti Pain  Best Overall Combination •Hawkin’s •Painful Arc •Infraspinatus test Weakness McClure 4

  16. Rotator Cuff Tendinopathy: Examination 1/28/2013 Diagnosis of Rotator Cuff Tendinopathy  (aka subacromial impingement) My bottom lines: • Always some degree of uncertainty • Correlate with hx and sx’s • Look for multiple tests to be positive/negative • Try to identify other coexisting pathology – Do these affect outcome? N=55,  Surgical Dx was gold standard 16/55 confirmed impingement, 39/55 negative + LR ‐ LR Neer 1.8 0.35 Hawkins 1.6 0.61 Painful Arc 2.3 0.36 Empty can  (weakness) 3.9 0.57 Ext Rot Resist (weakness) 4.4 0.5 • Pathoanatomic diagnosis may not be critical  to directing rehab treatment >3/5 positive 2.9 ‐ < 3/5 positive 0.34 Rotator Cuff Tendinopathy: Examination  Differential Diagnosis Complaint of “Shoulder Symptom” Level 1 Screen History (A), Basic PE (B), Red Flags (C) Summary: Pathoanatomic/Medical  Dx • Rule Out Other Diagnoses – C‐spine / TOS / FrozenShdr / Nerve Injury / Red Flag C spine / TOS / FrozenShdr / Nerve Injury / Red Flag • Identify Additional problems – RC Tear / SLAP / Instability / AC Jt / Trigger Pts • Rule In RC tendinopathy – (+) Neer or Hawkins  – (+) Pain/weakness with resisted Empty can or Ext Rot – Painful arc Non-shoulder origin of sx Shoulder origin of sx Level 2 Pathoanatomic Pathoanatomic (Med Dx) Specific Phys Exam (D) Glenohumeral Instability Rotator Cuff / Impingement Frozen Shoulder Level 3 Rehab Dx High Irritability (E) Mod Irritability (F) Low Irritability (G) Rotator Cuff Tendinopathy: Examination  “Rehab Diagnosis” Rotator Cuff Tendinopathy: Examination  Irritability Classification • Identify Stage of Irritability • Identify specific impairments that guide treatment – Weakness (Cuff ) Tightness (post capsule pec minor lats t spine) – Tightness (post capsule, pec minor, lats, t‐spine) – Scapular Dysfunction Irritability High  Moderate   Low  • High Pain (> 7/10) • night or rest pain • consistent • Pain before end ROM Pain before end ROM • AROM < PROM • High Disability •(DASH, ASES) • Mod Pain (4-6/10) • night or rest pain • intermittent • Pain at end ROM Pain at end ROM • AROM ~ PROM • Mod Disability •(DASH, ASES) •Low Pain (< 3/10) • night or rest pain • none • Min pain Min pain w/overpressure • AROM = PROM • Low Disability •(DASH, ASES) History  and  Exam • pain reduction • activity modification • pain reduction • impairments • basic function • High demand functional activity restoration Treatment  Focus Kelley et al JOSPT 09 McClure 5

  17. Rotator Cuff Tendinopathy: Examination 1/28/2013 Matched Treatment Strategy Rotator Cuff Tendinopathy: Examination  Specific Impairments: Cuff Weakness High Irritability Moderate Irritability Low Irritability + + + Patient Education • Cuff “weakness” (? inhibition)  allows superior migration which  may perpetuate impingement + + / -- -- Activity Modification Pain-free passive AAROM AAROM  AROM End-range/ overpressure ROM/ Stretch Low grade Low / High grade High grade Manual Techniques -- Light  mod resistance Mid-ranges Mod  high resistance End-ranges Neuromuscular Performance -- Basic High demand Functional Activities Modalities +/‐ +/‐ ‐‐ + / -- + / -- + / -- Taping / functional support (brace / external) Mechanisms of Impingement Muscle Performance “Gaps” related to muscle performance • Does an isometric test of peak force  adequately capture “muscle performance”?  – Motor control during dynamic activity? – Deltoid/cuff  balance? / – Endurance ? – What is the source of weakness? • Poor motor control => quality vs quantity in exercise • Poor neural activation from CNS => estim, biofeedback or better  pain control to avoid inhibition • Disuse atrophy => traditional PRE • Tear => surgery or compensatory strategy • Several studies have  documented abnormal  superior glide under  different conditions: • Cuff tear: – 100% with full RC tear   – 14% after cuff repair  – Paletta JSES ’97 • Cuff tear or Stage II  impingement – Deutsch  JSES ’96 • Muscle fatigue – Chen JSES ‘99 Posterior Shoulder Tightness: What do we measure? Rotator Cuff Tendinopathy: Examination  Specific Impairments: Posterior Tightness • Posterior Capsule  (Harryman, 1990) increased posterior shoulder tightness          HH sup translation &  ed GH IR AROM HH sup translation &  ed GH IR AROM   Awan et al APMR, 2002 decreased subacromial space           Tyler et al; JOSPT, 1999 Decreased IR ROM on side of  impingement compared to  unaffected side Tyler et al, 2000 AJSM mechanical compression of SA tissues Glenohumeral Internal Rotation Deficit Mallon et al JSES, 1996 Edwards et al JSES 2002 An increase in IR ROM correlated  well (r=0.54) with improved  outcome following rehab at 6wks McClure 04, PTJ ASES: Richards et al JSES 94 McClure 6

  18. Rotator Cuff Tendinopathy: Examination 1/28/2013 PROM: Internal Rotation 90° abduction Total Arc of Rotational Motion • Supine  • Humerus 90° abduction,  elbow flexed 90° • Fulcrum at olecranon  process • Stationary arm • Stationary arm  perpendicular to floor • Align moveable arm with  ulnar styloid • End the movement when  the acromion elevates  anteriorly (beyond dashed  line in top picture) Throwers - Increased ER - Decreased IR - may be attributable to bony changes in glenoid or humeral retroversion F From Wilk 09 JOSPT Wilk 09 JOSPT PROM: Horizontal adduction    Accessory Motion: GH and AC jts • Pain • End‐Feel • Motion • Reliability? ICC= 0.79 MDC90=8 deg r= 0.54 w/IR90 ICC= 0.94 MDC90=4.2 deg r= 0.35 w/IR90 Salamh, IJSPT, 2012 Myers, AJSM 2007 Rotator Cuff Tendinopathy: Examination  Specific Impairments: Tightness (Latissimus) Rotator Cuff Tendinopathy: Examination  Specific Impairments: Posture, Thoracic Spine, Pec minor Tightness  (Kendall and McCreary, 1993, Cleland et al, 2007) • Reduced latissimus  length indicated by  obviously decreased  flexion in B flexion in B  compared to A • A Posture – Thoracic kyphosis and protracted  shoulder may decrease subacromial  space and put rot cuff at mechanical  disadvantage • Kebeatse 99 APMR, Solemn‐Bertoft 93 CORR  – No good evidence suggesting  posture is strongly related to sx’s Pec Minor tightness  – may alter scapular kinematics – Less post tilt, less scap ext rot • Borstadt 05 JOSPT – Shorter in symptomatic HS swimmers  (Tate  2012, JAT) – No good evidence suggesting pec  minor is strongly related to sx’s Lewis 07 BMC Musc Kluemper 06, J Sp Rehab B • Tate 12 JAT Borstad 05 JOSPT McClure 7

  19. Rotator Cuff Tendinopathy: Examination 1/28/2013 Rotator Cuff Tendinopathy: Examination  Specific Impairments: Tightness (Thoracic mobility) Rotator Cuff Tendinopathy: Examination  Specific Impairments: Scapular Dysfunction • Spring testing – Based on examiners perception  of mobility at a level relative to  those above and below  and  examiner’s experience and  perception of normal perception of normal – Hypomobile/Hypermobile – ? Pain • Biomechanic vs Neurophysiologic   Mechanisms • If not stiff, do we still manipulate? • Visual Classification – Scapula Dyskinesis Test (McClure  09 J Athl Tr) • Symptom Altering Tests – Scapula Reposition Test (Tate 08, JOSPT) – Scapula Assistance Test  (Rabin 06, JOSPT)  • Force Measures – Trap – Serratus Scapular Examination: Specific Impairments  Scapular Dysfunction • Is it related to common  shoulder pathologies? – Maybe – Most studies show small (but  stat sig) motion differences  between groups  (sx vs asymp) – Large variability in “normal” or  asymptomatic subjects – Strong evidence showing scap  dysfunction causing shoulder  pain / pathology is lacking – Must try to relate sx’s to scap  dysfunction in specific patient  • Is there “Dysfunction”? • Visual Classification • Scapula Dyskinesis Test (McClure  09 JAT, Tate 09, JAT) • “Yes /No” test  (Uhl , 09, Arthros) • Symptom Altering Tests • Scapula Retract/Reposition Test (Kibler 06 AJSM, Tate 08, JOSPT) • Scapula Assistance Test  (Rabin 06, JOSPT)  • If there is Dysfunction…Why?  • Muscle Strength / Motor Control • Trap • Serratus • Flexibility of Key Structures: Pec Minor, T‐spine, Post Cap Classifying scapular motion:   the scapula dyskinesis test (SDT) Dyskinesis: Winging • Movement of medial border  and/or inferior angle away  from the thorax, becoming  more prominent during arm  motion with a sulcus/gap  between the scapula and the  thorax:  ≥1” is considered abnormal  May be unilateral or bilateral • 5 repetitions:: – Flexion (weighted) – Abduction (weighted) Rate scapular motion on each test as: – Normal (N) motion: no evidence of  abnormality • Medial border and inferior angle relatively  flat – Subtle (S) dyskinesis: mild/questionable evidence of abnormality, not consistently  present – Obvious (O) dyskinesis: striking, clearly  apparent abnormalities, evident on at  least 3/5 trials  • Winging 1” or greater displacement of  scapula from thorax • Dysrhythmia  Subjects may repeat test  • Picture: Posterior view of winging • Picture: Superior view of winging McClure 8

  20. Rotator Cuff Tendinopathy: Examination 1/28/2013 Dyskinesis: Dysrhythmia Winging Describes a lack of “smooth”  scapulohumeral rhythm – A “hitch or a jump in the  otherwise smooth motion.”  (Kibler, 2003) – Most common pattern is  early/excessive scapular  elevation (shrug) – Another common pattern:   rapid downward rotation  during lowering (dump) Picture: Example of “shrug” during arm raising Dysrhythmia: “Dumping” Picture:“Dumping” during arm lowering Are Symptoms Related to Dyskinesis? Arthros 09 • Penn Shoulder Score (Leggin et al 06) – Pain Sub‐Scale  • Total 30 – Sx’s at rest (0‐10) – Sx’s with normal use (0‐10) Sx’s with strenuous use(0 10) – Sx s with strenuous use(0‐10) • n = 104 – Only subjects rated as obvious or  normal by two raters – Rater disagree or subtle discarded • Odds ratios (95% CI) – Does having dyskinesis  increase your odds of  having sx’s? … NO   Pain > 3/30 - Dyskinesia + Dyskinesia -Sx's 39 16 + Sx's 37 12 Compared asymmetry in 3D testing -sx’s (n=35) vs no sx’s (n=21) OR = 0.79 (0.33 OR = 0.79 (0.33 - -1.89) 1.89) - Flexion probably most sensitive - Asymmetry common Pain > 6/30 - Dyskinesia + Dyskinesia -Sx's 61 24 + Sx's 15 4 Type 2 Type 1 OR = 0.68 (0.2 OR = 0.68 (0.2 - -2.25) 2.25) Type 3 Type 4 (normal/sym) Measuring Shoulder Outcome:  Keeping Score! Symptom Altering Tests • Modified Scapular  Assistance Test – Posteriorly tilt and upwardly rotate scapula  (Rabin et al, JOSPT 2006) – Documented reliability  (77‐91% agreement) – 40‐49% tested “positive” (> 2pt change) • Scapula Retraction Test – Kibler et al AJSM,  2006 – Patients and healthy – increased strength with scap stabilization – No sig change in pain • Scapula Reposition Test – Tate, McClure, Kareha, Irwin (JOSPT 2008) – Overhead athletes, Empty can test – 26‐29% had significant increase in strength – 48% had decrease in pain McClure 9

  21. Rotator Cuff Tendinopathy: Examination 1/28/2013 Shoulder Pain  Shoulder Outcome Scales • DASH (Disabilities of the Arm, Shoulder, Hand) • Quick DASH  • ASES (American Shoulder and Elbow Surgeons) • PENN Shoulder Scale • Lots of others! Michener et al, JSR, 2010 Mintken et al JSES 2009 • Ave of 3 Pain items • NPRS 0‐10 Current – Current – Least 24 hr – Worst 24 hr – 2‐4 wk Rx • MCID  1.1 • MDC  2.5 • Ave of 3 Pain items • NPRS 0‐10 Rest – Rest – Normal ADL – Strenuous – 4‐6 wk Rx • MCID: 2.2  Bottom Line: Look for at least a 2 pt change in pain DASH/Quick DASH Sports/Performing Arts Module Shoulder Outcome Scales Scale MDC MCID Content 30 questions sx’s (5), & function (25) 0-100 scale DASH 12.8 10.2 11 questions q sx’s (3)& function (8) 0-100 scale Quick Quick DASH 11 2 11.2 8 0 8.0 10 function (50%) Pain (50%) 0-100 scale ASES 9.7 6.4 30 Pain 10 Satisfaction 60 function 100 Total Penn SS 12.1 11.4 Rotator Cuff Tendinopathy: Examination  Summary • Differential Dx (Medical Dx)  – C‐spine, TOS, Frozen Shdr, Nerve Injury, RedFlags – RC Tear, labral injuries, GH instab, AC jt, Trigger pts • Rehab Dx – Irritiability (guides Rx strategy and intensity) – Key Impairments • “Weakness” (cuff & scapula) • Tightness (post capsule, pec minor, lats, cervicothoracic ) • Scapular Dysfunction (motion and sx altering tests) • Outcome Measures (keeping score) – DASH, Quick DASH, ASES, Penn Scale, others Evaluate/Manage Patient Expectations Questions • Do you expect to get better? • Do you think PT will be helpful? • Any specific treatment you think  y p will be most effective? y • Use to evaluate and influence  patient expectations. McClure 10

  22. Rotator Cuff Tendinopathy: Examination 1/28/2013 Rotator Cuff:  Examination Consensus (evidence): • r/o other pathology • Key Sx’s – Ant/lat arm pain – Often overuse • Key Signs • Key Signs – Multiple should be present • Key Impairments: – Cuff “weakness” • Source? Endurance? – Posterior tightness • Use an Outcome scale Controversy (weak/no evidence) • Does co‐existing pathology  predict worse outcome or require  different treatment? • What impairments are truly  related to sx’s ? (causal or  perpetuate) – Scapular Dysfunction • Motor control / weakness • Tightness – Pec tightness (clinical measure?) – Thoracic mobility McClure 11