Rotator Cuff Tendon Ruptures In Older Patients example essay topic

The shoulder is the most complex joint in the body. It is capable of moving in more than 16,000 positions. Many of its ailments, including the most common ones, involve biomechanical mechanisms that are unique to the shoulder. The most common shoulder problem for which professional help is sought out for is shoulder impingement (Haig 1996).

Shoulder impingement is primarily an overuse injury that involves a mechanical compression of the tendon, sub acromial bursa, and the long head of the biceps tendon, all of which are located under the coraco acromial arch (Prentice 2001). Impingement has been described as a continuum during which repetitive compression eventually leads to irritation and inflammation that progresses to fibrosis and eventually to rupture of the rotator cuff. Because impingement involves a spectrum of lesions of tissue in the shoulder, a working knowledge of its structural relationships will facilitate an understanding of the factors that result in abnormalities. This paper will provide knowledge of the anatomy, biomechanics, and correct rehabilitation involved with shoulder impingement. Impingement syndrome was originally described by Dr. Charles Neer as mechanical impingement of the muscle and the long head of the biceps tendon underneath the acromial arch. Neer classified three stages of impingement.

Stage I is characterized by edema and hemorrhage of the rotator cuff and supra humeral tissue. Stage II is characterized by fibrosis of the glenohumeral capsule and sub acromial bursa and tendonitis of the involved tendons. Patients usually demonstrate a loss of active and passive range of motion because of capsular fibrosis. Stage is the most difficult to treat and is characterized by disruption of the rotator cuff tendons. This includes rotator cuff tears, biceps rupture, and bone changes. Since this is a continuous disease process, there is often overlap of signs and symptoms (Hawkins and Abrams 1987).

For descriptive purposes, factors related to shoulder impingement can be divided into intrinsic and extrinsic categories. Intrinsic factors directly involve the sub acromial space and include changes in vascularity of the rotator cuff, degeneration, and anatomy or bony anomalies. Extrinsic factors include muscle imbalances and motor control problems of the rotator cuff and para scapular muscles, functional arc of movement, postural changes, training errors, and occupational or environmental hazards. More likely, the cause of impingement has multiple factors.

However, all factors may be important and the key factor in any case depends on individual circumstances. According to Neer, the one third of the acromion is thought to be the causative factor in mechanical wear of the rotator cuff through a process called impingement (Donatelli 2004). Neer believes that the and long head of the biceps are subjected to repeated compression when the arm is raised in forward flexion. The result of repeated forward flexion is that the supra humeral tissue is effectively driven directly under the one third of the acromion. A force couple is defined as two forces of equal magnitude, but in opposite direction that produce rotation on a body. Two primary force couples are used in the shoulder to control the scapula and humerus.

The scapular force couple is formed by the upper fibers of the trapezius, levator scapulae, and the upper fibers of the serratus anterior. The lower portion of the force couple is formed by the lower fibers of the trapezius and lower fibers of the serratus anterior. Simultaneous contraction of these muscles produces a smooth rhythmic motion to rotate and protract the scapula along the posterior thorax during elevation of the arm (Donatelli 2004). The scapular muscles function to rhythmically position the glenoid relative to the humeral head, therefore maintaining a normal length-tension relationship with the rotator cuff (Prentice 2001).

The internal rotators must be capable of producing humeral rotation on the order of 7,000 degrees per second. Thus the subscapularis tends to be stronger than the and teres minor, creating a strength imbalance. The opposite can also occur due to a poorly conditioned or fatigued subscapularis. The subscapularis is unable to control the excessive external rotation and extension of the humeral head. Over-hand throwing athletes are the most susceptible to develop rotator cuff muscle imbalance. The primary intrinsic factors can be divided into vascular, degenerative, and anatomic categories.

Rotator cuff vascularity is mostly affected in an area known as the critical zone. This zone is located approximately one centimeter medial to the insertion of the tendon. It is in this are where the is most likely to rupture. Rathbun and Mac nab noted that the critical zone of the rotator cuff had an adequate blood supply when the vessels were injected with the arm in the abducted position, but this area was hypo vascular when the injection was given with the arm in the adducted position. The authors propose a hypothesis of transient hypo vascularity in the critical zone as a result of the vessels being "wrung out" when the arm was in the adducted position (Donatelli 2004). The authors indicated that most degenerative rotator cuff tears occur with in this zone, suggesting that hypo vascularity of the tendon may play a role in the pathogenesis of rotator cuff tears.

Although there is not yet any definitive scientific evidence of a direct cause and effect relationship, the finding seems to indicate a vascular predisposition to the pathogenesis of rotator cuff disease and impingement. Evidence indicates that there is a natural age-related degeneration of the rotator cuff tendons. Rotator cuff tendon ruptures in older patients normally occur bilaterally and in the presence of preexisting tendon degeneration. The result of rotator cuff tendon degeneration puts the elderly population at a greater risk for developing type shoulder impingement. An abnormally shaped acromion will also cause impingement on the cuff tendons. Three types of acromions have been identified.

They are: type I (flat), type II (curved), and type (hooked). In a study performed by Morrison and Bigliani, 70% of rotator cuff tears were associated with type II and acromions. None had type I. Although the causal relationship between the shape of the acromion and rotator cuff tears or impingement can be concluded, the clinical findings support Neer's theory of impingement occurring primarily along the acromion (Donatelli 2004). Haig (1996) describes shoulder impingement as producing an atrophic, "worn away" appearance of the cuff tendons, which are frequently retracted. As compared to many joints in the body, rehabilitation of the shoulder is extremely important to the successful management of return to normal function for the entire upper extremity.

It is probably the most difficult joint in the body to rehabilitate because of its great range of motion and the complex interaction of muscle functions. Current rehab programs for the shoulder should focus on restoration of functional ability rather than focusing solely on resolution of symptoms (Kibler, McMullen, & Uhl 2001). The first stage of rehab for an athlete with shoulder impingement involves restoration of full range of motion. The purpose of range of motion exercises is to restore or maintain the range of motion in the shoulder complex. Warm up exercises should include: keeping the elbows straight, raise the arms forward and upward as far as possible, taking arms straight back as far as possible, and raising the arms until they reach shoulder level. The patient can also bend the elbows to ninety degrees, and while keeping them at ninety, fold palms across abdomen, then move hands away from body as far as possible.

Codman's pendulum exercises are performed to eliminate the force of gravity. The patient leans forward at the waist and supports the trunk with the unaffected hand on a table. From this position shoulder flexion, extension, adduction, abduction, and can be executed. Once the arm is in motion, the momentum of the moving limb should be enough to sustain the movement. Variations include: starting with small circles to the left and gradually increase in size, reversing and making circles to the right. Wall finger-walking exercises are specifically designed to increase the range of motion in the shoulder complex.

The patient should stand slightly closer than an arm's length away from a wall. Then the patient should slowly "walk" the injured arm up the wall by using the fingers for locomotion. This exercise should be done in flexion, abduction, and horizontal adduction and abduction. A total of 20-25 "walks" in each direction should be the goal. How you address pain with your patients in stage one has substantial psychological ramifications that will have an impact on them psychologically and physically later in the course of rehabilitation (Taylor & Taylor 1997). Once pain-free full range of motion is achieved, low-intensity weight training can be started.

This stage is where patients put the injured shoulder under its first tangible stress since the occurrence of the injury. In the second phase the injured tissue and surrounding muscles can withstand higher loads and thus be more actively mobilized (Frontera 2003). Exercises should concentrate on strengthening the dynamic stabilizers and the rotator cuff muscles, which act to both compress and depress the humeral head relative to the glenoid. The inferior rotator cuff muscles in particular should be strengthened to re-create a balance in the couple with the deltoid. Supraspinatus should be strengthened to assist in compression of the humeral head into the glenoid. Strengthening exercises can include a wide variety of ideas and movements.

Thera-Band can be used to provide resistance much like free weights. Resistive external / internal rotation, extension, and flexion are the most common movements used with resistive Thera-Band. To increase the resistance, simply shorten the length of the tubing. Hand weights, sandbags, and dumbbells can also be used to provide isotonic resistance. These exercises should be done slowly, then held at the top position for a three count.

Forward raises, lateral raises, shoulder rotation, and shoulder shrugs are some of the isotonic exercises used to strengthen the shoulder muscles. Specific exercises to strengthen the rotator cuff muscles should also be performed. Pecina and Bojanic (1993) give examples to strengthen the rotator cuff. Infraspinatus and teres minor: The patient should lie on one side and his elbow lies on his thorax in a position of 90 degrees.

The weight is slowly lifted in the external rotation direction and slowly lowered in the internal rotation direction. Subscapularis: The patient lies on his back, with his elbow along his thorax in a position of 90 degrees. The weight is lowered in an external rotation direction and then lifted in the internal rotation direction. Supraspinatus: The patient sits erectly, with his shoulder in a 90-degree abduction, 30-degree horizontal abduction, and total interior rotation.

The weight is slowly lowered in a 45-degree arch and then lifted to the starting position. Proprioception can be defined as a special type of sensitivity that informs about the sensations of the deep organs and of the relationship between muscles and joints (Frontera 2003). Proprioception involves balance and a more complex use of the shoulder muscles groups. These exercises are done to re-educate the that gather information on the position of the shoulder complex and how the tendons and ligaments are stretched. These exercises can begin by introducing the athlete to the D 1 and D 2 upper extremity movement patterns.

D 1 and D 2 are distinct diagonal and rotational movements of the upper extremity. They are initiated with the shoulder in a lengthened position, then contracted moving the shoulder through the range of motion to a shortened position. These movement patterns can also be accompanied with resistance or added weight as the athlete progresses. Thera-Band can be used to add resistance as the athlete moves through the D 2 pattern. Oscillating a Body Blade through the movement patterns can also be added to increase the difficulty. One final exercise to asses the athlete's proprioception of the shoulder is to perform rhythmic contractions.

The athlete will raise the arm to a specific level while the therapist repeatedly changes the direction of passive pressure, the athlete should use isometric co-contractions to maintain the specific position. Increased proprioception will decrease the likelihood of re-injury to the shoulder complex. The final stage of shoulder impingement rehabilitation is concluded with specific functional exercises. These exercises are used to re-create the movements and stress the athlete or patient will undergo during daily living or specific sport conditions. For example, a baseball player that is diagnosed with shoulder impingement will begin throwing a baseball during the final stage of rehab. Emphasis should be on execution of proper mechanics and endurance (Shamus 2001).

The number of throws and time spent throwing should be minimized initially and progressed only as tolerated. It is important to gradually progress the athlete and not overwhelm the structures. If pain occurs at any point in the program, the thrower should be returned to the previous level until pain free (Shamus 2001). The work and rest periods should mimic competition.

For example, a tennis player with shoulder impingement, trying to build local muscular endurance of the posterior shoulder may do three sets of 15 repetitions of a particular exercise. To replicate a typical play-rest period between points, allow a 25-second rest period between each set of 15 repetitions (Placzek and Boyce 2001). A final exercise that can be used to restore normal strength and endurance of the shoulder is sliding the hands across a slide board. The athlete should kneel with the hands on towels and trace certain patterns on the slide board. Patterns can include an "S" which simulates the movement pattern of the freestyle stroke in swimmers while the hands are underwater. Functional exercises should be creative and fun for the athlete.

The primary psychological emphasis in this shift is on establishing the confidence for athletes to perform at a level that is consistent with their rehabilitated physical conditions, namely, at or above their pre-injury levels of performance (Taylor 1997). A shoulder problem can be merely nagging, or it can completely destroy the quality of a person's life. Shoulder impingement can be a debilitating process if it is not treated correctly. Good understanding of the anatomy, physiology, and rehabilitation process will ensure the athlete or patient that everything will return to normal. Because shoulder impingement is becoming increasingly common in the athletic and occupational world, therapist should treat each case individually with compassion and concern. One of the most important contributors to successful rehabilitation and return to sport is social support.

Not only is your goal as a therapist to completely facilitate the injured shoulder, but also provide a sense of interpersonal connectedness that fosters positive expression of emotions, and offer encouragement in times of uncertainty.

Bibliography

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