Supraspinatus tendinitis 30may2013

1. Supraspinatus Tendinitis RAHILA NAJIHAH ALI DPH/0102/11 30 th MAY 2013

2. Skeletal Structure

3. Humans have a strong and well developed clavicle that acts as a lateral strut (support) to the scapula and the humerus. This increase glenohumeral mobility to permit reaching & climbing activities Laura K.Smith, 1995, Brunnstrom’s Clinical Kinesiology, 5 th Edition, Book Promotion & Service LTD

4. Scapulo-Humeral rhythm describes the timing of movement at these joints during shoulder elevation 1 st 30° of shoulder elevation : glenohumeral jt. : large scapulothoracic jt. : small & inconsistent after 1 st 30° of shoulder elevation : glenohumeral jt. & scapulothoracic jt. move simultaneously ratio : 2 : 1 Function :   preserves the length-tension relationships of the glenohumeral muscles Prevent impingement Laura K.Smith, 1995, Brunnstrom’s Clinical Kinesiology, 5 th Edition, Book Promotion & Service LTD http://moon.ouhsc.edu/dthompso/namics/scapryme.htm

5. Ligament & Capsule

6. Muscles

7. Supraspinatus Muscle Origin - supraspinous fossa of scapula Insertion - greater tubercle of humerus Action – Assists deltoid muscle in abducting arm at shoulder joint Joseph E. Muscolino, . The Muscle and Palpation Manual with Trigger Points, Refferal Patterns, and Stretching

8. Supraspinatus Tendon Most frequently irritated tendon of most superior tendons of glenohumeral joint Vulnerability of this tendon to inflammation is due to its anatomical location

9. Supraspinatus Tendinitis Inflammation of supraspinatus tendon Most common affected structure in rotator cuff muscle that lead to development of pain due to impingement in shoulder

10. Impingement Occur beneath coraco-acromial arch Most vulnerable structures between undersurface of acromion and head of humerus are greater tuberosity, the overlying supraspinatus tendon and long head of biceps Major site of compression is slightly anterior to angle of acromion Proper term is painful arc syndrome John Ebnezar,2011, Essential of Orthopaedics for Physiotherapy, 2 nd edition,India, Jaypee Brother

11. Painful Arc Syndrome  painful arc occur on resisted abduction between 60 and 120 degrees when the inflamed tendon presses against the acromium outside of this range, abduction is painless Patricia A.Downie,1983, Cash’s textbook of Orthopaedics and rheumatology for physiotherapists, London, JP

12. Causes Repeated use of arm overhead in occupation, functional or sports stresses Arm kept at the side or moved with horizontally adducted position Over stress to tendon due to muscle weakness, tight muscle, tight capsule, or bony impingement Poor posture like kyphosis and shoulder complex protraction Poor body mechanic Otto D.Payton, 1989, Manual of Physical Therapy, New York, Edinburgh, London, Churchill Livingstone

13. Signs Active movement produce painful arc with coronal abduction Patient complain of pain discomfort when therapist do passive stretching of supraspinatus tendon Patient complain of pain when therapist do resisted isometric contracture of external rotation and both diagonal and coronal abduction Otto D.Payton, 1989, Manual of Physical Therapy, New York, Edinburgh, London, Churchill Livingstone

14. Symptoms Pain or limited of ROM Pain at rest with highly reactive condition Example - lying on side of dysfunction - sit in chair with too high arm rest Limitation of function with elevated diagonal movement Otto D.Payton, 1989, Manual of Physical Therapy, New York, Edinburgh, London, Churchill Livingstone

15. Radiograph X-ray MRI

16. Treatment Transverse friction massage to the supraspinatus tendon Use modalities to reduce inflammation like ultra sound, iontophoresis, phonophoresis, IFT and high voltage stimulation Educate in posture and body mechanics Stretch tight muscle Strengthen weak muscle Manipulate thigh capsule Otto D.Payton, 1989, Manual of Physical Therapy, New York, Edinburgh, London, Churchill Livingstone

17. Transverse Friction Massage Position of patient : sitting with hand of injured shoulder placed behind the back and relax the arm Position of therapist: Stand in behind of the client’s shoulder to find the supraspinatus tendon Procedure : video Val Robertson, 2009, Electrotherapy Explained principles and practise , 4 th edition, China, Elsevier

18. Strengthening weak muscle Muscle that need to be strengthen: -external and internal rotators -deltoid -scapular stabilizers (rhomboids, trapezius, serratus anterior, latissimus dorsi) Do the proprioceptive neuromuscular facilitation (PNF) http://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis

19. • D1 Flexion pattern: shoulder flexion, elbow flexion, forearm supination, wrist flexion, and finger flexion. • D1 Extension pattern: shoulder extension, elbow extension, forearm pronation, wrist and finger extension. • D2 Flexion pattern: shoulder flexion, elbow extension, forearm supination, wrist extension, and finger extension. • D2 Extension pattern: shoulder extension, elbow flexion, forearm pronation, wrist and finger flexion http://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis

20. Increase ROM  pendulum exercises active assisted ROM exercises active exercises in all planes self-stretches concentrating mainly on posterior joint capsule http://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis

21. Manipulate tight capsule Joint mobilization of the shoulder joint inferior, anterior, and posterior glides of shoulder http://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis

22. CASE STUDY SOAPIER

23. Subjective NAME : Madam Y AGE : 63 years old GENDER : Female OCCUPATION : Housewife DOMMINANT HAND: Left hand DATE OF ASSESSMENT : 22 nd Mei 2013 CHIEF COMPLAINT : Patient complaint pain at her left shoulder when lifting up the left hand above the head level and try to lift heavy things. Patient also complain difficulty in dressing especially when trying to wear bra and take out her cloth.

24. PRESENT HISTORY : Patient had fall down about 4 weeks ago due to wet floor at a bank. She fall with outstretched left hand. She only felt pain after 3 days prior to the injury. She went to traditional Chinese doctor and did massage but the pain became worse. PAST HISTORY : NIL SOCIAL HISTORY : She stays with her husband and daughter at a terrace house in Kuala Lumpur. She takes care of her husband that has Alzheimer's disease since 12 years and also does a lot of housework. Sometimes she takes her husband for morning walk around her housing area. Patient is a non-smoker and doesn’t consume alcohol.

25. SPECIAL QUESTION General health : High blood pressure and depression PMHx/Surgery : ankle sprain on 2006 and low back pain since 2008 Lx/X-Ray/MRI : X-Ray for ankle on 2006 MRI for whole body on 2008 MEDICATION/STEROID : under medication Patenolol 100mg 1 tablet, 2 times per day for high blood pressure Patient taking another type of high blood pressure medicine but does not remember it’s name Lexapio 5mg 2 tablet per day for depression

26. Pain assessment Site : Anterior and posterior shoulder near to glenohumeral joint Pain scale : 4/10 when rest 6/10 when lift up the hand above head level and carry heavy things Nature of pain : Pulling pain Aggravating factor : Lift up the hand above head level and carry heavy things Easing factor : Resting hand on the abdomen in internal position of shoulder Irritability : Medium 24 hours :am : No pain pm : sometime disturb sleep Onset : Gradual

27. Body Chart xx X

28. Objective On observation Body built : Medium Deformities : NIL Swelling : mild swelling around the left shoulder Posture : Slightly kyphotic On palpation Spasm : on the anterior and posterior part of left shoulder Warmth : no Tightness : on anterior part of left shoulder

29. On examination (Range of motion ) Shoulder * ( )-degree where patient start feel pain patient feel pain when do the flexion, extension, abduction and medial rotation of left shoulder all action of right shoulder is FROM ACTIVE PASSIVE ACTION ACTIVE PASSIVE 0-180° 0-180° Flexion 0-160° (150°) 0-170° 0-60° 0-60° Extension 0-50° (30°) 0-60° 0-180° 0-180° Abduction 0-165° (70-120°) 0-170° Adduction 0-80° 0-80° Medial Rotation 0-70° (60°) 0-80° 0-90° 0-90° Lateral Rotation 0-90° 0-90° Right Left

30. 2) Elbow The ROM of right and left elbow joint is FROM There’s no complain of pain when do all the movement ACTIVE PASSIVE ACTION ACTIVE PASSIVE 0-140° 0-140° Flexion 0-140° 0-140° 140-0° 140-0° Extension 140-0° 140-0° 0-80° 0-80° Pronation 0-80° 0-80° 0-80° 0-80° Supination 0-80° 0-80° Right Left

31. 3) Wrist The ROM of wrist joint is FROM there’s no complain of pain when do all the movements ACTIVE PASSIVE ACTION ACTIVE PASSIVE 0-70° 0-70° Flexion 0-70° 0-70° 0-60° 0-60° Extension 0-60° 0-60° 0-20° 0-20° Ulnar dev. 0-20° 0-20° 0-30° 0-30° Radial dev. 0-30° 0-30° Right Left

32. Muscle girth *Differences of the muscle girth are 0.5 cm. There’s no muscle wasting MUSCLE MEASUREMENT (RIGHT) MEASUREMENT (LEFT) DELTOID 31.5 CM 31.0 CM BICEPS 30.5 CM 30.0 CM TRICEPS 29.5 CM 29.0 CM BRACHIALRADIALIS 23.0 CM 22.5 CM

33. Muscle Power (Shoulder) MUSCLE ACTION RIGHT LEFT Anterior Deltoid & Coracobranchialis FLEXION 4/5 3/5 Latisimus Dorsi, Teres Major, Posterior Deltoid EXTENSION 4/5 3/5 Middle Deltoid & Supraspinatus ABDUCTION 4/5 3/5 Pectoralis Major ADDUCTION 4/5 3/5 Subscapularis MEDIAL ROTATION 4/5 3/5 Infraspinatus & Teres Major LATERAL ROTATION 4/5 3/5

34. Special Test TEST RESULT Neer Impingement Test Negative Hawkins-kennedy Impingement Test Negative Empty Can Test Positive

35. Analysis Physiotherapy impression - pain at the anterior and posterior site of left shoulder -reduce full ROM of left shoulder due to pain -reduce muscle power in left hand due to weakness -left Supraspinatus tendinitis Goals Short Term Goal - To reduce pain at the left shoulder - To increase range of motion of flexion, extension, abduction and medial rotation of left shoulder - Improve the muscle power of left shoulder Long Term Goal - To improve functional activity of daily life ( patient can take care of her husband and able to do housework with no pain )

36. Plan of treatment Pain relief Soft tissue manipulation Home program exercise Patient education

37. Intervention 1) Pain releif Interferential therapy site : around the left shoulder position of patient : sitting with shoulder in relax position procedure : apply 4 pole at left shoulder duration: 10 minutes purpose : relieve pain Ultrasound site : anterior site of the left shoulder position of patient : sits with his arm behind the back in medial rotation duration : 5 minutes purpose : promote healing process Crayo cuff site : left shoulder position : sit with the shoulder in relax position duration :10 minutes purpose : to reduce swelling

38. 2) Soft tissue manipulation Superficial soft tissue manipulation site: around the left shoulder procedure : apply Repairil and Ultimax gel around the left shoulder purpose : relaxing the muscle Transverse friction massage Site : anterior to acromion process Duration : 5 minutes Position of patient : patient sits with his arm behind the back in medial rotation Procedure : index finger of the ipsilateral hand, reinforced by the middle finger. The thumb should be placed quite far down the arm. So that a downward pressure is exerted on the greater tuberosity, the index finger-nail remaining horizontal. Purpose : to break the adhesion around the joint

39. Contd. 3) Home program exercise Stretching the Supraspinatus muscle position of patient : sitting or standing action : patient’s left hand is extended and adducted behind the body repetition : 10 repetition 3 times daily

40. 4) Patient education Put ice on swelling part of the shoulder Avoid heavy lifting Rest the affected shoulder Don’t lean on affected side during sleeping Avoid sudden movement of the affected shoulder

41. Evaluation Patient fell better after do the treatments Patient able to lift up the hand over the head with less pain after Transverse Friction Massage at the shoulder joint Review Reassess ROM , muscle girth for next visit Review the muscle power

42. First follow up

43. Date of assessment : 27 th may 2013 Complain : patient is complain of pain increase due to lift the wheel chair into the car Pain scale : 5/10 when rest 7/10 when lift up the hand above head level and carry heavy things On observation Swelling : mild swelling around the left shoulder On palpation Warmth : no Tightness : on anterior part of left shoulder

44. On examination (Range of motion ) 1) Shoulder right left * ( )-degree where patient start feel pain patient feel pain when do the flexion, extension, abduction and medial rotation of left shoulder all action of right shoulder is FROM ACTIVE PASSIVE ACTION ACTIVE PASSIVE 0-180° 0-180° Flexion 0-160° (150°) 0-170° 0-60° 0-60° Extension 0-50° (30°) 0-60° 0-180° 0-180° Abduction 0-165° ( 70-120°) 0-170° Adduction 0-80° 0-80° Medial Rotation 0-70° (60°) 0-80° 0-90° 0-90° Lateral Rotation 0-90° 0-90°

45. 2) elbow -the movements are FROM -there’s no complain of pain when do the movements 3) wrist -the movements are FROM -there’s no complain of pain when do the movements 4) Spasm : on the anterior and posterior part of left shoulder

46. Muscle Power (Shoulder) MUSCLE ACTION RIGHT LEFT Anterior Deltoid & Coracobranchialis FLEXION 4/5 3/5 Latisimus Dorsi, Teres Major, Posterior Deltoid EXTENSION 4/5 3/5 Middle Deltoid & Supraspinatus ABDUCTION 4/5 3/5 Pectoralis Major ADDUCTION 4/5 3/5 Subscapularis MEDIAL ROTATION 4/5 3/5 Infraspinatus & Teres Major LATERAL ROTATION 4/5 3/5

47. Analysis Physiotherapy impression - pain at the anterior and posterior site of left shoulder -reduce full ROM of left shoulder due to pain -reduce muscle power in left hand due to weakness -patient did not do the stretching that had taught by therapist Goals short term goal - To reduce pain of the left shoulder - To increase range of motion the flexion, extension, abduction and medial rotation of left shoulder - Improve the muscle power of the left shoulder Long Term Goal - To improve functional activity of daily life ( patient can take care of her husband and able to do housework with no pain )

48. Plan of treatment Pain relief Soft tissue manipulation Home program exercise Patient education

49. Intervention 1) Pain relief Interferential therapy site : around the left shoulder position of patient : sitting procedure: apply 4 pole at left shoulder duration: 10 minutes purpose : relieve pain Ultrasound site : anterior site of the left shoulder position of patient : sitting duration : 5 minutes purpose : promote healing process Crayo cuff site : left shoulder position : 10 minutes purpose : to reduce swelling

50. 2) Soft tissue manipulation Superficial soft tissue manipulation site: around the left shoulder procedure : apply Repairil and Ultimax gel around the left shoulder purpose : relaxing the muscle Transverse friction massage Site : between glenohumeral joint Duration : 5 minutes Position of patient : patient sits with his arm behind the back in medial rotation Procedure : index finger of the ipsilateral hand, reinforced by the middle finger. The thumb should be placed quite far down the arm. So that a downward pressure is exerted on the greater tuberosity, the index finger-nail remaining horizontal. Purpose : restoring mobility to muscles

51. Contd. 3) Home program exercise Stretching the Supraspinatus muscle position of patient : sitting or standing action : patient’s left hand is extended and adducted behind the body repetition : 10 repetition 3 times daily

52. 4) Patient education Avoid heavy lifting Rest the affected shoulder Don’t lean on affected side during sleeping Avoid sudden movement of the affected shoulder Therapist emphasize the importance of stretching

53. Evaluation Patient fell better after do the treatment Patient able to lift up the hand over the head with less pain after Transverse Friction Massage at the shoulder joint Review Reassess ROM , muscle girth for next visit Review the muscle power

54. Second follow up

55. Date of assessment : 29 th may 2013 complain : patient fell pain decrease Pain scale : 3/10 when rest 5/10 when lift up the hand above head level and carry heavy things On observation Swelling : mild swelling around the left shoulder On palpation Spasm : on the anterior and posterior part of left shoulder Warmth : no Tightness : on anterior part of left shoulder

56. On examination (Range of motion ) 1) Shoulder right left * ( )-degree where patient start feel pain patient feel pain when do the flexion, extension, abduction and medial rotation of left shoulder all action of right shoulder is FROM ACTIVE PASSIVE ACTION ACTIVE PASSIVE 0-180° 0-180° Flexion 0-160° (150°) 0-170° 0-60° 0-60° Extension 0-50° (30°) 0-60° 0-180° 0-180° Abduction 0-165° (70°) 0-170° Adduction 0-80° 0-80° Medial Rotation 0-70° (60°) 0-80° 0-90° 0-90° Lateral Rotation 0-90° 0-90°

57. 2) elbow -the movements are FROM -there’s no complain of pain when do the movements 3) wrist -the movements are FROM -there’s no complain of pain when do the movements

58. Muscle Power (Shoulder) MUSCLE ACTION RIGHT LEFT Anterior Deltoid & Coracobranchialis FLEXION 4/5 3/5 Latisimus Dorsi , Teres Major, Posterior Deltoid EXTENSION 4/5 3/5 Middle Deltoid & Supraspinatus ABDUCTION 4/5 3/5 Pectoralis Major ADDUCTION 4/5 3/5 Subscapularis MEDIAL ROTATION 4/5 3/5 Infraspinatus & Teres Major LATERAL ROTATION 4/5 3/5

59. Analysis Physiotherapy impression - pain at the anterior and posterior site of left shoulder -reduce full ROM of left shoulder due to pain -reduce muscle power in both hand due to weakness - patient did not do the stretching that already taught by therapist Goals short term goal - To reduce pain - To increase range of motion - Improve the muscle power Long Term Goal - To improve functional activity of daily life

60. Plan of treatment Pain relief Soft tissue manipulation Home program exercise KIV shoulder exercise Patient education

61. Intervention 1) Pain relief Interferential therapy site : around the left shoulder position of patient : sitting procedure: apply 4 pole at left shoulder duration: 10 minutes purpose : relieve pain Ultrasound site : anterior site of the left shoulder position of patient : sitting duration : 5 minutes purpose : promote healing process Crayo cuff site : left shoulder position : 10 minutes purpose : to reduce swelling

62. 2) Soft tissue manipulation Superficial soft tissue manipulation site: around the left shoulder procedure : apply Repairil and Ultimax gel around the left shoulder purpose : relaxing the muscle Transverse friction massage Site : between glenohumeral joint Duration : 5 minutes Position of patient : patient sits with his arm behind the back in medial rotation Procedure : index finger of the ipsilateral hand, reinforced by the middle finger. The thumb should be placed quite far down the arm. So that a downward pressure is exerted on the greater tuberosity , the index finger-nail remaining horizontal. Purpose : restoring mobility to muscles

63. Contd. 3) Home program exercise Stretching the Supraspinatus muscle position of patient : sitting or standing action : patient’s left hand is extended and adducted behind the body repetition : 10 repetition 3 times daily

64. 4) Patient education Avoid heavy lifting Rest the affected shoulder Don’t lean on affected side during sleeping Avoid sudden movement of the affected shoulder

65. Evaluation Patient fell better after do the treatment Patient able to lift up the hand over the head with less pain after Transverse Friction Massage at the shoulder joint Review Reassess ROM , muscle girth for next visit Review the muscle power

66. Reference Laura K.Smith , 1995, Brunnstrom’s Clinical Kinesiology, 5 th Edition, Book Promotion & Service LTD Joseph E. Muscolino , . The Muscle and Palpation Manual with Trigger Points, Refferal Patterns, and Stretching John Ebnezar,2011, Essential of Orthopaedics for Physiotherapy, 2 nd edition,India , Jaypee Brother Patricia A.Downie,1983, Cash’s textbook of Orthopaedics and rheumatology for physiotherapists, London, JP Otto D.Payton , 1989, Manual of Physical Therapy, New York, Edinburgh, London, Churchill Livingstone Val Robertson, 2009, Electrotherapy Explained principles and practise , 4 th edition, China, Elsevier http://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis http://moon.ouhsc.edu/dthompso/namics/scapryme.htm