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Saturday, December 5, 2015

Physiotherapy for Rotator cuff injuries


Bismillahirahmanirahim
Anatomy Of Rotator Cuff & Function

·         The rotator cuff is a group of four muscles and their tendons, which envelope the main shoulder joint (where the upper arm bone sits on a shallow socket in the shoulder blade .
·         The rotator cuff allows the arm to raise and rotate (at the shoulder joint) and helps to stabilize the shoulder joint during movement.
·         Though each rotator cuff muscle moves the arm (from the shoulder joint) in a specific direction, they all work together to stabilize the shoulder joint.
·         Muscles on the dorsum of the scapula, and the Triceps brachii.
·         The scapular and circumflex arteries


Muscles composing rotator cuff
(SITS)


Rotator cuff Injuries
This group of tendons can become torn, leading to pain and restricted movement of the arm. A torn rotator cuff can occur following a trauma to the shoulder or it can occur through "wear and tear" of the tendons (most commonly that of the supraspinatus) under the acromion. It is an injury frequently sustained by athletes whose duties involve making repetitive throws, such as baseball pitchers, American football quarterbacks, volleyball (due to their swinging motions), swimmers, boxers, kayaking, fast bowlers in cricket, and tennis players (due to their service motion). It is commonly associated with motions that require repeated overhead motions or forceful pulling motions

Causes / Risk Factors for Rotator Cuff Injury:
     
·         Whether injury develops gradually from overuse or suddenly from a traumatic injury, it is often because the rotator cuff is not strong enough for the given task !!!!!!!
·         Weak rotator cuff muscles
·         If any of the rotator cuff muscles are weak, the humerus may not be kept centered in the socket of the shoulder blade, and the surrounding soft tissues may be placed under abnormal pressure. This may lead to irritation and inflammation of the rotator cuff tendons.
·         Advanced age
·         Age-related changes in the tendons leave them weaker, less elastic, and more susceptible to injury.
·         Chronic overuse of shoulder
·         (especially activities involving repetitive overhead movement such as swimming, tennis, stacking objects on high shelves). Minor injuries that are not given a chance to heal can cause chronic inflammation and degenerative changes in the tissues. Early treatment is important.
·         Poor Posture
·         Slouching places undue stress on shoulder joint.
·         Participating in contact sports
·         Acute shoulder injuries are often due to a blow to the shoulder or a fall.


Symptoms of Rotator Cuff Injury
·         The main symptoms of rotator cuff injuries are shoulder pain and weakness. Symptoms worsen when lifting the arm above shoulder level. A rotator cuff tear will cause more weakness than rotator cuff tendonitis but the symptoms are similar.
·         Symptoms may occur suddenly if the rotator cuff in injured by a traumatic injury - such as an accident or fall. The majority of rotator cuff injuries occur gradually and symptoms appear gradually.

Preventing Rotator Cuff Injuries:
·         Rotator cuff exercises to strengthen the rotator cuff helps to stabilize the shoulder joint and reduce the risk of rotator cuff injuries. Strengthening exercises strengthen the muscles and the tendons.
·         Avoid lifting heavy objects, especially overhead. Use two hands to lift heavy objects to distribute the weight.
·         Take breaks from repetitive overhead activities. Fatigued rotator cuff muscles can't properly stabilize the shoulder joint.
·         Maintain Proper Posture. Keep shoulders down and back.


Test For Rotator cuff
The supraspinatus test
This test is carried out with the patient standing. With the elbow straight, the arm is placed in 20 degrees of abduction and flexion, and the patient is told to hold it there. The examiner assesses the strength of abduc­tion, and the patient reports the amount of pain produced by this manoeuvre. The examiner then tests the opposite normal shoulder for comparison. Weakness on testing denotes a rotator cuff tear. Unfortunately, if there is a lot of pain, then weakness will be apparent due to pain inhibition, and the test will have to be performed after an impingement injection test.
The supraspinatus test: active resisted abduction at 30 degrees tests supraspinatus strength.


The infraspinatus test
It is very similar to the supraspinatus test, and is a test of resisted active external rotation of the shoulder. The infraspina­tus is the only efficient external rotator of the glenohumeral joint. Pain and weakness are sought, weakness denoting a rotator cuff tear.
The infraspinatus test: active resisted external rotation with the elbow flexed to 90 degrees and the humerus at the side. Pain and weakness may denote a tear of infraspinatus.

The subscapularis test
This test is similar, but opposite, to the infraspinatus test. With the elbow locked against the patient's side active resisted inter­nal rotation of the glenohumeral joint is tested. Unfortunately this movement is produced by pectoralis major and latissimus dorsi, as well as subscapularis, and therefore is not such a sensitive test.
The subscapulars test: active resisted internal rotation of the glenohumeral joint.



Treatment Of Rotator Cuff Injuries:
   Treatment involves avoiding overhead activities and any activity that causes pain, rehabilitative exercises, anti-inflammatory medications, applying ice, applying heat, stretching exercises to prevent frozen shoulder, sometimes a cortisone injection, possible surgery
Relative Rest
Rest does not mean total rest. Using the shoulder for everyday activities prevents muscles from atrophying. Avoid activity that causes pain especially overhead activities. Avoid the activity that caused the injury in the first place (if it can be identified)
Rotator Cuff Exercises
Stretching exercises are usually started after the first couple of days to prevent frozen shoulder. Consult a physician before beginning exercises if you have shoulder pain.
Strengthening exercises are prescribed as the shoulder heals, when a physician or physical therapist determines the shoulder is ready. Exercises done too soon may cause further injury.
Applying Ice
For acute injuries, applying ice covered by a cloth for 20 minutes, every three or hours for the first couple of days helps limit swelling and pain and shortens healing time. Do not ice for over 20 minutes at a time to avoid frostbite. Do not apply ice directly to skin; cover ice with a wet or dry cloth. Moist cold penetrates more deeply than dry cold, but many people prefer to use dry cold.
For chronic injuries, applying ice after an exercise or activity that has aggravated the injury can minimize pain.

       If you have circulatory problems or nerve damage, consult a physician  or therapist before applying heat or cold.

Heat
Do not apply heat for the first few days after an acute injury. Do not apply heat to a swollen joint as it will increase inflammation. Wait about four or five days or until swelling has subsided. Heat increases circulation, helps relax the muscles, and relieves pain. Apply heat for 15 to 20 minutes at a time, and wait at least an hour before reapplying to avoid overheating the tissues.
For chronic injuries, apply heat before exercises or activities that may cause soreness. Warm muscles are more elastic than cold muscles. A warm bath or shower before stretching exercises decreases the chance of injury. Moist heat penetrates more deeply than dry heat.

Compression
Wrapping the shoulder with ace (elastic) bandages helps minimizes swelling after an acute injury. If numbness occurs, the wrap is too tight. An ace bandage may also be used to hold on an ice pack.

Massage Therapy
Deep tissue massage is often used in the treatment of soft tissue injuries such as tendonitis. Massage therapy relieves pain and increases range of motion while it increases circulation and speeds healing. Massage therapy also reduces stress and the production of stress hormones. Stress hormones heighten the perception of pain and contribute to tight muscles (which may cause or increase pain). Massage therapy is contradicted if there is swelling of the joint

Surgery (Dr Mx).
if conservative treatment does not bring sufficient relief of pain and/or restore adequate shoulder function, surgery may be recommended. Surgery may be needed to reattach a torn rotator cuff tendon or, in the case of shoulder impingement, to smooth rough surfaces and remove damaged tissue.

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