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Orthopedic Treatment 400 - Shoulder Tendonitis, Bursitis, Impingement
Terms in this set (79)
An overuse injury that causes inflammation to the tendons involved in repetitive movements.
Etiology --> intrinsic refers to
Etiolgoy --> extrinsic refers to
Pattern of tendonitis
Pain on Length
- Any mvmt, active or passive, that takes it into a lengthened position
Pain on Strength
- Anything that loads the tissue with resistance, AROM or RROM
Pain on Palpation
- Direct compression of the tendon gives them px
(+history of overuse, + postural fault)
Inflammation of a tendon with a sheath (ex; Biceps long head tendon)
Any noxious, repeated activity leading to microtauma to the involved tissues thus impeding its ability for self repair
What are the 3 main causes of tendonitis?
Overuse/Trauma = Extrinsic
Postural/Deformity = Intrinsic
S&S of tendonitis
-inflammation, pain, dysfunction, weakness, compensatory movement or stabilization
-pain on strength, length, palpation
What is the primary source of injury to the shoulder?
Overhead activity = overuse syndrome
Which muscle(s) is/are most prone to tendonitis in the shoulder?
Tendonitis of the shoulder commonly occurs with the tendons of the rotator cuff muscles and biceps brachii. These tendons are prone to tendonitis with sports that require repetitive upper limb movement and maximal muscle contraction - swimming, any throwing sport, volleyball, golf, tennis etc. These tendons also become inflamed with occupations that require repetitive movements - dry walling, painters etc.
Why is the Supraspinatus mm prone to tendonitis in the shoulder?
-It is a dynamic ligament, constantly challenged to maintain stability and congruency of the joint.
-Fatigue and strain via:
*Repetitive movements (abduction/flexion)
*Postural changes (kyphosis)
-Hypovascularity of RC mm (poor nutrition/repair, degneration, inflammation, scar tissue, calcification, tears)
-Age, overuse, abuse
What other conditions can supraspinatus tendonitis lead to?
-May also lead to Impingement Syndrome, bursitis, calcific tendonitis or adhesive capsulitis
Define Calcific Tendonitis:
-Supraspinatus is the most common site.
-Due to repetitive or severe trauma
-Fibroblasts change to chondrocytes; calcified deposits fill up intercellular spaces of tendons causing an increase in size.
-As tendon grows bigger, may lead to impingement under acromial arch.
-Bursitis may commence if calcium deposits rupture the bursa
-results in painful shoulder movement due to irritation of surrounding tissue.
-Usually self limiting and occurs most commonly in the
40 & 50
Why is calcific tendonitis self limiting?
Body can reabsorb calcium deposits
What can calcific tendonitis lead to?
Can abrade subacromial bursa and
Why is the Biceps mm prone to tendonitis in the shoulder?
-Acts as a humeral stabilizer (bicepts pully system) and elbow decelerator --> repetitive strain on tendon may be seen in some sports and/or certain occupations and activities --> inflammation
-Compression can occur in bicipital groove
Can you perform frictions on calcific tendonitis?
No --> CI for frictions.. If suspect they have it due to excessive pain or if they have it confirmed via imaging DO NOT perform frictions.
What condition may develop in the presence of biceps tendonitis?
Tenosynovitis (inflammation of a tendon with a sheath)
What happens to biceps if the supraspinatus mm is damaged?
-If SupraSpinatus breaks down, Biceps responsibility increases = more strain
(Biceps pulley system)
-Synovial sheath can't keep up with fluid production demands, abrasions, microtears, inflammation
What can happen to the biceps tendon in the bicipital groove of humerus?
-tendon can get compressed in the groove
-Inflammation may attach tendon to groove decreasing gliding motion
-Transverse humeral ligament can break down and sublux tendon
How many grades of tendonitis are there? Describe them:
= pain only after activity
= pain at beginning of activity and after. alleviates during activity.
= pain at beginning, during and after activity. pain may restrict activity.
= pain with ADL and continues to get worse (RISK OF RUPTURE)
S&S Tendonitis Shoulder
-Referral pain at lateral brachial region (supraspinatus) or antebrachial region to the insertion of biceps long head
Sleep disturbances if guest sleeps on affected side
-Soft tissue swelling, atrophy, redness etc.
-Px with palpation of tendons
What is a risk with Grade 4 tendonitis?
-@ risk of rupture
-Typically when Pt start to seak help
-No escape from inflammation/ no down phase
Extremely important to note if a Pt is on Anti-Inflammatories. Why?
• Any time a person is on antiinflammatories no XFF/LFF
• Corticosteroid injection = must wait 21 days (Rattray)
• NSAIDS (oral OTC anti-inflames), no XFF/LFF until after 4 days
Signs/Symptoms of Supraspinatus tendonitis:
Referral pain along lateral brachial region (over deltoid)
Palpation of Supraspinatus Tendonitis (Rattray):
-Arm held behind the back, with elbow in Flex.
-Humerus is maximally IR & maximally Ext, bringing humeral attachment of supraspinatus out from under acromion
-Tendon is palpated immediately inferior to AC joint.
-Therapist palpates through deltoid muscle in indentation between Ant and Mid Deltoid fibres
Palpation of Supraspinatus Tendonitis Image (Rattray):
Signs/Symptoms of Biceps tendonitis:
Referral pain along insertion of biceps
Supraspinatus & Biceps tendonitis will both have which symptom?
-Sleep disturbance if guest sleeps on affected side
-Soft tissue swelling, atrophy, redness, etc.
-Pain on length, strength, palpation
Special Tests for tendonitis in shoulder:
➢ Painful Arc
➢ NEER Impingement
➢ Drop arm
➢ Empty Can
➢ T&B Diff Test
Define painful arc sign:
-(P) presents b/w
-Increase in inflame = fibrosus = decrease in space for shoulder tissue to pass through Acrom Arch.
Max compression/(P) at 90° ABd
Why does pain diminish after 90° ABd?
Humerus rotates posteriorly at 90°, clearing the acromial arch
When does painful arc begin to show?
Later stages of supraspinatus tendonitis (usually)
Pt can also experience pain at 170° ABd. What is this called and why does it happen?
-Acromioclavicular painful arc
-Occurs due to
AC jt sublux or AC sprain
Important: if you see the signs of (P) arc, ask if Pt can continue w/o cheating. Can they? Why?
Want to see if pain goes away after 90° to confirm + painful arc (test)
Precautions and contraindications w/ tendonitis:
- Calcific tendonitis to the supraspinatus tendon
- Tenosynovitis of the bicipital tendon
- Anti-inflammatory medications
How do you know if tendonitis is acute?
It will be hot and very tender.
Tx for Acute tendonitis:
-Swedish over inflamed tendon
-Joint play but not mobs
-PROM, mindful that not compressing inflamed tendon
-Ice after activity (keep icing as long as they feel heat after the activity)
-Home care = pain free AROM, isometric contractions
NO HEAT AT TENDON, NO MFR OVER TENDON & NO FRICTIONS IN ACUTE
Tx for Chronic tendonitis:
-Swedish, warm up tissue
-NMT - mm stripping, O&I release
-Frictions (cross-fiber; if synovial sheath, longitudinal)
-Clear with swedish
-Reset - AROM or RROM
-Ice after frictions
-Home care = stretch the muscles, strengthen with isometrics then with isotonics (always the progression with remex)
• Educate guest of noxious activities or factors
Ice after exercise
short mm (
weak mm (
ONCE FIDS REDUCE -> STRENGTHEN AGONIST AS WELL
Inflammation of the bursa due to friction upon it from surrounding structures.
Etiology: What are the 3 common factors that contribute to Bursitis?
1. Overuse of surrounding structures leads to frictioning and inflammation of bursa - repetitive movements, poor postural habits & biomechanics
2. Blunt trauma
3. Arthritis or calcific tendonitis
-Situated on top of the supraspinatus muscle (tendon and belly) and under the acromian and deltoid mm.
-Susceptible to impingement by acromial arch esp. when inflamed or affected by a calcified supraspinatus tendon
-Lies over the anterior GH joint capsule and under subscapularis tendon
-Joint effusion may be apparent because of inflammation of the bursa
-Usually secondary to other conditions like calcific tendinitis
-The overuse of the structures surrounding the bursa --> excessive friction upon bursa --> inflammation of bursa
-Contributing factors include: repetitive movements, poor biomechanics/technique in sport, muscle imbalance, postural changes, lack of flexibility
-Trauma (blunt force or FOOSH)
-Infection (from needle)
-Joint pathologies like arthritis can cause bursitis
S&S of bursitis of shoulder:
➢Pain over lateral brachial region and into elbow
unique burning pain
➢Accompanying conditions (supra tendonitis)
➢AROM, PROM, RROM
What is the difference b/w acute and chronic bursitis?
Acute: all movements constantly hurt, heat, swelling, redness
Chronic: Painful Arc only sign
-Px with AROM, PROM, RROM to vary degress depending on acute, chronic
-Painful arc may be present
-PROM - non-capsular pattern, empty end-feel (w. px or anticipation of px)
-RROM - most hesiation with ABduction b/c of px and the sqeezing of inflamed bursa
Special tests Bursitis:
➢ Painful Arc = Positive (chronic)
➢ AROM, PROM, RROM & palpation = PAIN (acute)
➢ NEER Impingement
➢ T&B Diff Test
➢Similar to Tendonitis in all stages
➢Manage Inflammation first, then address the structures that have contributed to the bursitis
➢AVOID COMPRESSION of Inflamed Bursa (ACUTE)
➢ On-Site techniques are CI'd with Acute Bursitis
➢If infective bursitis is suspected, the patient is referred for medical attention (extreme heat, swelling, redness + fever/illness)
Remex for Bursitis:
• PF ROM
• SELF MASSAGE
An inflammatory condition that involves the space under the coracoacromial arch and structures in between that get pinched and compressed.
May range from supraspinatus tendonitis to bony changes to even rotator cuff tears.
What are the 3 theories for the etiolgoy of impingement syndrome according to Kessler?
1. Mechanical/Anatomic theory
2. Vascular Compromise theory
3. Kinesiologic factors
Define Mechanical/Anatomic theory:
Mechanical = structures too large (ex; inflamed tendon, mm malfunction)
Anatomic = Space too small
Define Vascular compromise:
Supra/Infra hypovascular = increased fibrosis = increased size
What structures make up the coracoacromial arch?
-"Roof" of the shoulder --> the acromial arch (acromian process), variations in shape that can predispose people to lesion
-Anterior acromioclavicular ligament
What can happen to rotator cuff tendons (esp. supraspinatus), biceps tendon and subacromial bursa?
Can undergo trauma and wear & tear when the head of the humerus is repeatedly pushed into acromial arch --> can lead to supraspinatus or biciptal tendonitis, subacromial bursitis, calcific tendonitis
Factors that can cause repeated trauma of head of humerus repeatedly pushing into acromial arch?
-A failed muscle force-coupling where the infraspinatus and teres minor don't depress humeral head to clear the acromion with abduction
-Hyperkyphosis --> relatively constant internal rotation therefore decreased external rotation which equates to compresssion
What impedes healing at the rotator cuffs, especially supraspinatus and infraspinatus?
Who is supraspinatus and bicipital tendonitis and subacromial bursitis most common in?
-Older people and women.
-People who play sports with repeated upper limb movements or who work/do activities that require working with the arm in a horizontal or higher position.
Define Kinesiologic factors
Poor Biomechanics = can develop fibrosis
◦Ex; humerus cannot rot post to clear arc
◦Ex; hyperkyphosis , cannot reach last 170°+ of ABd,
Structures involved in GH impingement syndrome:
● Supraspinatus tendon
● Subacromial bursa
● Biceps Long head tendon
● Coracoacromial Arc (Acromion, Coracoid Proc, Coracoacromial Ligament)
Traumatic contributing factors to Impingement syndrome in the shoulder:
I. A failed muscle force-coupling where the infraspinatus and teres minor don't depress humeral head to clear the acromion with abduction
II. Hyperkyphosis - Relatively constant internal rotation therefore decreased external rotation which equates to compression
How many stages of impingement syndrome are there? What are they?
The stages of impingement syndrome
-Self limiting overuse syndrome
-Supraspinatus tendonitis (grade 1-2)
-Reversible with manual tx, rest, stretching, progressive strengthening exercises
-Tendonitis grade 3-4
-Reversible with manual tx, rest, stretching, progressive strengthening exercises
-Incomplete or complete tendonous rupture
-Boney changes (bone spurs, eburnation)
Which stage(s) of impingement are reversible?
Both stages 1 & 2 are reversible with manual treatment, rest, stretching and progressive strengthening exercises
Tests for impingement syndrome
-Neer Impingement Test
-Drop arm test
-Empty can test
-Painful arc sign
S&S Impingement Syndrome:
Toothache like pain
n* with sharp twinges (mvt) over lateral brachial region
➢ AROM - full mvt (painful arc) - > decreases in later stages (when swelling decreases)
➢ PROM - similar to AROM
➢ RROM - Strong/Painful vs. Weak/Painful vs. Weak/Painless (nn.)
Important re; Tx impingement syndrome:
Figure out what structures involved, Tx & REMEX that structure specifically
Tests for Impingement Syndrome:
(confirms tendonitis/bursitis involvement)
Neer Impingement or Hawkins-Kennedy Test
, Drop Arm, Empty Can, Speed's Test, Painful Arc Sign
Precautions and contraindications impingement:
- As per bursitis and tendonitis
If there is boney change, avoid joint mobilizations
XFF CI'd if corticosteroid injections
to the shoulder
Make sure REMEX does not cause pain
Stage 1 & Stage 2
- Ice to decrease inflammation
- When inflammation ceases, apply heat and stretch
- Strengthening exercises
(improve force coupling)
- Similar as stage 1 and 2 but more conservative and gradual as the guest may be post surgical
1. MFR: skin roll mid scap; Bow UT
2. D-RLs (dynamic release): Infraspin, Teres Mnr
3. NMT: GTO Rls and strip supraspin
XFF supraspin T
5. SwM to clear post SH
6. MM reset
1.MFR: arm pull; Bow Pec Mjr; LL Pec Mjr/Mnr; shear Ant Delt; Bow Biceps; LL biceps
2.Jnt Mobes: Inf Glide GH
3.NMT: strip and GTO Rls biceps;
LFF biceps T
5.SwM to clear ant SH and arm
Specific tx techniqes for impingement
-Proximal effleurage and stroking to decrease edema
-TrP that may refer to the area - infrapspinatus, levator scap, biceps brachii, anterior delt, scalenes, supraspin., pec maj/min, coracobrachialis
-Reduce adhesions - delt/jpec maj, delt/humerus
-Decrease tone - NMT / swedish - supra, biceps, levator scap, UT
-Jt mobs --> GH (inf, ant, post glides), SC and AC jts
-Restore ROM (PROM, stretch pec maj, supraspinatus, ant delt, infra)
Treatment planning impingement:
Stage 1 and 2
- Circulatory strokes, lymphatic drainage to address inflammation
- Manual techniques to address muscle spasm and compensatory problems
- Friction therapy
- Joint mobilizations to address capsular pattern restrictions
- if surgery is needed deal with post-surgical healing and complications
Important post aggravating activity:
Icing after aggravating activity important
(5 mins, 3-5 times)
After you Friction:
STRETCH + RESET
FIRE THE MM -> AROM OR RROM
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