Tendonitis/Tendinosis

rotator cuff strengthening examples for scapulothoracic stabilizing

-Rows, pull downs, push ups, prone flies -use theraband or free weight -Work until muscle fatigue or loss of form noted rather than specific # of reps

What can OT's do

1. Control inflammation (?): PAMs, orthoses to rest tendon (acute) 2. Maintain mobility of involved tendon and muscle 3. Prevent recurrence, manage symptoms (client education, reconditioning of surrounding muscle groups)

Lateral Epicondylitis/OSIS symptoms resolve with time

6-9 mo

Medial Epicondylitis is less common with focal tenderness over

medial epicondyle and just distal to it

Trigger Finger Stenosing Tenosynovitis can develop _____ on tendon

nodule

Lateral Epicondylitis/OSIS therapeutic exercise:

optimize endurance of wrist extensors to prevent recurrence

treatment options for deQuervain's: conservative

orthoses, PAMs for pain, APL and EPB glides, activity modification

Medial Epicondylitis pain with ____ wrist extension

passive

TendinOSES: trigger finger/stenosing tenosynovitis

pathologic thickening of flexor tendon sheath or tendon itself

Typical site of initial inflammatory changes in ____

peritendon

Lateral Epicondylitis/OSIS symptoms

persistent pain on lateral side of elbow, burning, aching at night and pain with resisted wrist extension, FA pronation, gripping (esp w elbow extension)

TendinOSES: biceps tendon

proximally or distally

Chronic inflammatory cells present are typically assoc. with trauma and tissue ____

repair

Rotator Cuff Tendinopathy: tendons get less blood flow w age

repetitive micro trauma - predisposes tendons to deterioration

Medial Epicondylitis pain with

resisted wrist flexion and FA pronation

when is pain most pronounced for Tendonitis/Tendinosis

resistive use of muscle associated with tendons in question

treatment progression

rest, reduce pain, bring client to the point they can tolerate isometric activity and pain free arc of active motion, consider eccentric loading of tendon/muscle to facilitate collagen deposition

Rotator Cuff Tendonopathy target muscle forces that stabilize GH joints

serratus anterior, rotator cuff, deltoid, rhomboids, middle/lower traps

Rotator Cuff Tendinopathy: younger people's common cause

shoulder instability with excessive humeral head migration into SA space

Lateral Epicondylitis/OSIS: treatment progression is ____ and therapeutic management is not always ____

slow; successful

Trigger Finger Stenosing Tenosynovitis is inability to perform

smooth active digit motion; tendon cannot glide through pulley system

Rotator Cuff Tendonopathy most important component

strengthening

Rotator Cuff Tendonopathy tx

strengthening • PAMs for pain management, muscle recruitment (NMES) sometimes helpful •Education: UE postures that exacerbate condition: Repetitive overhead activities Forward head shoulder abd combined with IR movements heavy lifting with affected arm away from body

TendinOSES: rotator cuff

supraspinatus portion

Tendonitis/Tendinosis is the initial inflammatory changes in _____

tendon, synovial tissue or tendon sheath and followed by distinct histological changes like pain, swelling, and loss of function.

what is pain likely due to for tendonitis?

tissue ischemia

Lateral Epicondylitis/OSIS client education

tool use modification, proper body mechanics, ergonomic work stations and gripping

Astym is the use of hand held tools to

topically locate dysfunctional soft tissue and transfer particular pressures and shear forces to the dysfunctional tissues

Lateral Epicondylitis/OSIS PAMs

used to reduce pain (iontophoresis, ultrasound, heat, ice)??????

Trigger Finger Stenosing Tenosynovitis is most common in

women but kids sometimes get it in their thumb

TendinOSES: lateral or medial epicondylitis

wrist extensors or flexors

Intersection Syndrome

•APL and EPB muscle belly swelling as cross over ECRL and ECRB •swelling proximal to snuff box •Treatment the same as deQuervain's

Differential Diagnosis of deQuervain's

•CMC osteoarthritis •Scaphoid fracture •Intersection syndrome •Radial neuritis

Rotator Cuff Tendinopathy (common 40+): impingement syndrome

•Dysfunction of rotator cuff muscles due to decreased space beneath anterior acromion and AC joint

rotator cuff strengthening examples for RC and deltoid

•Internal, external rotation, forward flexion, abduction and extension, diagonal PNF •use closed chain exercises if cuff really weak

How to reduce strain on tissues

•Less forceful grip or pinch during ADLs •Pad handles on tools •Reduce forearm pronation, wrist extension during lifting •Second class levers/improve mechanical advantage during tasks •Two hands whenever possible •Proper posture/body mechanics during lifting

Trigger Finger Stenosing Tenosynovitis tx

•MCP or DIP flexion block orthosis* •Protective motion of flexors once pain subsides •Avoid gripping activities -typically don't need therapy

rotator cuff strengthening suggestions

•No pain, no gain NOT rule •Start slowly, work up as tolerated

Medial Epicondylitis tx is similar to lateral epicondylitis

•Orthosis •PAMs for pain •Deep transverse friction massage •reconditioning for wrist flexors once pain subsides

Typical Client with Tendinosis

•Over 35 years of age •Active •Physically fit (or adequate level of fitness) •High intensity occupation/sports •Performs repetitive tasks on UE more than 3 times per week •Symptoms appear due to reaction of tissues to stress

Reduced synovial fluid perfusion:

loss of blood flow, nutrition to tendon

Trigger Finger Stenosing Tenosynovitis surgical tx

A1 pulley cut/released

TendinOSES: DeQuervain's

APL, EPB (first dorsal compartment)

Lateral Epicondylitis/OSIS muscles

ECRB but also ECRL, ED

TendinOSES: intersection syndrome

ECRL, ECRB and APL, EPB (site where tendon masses cross each other)

Lateral Epicondylitis/OSIS surgical intervention

Lateral epicondyle/ECRB tendon debrided, ECRB origin taken off, holes can be drilled into bone to promote bleeding, ECRB put back

anatomy can differer for deQuervain's

No EPB, two slips of APL or EPB

Medial Epicondylitis degenerative changes of ____ at origin

PT, FCR

Lateral Epicondylitis/OSIS elbow band orthosis tx

Reduce force of ECRB contraction during hand use. Band placed over wrist and digit extensor mass

treatment options for deQuervain's: surgical

Release of sheath overlying first dorsal compartment tendons

Most cases of tendonitis: ____ of acute inflammatory cells

absence

Astym tools will

amplify the tactile sensation of the tissue texture so the clinician can apply appropriate pressure to that tissue, aimed at initiaing a reparative cellular response in dysfunctional tissue

Common UE TendinOSES is

anywhere where there is a tendon

Lateral Epicondylitis/OSIS injection tx

cortisone

tendonitis is ____ in nature vs acute

degenerative

what changes does the tendon experience during Tendonitis/Tendinosis

degenerative and fibroblastic

Trigger Finger Stenosing Tenosynovitis associated conditions

diabetes, RA, gout, CTS, Dupuytens

Trigger Finger Stenosing Tenosynovitis is thickening of ____

flexor tendon

Rotator Cuff Tendonopathy : remember ____ of scapula

force couple

Medial Epicondylitis is also known as

golfers elbow

Tendonitis/Tendinosis: symptoms occur following _____ use of associated muscle(s)

heavy, resistive

Lateral Epicondylitis/OSIS wrist orthosis tx

helps reduce ECRB activity during hand and wrist use (35 degrees ext)

Rotator Cuff Treatment Pearls

•Remember pearls stated for elbow tendonosis •Same principles •Reconditioning, activity modification most important aspect of treatment •At least 3 months of treatment necessary in typical case •Exercises can be done AT HOME in most cases

Why do we strengthen the Rotator Cuff?

•Stronger RC opposes superior translation of humeral head...less impingement •Muscles serve as shock absorbers; helps to protect shoulder •Tendon healing enhanced •Normal scapular rhythm restored; acromion cleared easier during AROM

Lateral Epicondylitis/OSIS

•Tendon undergoes physiological changes as condition progresses (degenerates) •chronic in nature •symptoms resolve with rest, time (6-9 months) •Surgical intervention last resort

Evaluation

•Use of provocative maneuvers to reproduce symptoms •MMT •ROM •Guides determination of treatment strategies

Angiofibroblastic Hyperplasia

•Visible changes in tendon appearance •Fibers invaded by fibroblasts •Atypical granulation tissue •Adjacent tissue degenerates •Small number of inflammatory cells present

treatment options for deQuervain's: orthosis

•Wrist in slight extension, thumb in palmar abduction •4-6 weeks •Assess client's goals/ADLs •Reduce force of gripping, pinching •Built up handles •Avoid passive stretching of tendon(s) make changes in ADLs to avoid recurrence...

deQuervain's Tenosynovitis

•first dorsal compartment •Pain dorsal, radial wrist •Often associated with swelling •Hx of pregnancy, overuse of involved tendons •+ Finkelstein's test

activities that cause deQuervain's Tenosynovitis

•towel wringing, opening jars, piano, typing, knitting, ratchet sports