Боль в передней части плеча. Тугоповижность плечей. Подостная мышца

Diagnostic procedures

Physical examination

  • Subjective interview:
    • Onset: Spontaneous or after injury
    • Duration of pain
    • Pain provocation/aggravating factors
    • Night rest
    • Same problems in the past?
    • Activity limitations
    • Localize pain
    • Past medical history
    • Recreational or sport activities (possible overhead activities)
  • Observation:
  • Range of motion:
    • Expect reductions in flexion, abduction and external rotation
    • If passive abduction range is more than active range, it is an indication of a rotator cuff tear
  • Muscle power:
    • Test supraspinatus by resisting abduction at 90° and internal rotation
    • Scapular movement may be affected
  • Palpation: Forearm behind back to palpate rotator cuff just anterior and below the acromion
    • Muscle atrophy present
    • Tenderness
  • Special tests:
    • Drop-arm test: Active shoulder abduction to 90°, then return

      Positive: Dropping the arm down with pain indicates a positive test

https://youtube.com/watch?v=JXgRBeqToik%3F

    • Jobe/supraspinatus/empty can test: Resist shoulder abduction and internal rotation

      Positive: Pain/weakness

https://youtube.com/watch?v=5BjDQ-jcBek%3F

    • Full can test: Resisted shoulder abduction in external rotation

https://youtube.com/watch?v=NuBOHdm20cc%3F

    • Subacromial grind test: Patient standing and examiner standing facing the patient, the examiner grasps the patient’s flexed elbow. The shoulder is passively abducted in the scapular plane to 90°. The examiner’s other hand is placed over the patient’s shoulder overlying the anterior acromion and greater tuberosity. The examiner passively internally and externally rotates the shoulder detecting the presence of palpable crepitus.

https://youtube.com/watch?v=f5yOT2hpTac%3F

Special investigations

  • X-rays:
    • Exclude sclerosis and osteophyte formation on the acromion
    • Measure the size of the subacromial space
    • Unable to see tendon
  • MRI Shows partial or full tears in the tendons of the rotator cuff, inflammation to weak structures and cracks in the capsule
  • CT scan: Able to localize tendon when patient positioned with forearm behind back
  • Ultrasound: Able to localize tendon

Medical management

Conservative management

Indications:

  • Older (>70 years) patients with chronic tear
  • Patients with irreparable tears with irreversible changes
  • Patients of any age with small (
  • As a result of the slow rate of progression of these tears

Patients without a full-thickness tear

Management include:

  • NSAID’s:
    • Ibuprofen
    • Corticosteroid injections:
      • Eliminate pain for a period of time, making physiotherapy management easier
      • Tendon tissue can be weakened by these injections (which would have an adverse effect on the outcome of a possible surgery)
      • Limited to 2 injections

Physiotherapy (see Physiotherapy management below)

Surgical management

Indications:

  • Failed conservative management
  • Larger symptomatic full-thickness tears ( 1-1,5cm) as a result of the high rate of progression
  • Acute large tears (>1 cm-1.5 cm) or
  • Young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes
  • Complete tear with significant pain and dysfuction after 6 months of treatment
  • Repeated dislocations

Surgery: Rotator cuff repair

  • Mostly done arthroscopically
  • Severity (partial vs full-thickness) will determine approach
  • Partial repair:

    The tendon and surrounding bone will be smoothed to avoid further damage and therefor allowing the tendon to heal mostly on its own

  • Complete tear:
    • Tear in middle of tendon: Suture the two parts of the tendon back together.
    • Tear close or on its point of attachment on the head of the humerus: Attach the tendon back to its original place by an anchor (sometimes two). This anchor actually consists of a small screw that is bored into the head of the humerus with on the back surgical wires which hold the tendon in place.

Physical Therapy Management

The main goal in the acute phase (initial phase) is to alleviate pain, inflammation, prevent aggravation of pain, reduce muscle wasting and normalize the arthrokinematics of the shoulder girdle. A period of rest should be considered in order to avoid further aggravation and shoulder discomfort. 

Passive modalities should be considered in order to avoid painful aggravation. Modalities such as ultrasound, cryotherapy and electrical muscle stimulation can provide temperory relief in acute phase. Strengthening exercises such as isometric exercises should be considered in order to work out the shoulder girdle musculatures. Proper home exercise programs should also be taught in conjuction with proper ergonomics. 

The management of a supraspinatus tendinopathy consists of different progressive exercises. There are three phases of treatment: Immobilization, passive/assisted range of motion, progressive resistance exercises (Level of Evidence: 5).

Early management includes avoidance of repetitive movements that aggravate the pain.  Patients should be informed about pain provoking postures and movements. Cryotherapy, soft tissue techniques and wearing a sling/taping are some other techniques to relieve pain (Level of Evidence 5). Gentle range-of-motion exercises, such as Codman’s classic pendulum exercises, maintain range of motion and prevent development of adhesive capsulitis(Level of Evidence: 3A) (Level of Evidence: 3A). Once pain has been reduced, joint mobilisations, massages, muscle stretches, active-assisted and active exercises are needed to improve the ROM again. Active-assisted mobilisations can be done by the patient himself/herself by using an exercise bar. We can also use a rope and pulley, this way the unaffected arm is able to pull the affected one into anteversion (Level of Evidence 5).  Strengthening exercises should work on the external rotators, internal rotators, biceps, deltoid, and scapular stabilizers(Level of Evidence: 2B).

Strengthening these muscles will keep the shoulder joint more stable and prevent further injuries. Eccentric exercises will also be more effective than concentric exercises (Level of Evidence 1A).

I.E.:

  • Sidelying external rotation with dumbbell against gravity
  • Prone horizontal abduction with dumbbell against gravity
  • Prone anteflexion in the plane of the scapula
  • Prone row with external rotation
  • External rotation with Thera-tubing (standing position)
  • Horizontal abduction with Thera-tubing (standing position)
  • Rows with Thera-tubing (standing position)
  • Elevation in the plane of the scapula (standing position)

Scapula settings

Scapular protraction and retraction(Level of Evidence: 5)

Joint mobilization may be included with inferior, anterior, and posterior glides in the scapular plane(Level of Evidence: 3A). Stretching exercises should be done by repeating the exercise 3 times and holding the stretch each time for 30 seconds. Examples of the stretches for home exercise program are:

Neuromuscular control exercises also may be initiated(Level of Evidence: 3A). PNF patterns will increase strength in rotator cuff muscles and increase the stability of the shoulder. We can use four different patterns.

Modalities that also may be used as an adjunct include cryotherapy, hyperthermia(Level of Evidence: 1B), transcutaneous electrical nerve stimulation and ultrasound. Intensive ultrasound therapy has been shown to increase calcium resorption, but this requires frequent treatment that may not always be practical(Level of Evidence 1B).

Self-exercise

  • Patient’s starting position: sitting, arm abducted to a position before symptoms appear, contact with three finger tips of the left hand in the supraspinous fossa (a).
  • Movement: pressure into the supraspinous fossa, active adduction of the right glenohumeral joint, then releasing the pressure into the supraspinous fossa, and back to the starting position (b).

Patients suffering from non-calicfying supraspinatus tendinopathy may benefit from low energy extracorporeal shock wave therapy, at least in short-term(Level of Evidence: 1B).

At the end of the therapy you should initiate plyometric and sports-specific exercises.

Patient education is again reemphasised, maintaining proper mechanics, strength, and flexibility, and having a good understanding of the pathology. The patient should also show an understanding of a home exercise program with the proper warm-up and strengthening techniques (Level of Evidence: 3A) (Level of Evidence: 2B).

Outcome Measures

Diagnosis is usually clinical, but imaging can be useful. Shoulder x-rays can reveal calcifications in rotator cuff tendons and in the bursa. In longstanding cases, there may be degenerative changes, such as cystic/sclerotic changes at the greater tuberosity and decreased humeral head-acromion distance, secondary to upward migration of the humeral head. In acute calcific tendinopathy, calcifications may be irregular, fluffy and ill-defined. Dynamic ultrasound can demonstrate thickening of the subacromial bursa and impingement during abduction. Magnetic resonance imaging (MRI), rather than computed tomography (CT), is the preferred modality, since it produces more detailed soft-tissue images.

CharacteristicsClinical presentation

Supraspinatus tears normally present as partial or full-thickness tears. The can be asymptomatic or symptomatic.

  • Partial thickness: Incomplete disruption of muscle fibers

    Can progress to complete tear — Increasing pain is normally the first sign of progression of a tear

  • Full thickness: Complete disruption of muscle ibers
    • Large tears (1-1,5cm) have high rate of progression
    • If progression is suspected in conservatively managed cases — further investigation is warranted
    • Smaller tears (

Signs & symptoms

Patients normally present with:

  • Pain/worsening pain (in cases where tears are progressing): Most common symptom
    • Pain when lifting and lowering your arm or with specific movemen
    • Pain at rest
    • Pain at night, predominantly when you lie on the affected shoulder
    • Traumatic tears: Sudden, intense pain often accompanied by a snapping sensation and immediate weakness in the upper arm
    • Located anterolaterally and superiorly
    • Referred to the level of the deltoid insertion with full-thickness tears
    • Repetitive strain tear: Starts off mild and only when lifting your arm; over time the pain can become more noticeable at rest
    • Aggravated in overhead or forward-flexed position
  • Limited range of motion:
    • Reduced forward elevation, external rotation and abduction
    • Struggle with activities like reaching behind back, combing hair and overhead activities
  • Weakness when rotating or lifting your arm
  • Crepitus
  • Clicking
  • Stiffness
  • Limited range of motion:
    • Reduced forward elevation, external rotation and abduction
    • Struggle with activities like reaching behind back, combing hair and overhead activities
  • Instability

Differential diagnosis

  • Bicipital tendinopathy
  • Cervical radiculopathy
  • Cervical spine sprain
  • Cervical strain injuries
  • Cervical nerve root injury
  • Cervical Spondylosis
  • Cervical discogenic pain syndrome
  • Clavicular fracture
  • Sternoclavicular joint disorders
  • Infraspinatus syndrome
  • Contusions
  • Rotator cuff tear
  • Shoulder dislocation
  • Myofascial pain
  • Shoulder impingement syndrome
  • Superior labrum lesions
  • Shoulder subluxation
  • Angina pectoris
  • Myocardial infarction
  • Subacromial impingement
  • Osteoarthritis
  • Rheumatoid arthritis
  • Subscapular nerve entrapment
  • Shoulder instability
    • Anterior instability
    • Posterior instability

DefinitionDescription

Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse.

The supraspinatus tendon of the rotator cuff is involved and affected tendons of the musculoskeletal system and becomes degenerated, most often as a result of repetitive stresses and overloading during sports or occupational activities.The tendon of the supraspinatus commonly impinges under the acromion as it passes between the acromion and the humeral head. This mechanism is multifactorial (see below).

Differential Diagnosis19

In general, the causes of an acute painful shoulder can be classified into different categories, according to the prevailing pathoanatomy. These include

  • Cervical Disc Injuries
  • Cervical Discogenic Pain Syndrome
  • Cervical Spine Sprain/Strain Injuries
  • Clavicular Injuries
  • Contusions
  • Infraspinatus Syndrome
  • Myofascial Pain in Athletes
  • Neoplastic causes like tumor metastasis
  • Swimmer’s Shoulder
  • Traumatic fractures and dislocations

More probing investigations can narrow down the differential diagnoses, which could include:blood for white cell counts, search for abnormal blood biochemistry and inflammatory markers, as well as radionuclide imaging and MRI.

Examination

The anamnesis often reveals that, in case of a calcification, due to a trauma, pain emerges later on, after a few hours.The physical examination consist of taking the fever, looking for external wounds or bruises over the affected shoulder and checking the skin temperature. Further, the examinator will palpate in the area of the tendinous insertion of the supraspinatus muscle for checking tenderness and pain. Both passive and active movements will be performed.

Specific questionnaires can be used: Simple Shoulder Test (SST), Oxford Shoulder Score (OSS).

With clinical examination, other causes of shoulder pain should be excluded. So the neck, shoulder and chest wall have to be examined (Caroline, Adebajo, Hay & Carr, 2005)

The shoulders are inspected for symmetry, localized swelling and muscle atrophy. There may be tenderness below the acromion and over the greater tuberosity. Internal rotation of the shoulder can facilitate palpation of the supraspinatus insertion on the greater tuberosity. The most important clinical maneuvers are as follows:

Painful arc

Testings:

  • Neer’s sign
  • Hawkin’s sign
  • Supraspinatus challenge test = “The Empty Can” sign = Job ‘s test
  • Drop arm test
  • Impingement test

                      Neer’s test                                               Hawkin’s sign                                                        Empty Can sign

If sonografy is done, the standard method for sonographic evaluation of the supraspinatus tendon requires the arm behind the back (Crass position) or hand on the back pocket (modified Crass position). Crass et al described scanning the shoulder in extension and internal rotation, achieved by placing the patient’s hand behind the back.

Close-up view of the calcified lesion

Yet diagnosis is usually clinical, but imaging can be useful. Shoulder x-rays can reveal calcifications in rotator cuff tendons and in the bursa. In longstanding cases, there may be degenerative changes, such as cystic/sclerotic changes at the greater tuberosity and decreased humeral head-acromion distance, secondary to upward migration of the humeral head (6). In acute calcific tendinopathy, calcifications may be irregular, fluffy and ill-defined. Dynamic ultrasound can demonstrate thickening of the subacromial bursa and impingement during abduction. Also sonografy and Magnetic resonance imaging (MRI) can be done.

Supraspinatus tendinopathy can be graded using a modified 4-point scale from 0 to 3 based on previous studies. Diagnosis is based on the appearance of the rotator cuff tendons (grading system) and the presence or absence of signs denoting involvement of the subacromial bursa and subacromial–subdeltoid plane

Medical Management

The treatment used to manage a supraspinatus tendinopathy depends on the etiology of the pathology. At first a conservative treatment is preferred. This treatment involves physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), ice treatments and resting. Corticoid injections can also be used additional to physical therapy. A surgical intervention can be a solution if there is no improvement after 3-6 months of conservative treatment.

NSAIDs may be the first choice for mild to moderate symptoms, if there are no contraindications to these agents. A short term use (7-14 days) of NSAIDs is useful to relieve the pain associated with a tendinitis. However, there is little evidence supporting a long term course of NSAIDs.Moderate to severe symptoms may require a local subacromial corticosteroid injection. For more information about corticosteroid injections.

The major indications for surgery are ongoing pain, loss of function, failure to respond to conservative therapy for 3 months or evidence of an acute tear in a younger patient. Surgical approaches include calcium deposit resection, with or without subacromial decompression, bursal resectionA and acromioplastyB, using either arthroscopic or open methods. It’s also possible to split off the coraco-acromial ligament to enlarge the space between acromion and humerus. This can cause instability, but we can compensate it with some training of the rotator cuff. With physical therapy it takes patients up to 4 months to recover. The goal of a surgery is to obtain pain relief, increased range of motion and increased power. ABursal resection: Removement of the subacromial bursa.

Acromioplasty: Generally, it implies removal of a small piece of the surface of the acromion that is in contact with a tendon causing, by friction, damage to the latter tissue.

EpidemiologyEtiology

The etiology of supraspinatus tears is multifactorial, consisting of age-related degeneration, microtrauma and macrotrauma. The incidence increases with the age to about 50% during the 80s, mostly affecting the dominant arm.Injury and degeneration are the two main causes of rotator cuff tears. Rotator cuff tears are associated with older patients, a history of trauma and mostly affect the dominant arm. The most common risk factors for a tear consist of a history of trauma, dominant arm and age.

Mechanism of injury

  • Acute tear: Can occur with other shoulder injuries (e.g. clavicle fracture of shoulder dislocation)
    • Fall on your outstretched arm
    • Heavy lifting something too heavy
  • Degenerative: Wear and tear of the tendon slowly over time
    • Increases with the age
    • More common in the dominant arm
    • When you have a degenerative tear in one shoulder, you have a greater risk for a tear in the opposite shoulder, even if you have no pain in the opposite shoulder.

Risk factors

  • > 40 years old
  • Male > Female
  • Smoking
  • Genetics
  • Hypercholesterolemia
  • Body mass index
  • Height
  • Repetitive stress/lifting
  • History of trauma
  • Lack of blood supply
  • Bony spurs
  • Overhead activities and other people who do overhead work:
    • Tennis players
    • Baseball pitchers
    • Painters
    • Carpenters
    • Plumbers
  • Traumatic injury e.g. fall (more common cause in younger individuals)

Physiotherapy management

Physiotherapy management depends on the extend of the tear, and plays in important role in both conservative management as well as post-surgical rehabilitation. More details can also be obtained from the rotator cuff page.

Conservative management

Physiotherapy goals:

  • Improve pain together with NSAID’s (2-6 weeks)
  • Cryotherapy (only in first 48 hours)
  • Massage
  • Improve circulation (to control inflammation and speed up the healing process)
  • Improve range of motion:
    • Stretching (careful with timing, as stretching of acute injury may aggravate the tear):

      Crossover arm stretch: 12 seconds, 5 times a day; 5-6days/week 

       

Kristian Berg. Prescriptive stretching; Human Kinetics 

Door stretch: 5 x 30 seconds (5 second rest in between)

  • Passive/Active range of motion:
    • Pendulum exercises: Forward and back, side-to-side, circular motion. 2 sets of 10 a day, 5-6days/week
    • Symptom limited active-assisted range of motion exercises

Kristian Berg. Prescriptive stretching; Human Kinetics

  • Increase strength:
    • Rotator cuff (especially supraspinatus) strengthening to improve muscle control and strength – 13,19
    • Prone Horizontal Abduction progress by using theraband
    • Prone Row with External Rotation
  • Regain function of affected upper limb (up to 3 months)
  • Home exercise programme

CharacteristicsClinical presentation

Patients present with progressive subdeltoid aching that is aggravated by abduction, elevation, or sustained overhead activity. They feel also tenderness and a burning sensation in their shoulder. The pain may radiate to the lateral upper arm or may be located in the top and front of the shoulder. It typically becomes worse with overhead activity. Initially, the pain is felt during activities only, but eventually may occur at rest.

One has to think of supraspinatus tendinopathy when the patient says:

  • Pain increases with reaching.
  • Pain is felt after frequent repetitive activity at, or above shoulder.
  • Patient feels weakness of resisted abduction and forward flexion, especially with pushing and overhead movements.
  • Patient has difficulty sleeping at night due to pain, especially when lying on the affected shoulder, and with an inability to sleep.
  • Patient has difficulties with simple movements, such as brushing hair, putting on a shirt or jacket, or reaching the arm above shoulder height.
  • Patient has a limited range of motion in the shoulder.
  • Patient had a former shoulder trauma.

The shoulder may be warm and there may be fullness anterolaterally. Further, there is a painful arc between 70° and 120° of abduction.

So supraspinatus tendinopathy is usually consistent with anterior instability causing posterior tightness. The problems that patient with Supraspinatus Tendinopathy complain off, are pain, inflammation, decreased ROM, strength, and functional activity.

References

  1. Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus: Algemene anatomie en bewegingsapparaat, 2010. p600.
  2. Sawalha S, Fischer J. The accuracy of “subacromial grind test” in diagnosis of supraspinatus rotator cuff tears. International journal of shoulder surgery 2015;9(2):43-46.
  3. Walters J, editor. Orthopaedics — A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.
  4. Orthop J. Rotator cuff tear: physical examination and conservative treatment. Department of Orthopaedic Surgery Tohoku University, 2013:197–204.
  5. ↑ Millar NL, Wu X, Tantau R, Silverstone E, Murrell GA. Open versus two forms of arthroscopic rotator cuff repair. Clinical orthopaedics and related research 2009;467(4):966-78.
  6. ↑ Kristian Berg, Human Kinetics:. Prescriptive stretching. 2011.

Clinical Bottom Line

Supraspinatus tendinopathy is a common source of shoulder pain in athletes that participate in overhead sports (handball, volleyball, tennis, baseball). This tendinopathy is in most cases caused by an impingement of the supraspinatus tendon on the acromion as it passes between the acromion and the humeral head. Pain, and a decrease in range of motion, strength and functionality are the main complaints that accompany this injury and should be addressed in the physical therapy. There is enough evidence to prove that physical applications such as ultrasound , cryotherapy, hyperthermia, transcutaneous electrical nerve stimulation and extracorporeal shock wave therapy have a beneficial effect on the recovery of supraspinatus tendinopathy. But we have to remember that it is very important to use these methods as an adjunct to physical therapy (increasing ROM, strength training of the rotator cuff muscles and other shoulder stabilizers).

Clinical relevant anatomy

The shoulder joint is made up of three bones: the humerus, scapula and clavicle. The head of humerus and glenoid of the scapula form a ball-and-socket joint. The supraspinatus muscle is located on the back of the shoulder, forming part of the rotator cuff. The rotator cuff consists of Supraspinatus, Infraspinatus, Subscapularis and teres minor. The rotator cuff covers the head of the humerus and keeps it into place. These muscles help to lift and rotate the arm. Also see the page for the shoulder for more detailed information.

Supraspinatus

  • Origin: Supraspinous fossa of the scapula
  • Insertion: Greater tubercle of the humerus
  • Innervation: Supraspinatus nerve (C5-C6)
  • Function: Abduction of the glenohumeral joint; assists the rotator cuff in stabilizing, control and movement the shoulder; assists in preventing sublaxation at the shoulder

Clinical Relevant Anatomy

The supraspinatus muscle is of the greatest practical importance in the rotator cuff, derives its innervation from the suprascapular nerve and stabilises the schoulder, exorotates and helps abduct (lift up sideways) the arm, by initiating the abduction of the humerus on the scapula. Any friction between the tendon and the acromion is normally reduced by the subacromial bursa.

The anterior margin of the supraspinatus is defined by the posterior edge of the rotator interval that separates the supraspinatus from the rolled superior border of the subscapularis. The posterior margin of the supraspinatus is marked by the extension of the raphe between supraspinatus and infraspinatus around the scapular spine. The anterior portion of the supraspinatus is composed of a long and thick tendinous component whereas the posterior portion has been shown to be short and thin.

An anatomic dissection study of the supraspinatus footprint found that the mean anterior to posterior dimension of the supraspinatus tendon was 25 mm, with a mean medial to lateral thickness of the footprint of 12 mm — the mean distance from the cartilage to the supraspinatus footprint was 1.5 mm at mid tendon.

The supraspinatus and infraspinatus tendons fuse 1.5 cm proximal to their insertions. Collagen is the major matrix protein of supraspinatus tendons, consisting of > 95% type I collagen, with lesser amounts of other collagens including collagen type III.

The anatomy of the supraspinatus’s insertion is of key relevance in terms of its extracellular matrix composition and has been categorised into four transition zones. The first zone is proper tendon, made up of largely type I collagen and small amounts of decorin. The second zone is fibrocartilage and consists of largely types II and III collagen, with small amounts of types I, IX and X collagen. The third zone is mineralised fibrocartilage and consists of type II collagen, with significant amounts of type X collagen and aggrecan. The fourth zone is bone and is largely type I collagen with a high mineral content. This effective bone-tendon attachment is achieved through a functional grading in mineral content and collagen fibre orientation. The supraspinatus enthesis is a highly specialised in homogeneous structure that is subjected to both tensile and compressive forces.

Список источников

  • www.physio-pedia.com
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