Musculoskeletal arm pathology

Rotator cuff tendinitis

Rotator cuff tendinitis Is a repeat of overhead activity that can produce impingement of the supraspinatus tendon immediately proximal to the greater tubercle of the humerus. The impingement is caused by an inability of a weak superspinatusy muscle to adequately depress the head of the humerus in the glenoid fossa during elevation of the arm. As a result the humerus translate superior due to the disproportionate action of the deltoid muscle. Primary impingement occurs from intrinsic or extrinsic factors within the subacromial space. Secondary impingement describe symptoms that occur from poor mechanics or instability at the shoulder structures that are involved • superspinatus muscle is most commonly involve tendon in the rotator cuff • bicipital and infraspinatus tendon as well as bursitis may also coexists as a contributing factor for rotator cuff tendinitis

treatment

- initial immobilization with a sling for 3 to 6 weeks. - Rice and NASID. In the early phase. Following immobilization, -range of motion and isometric strengthening should be initiated followed by progressive resistance exercise emphasizing the internal and external rotators, as well as the large scapular muscle

Risk factor

-Postural changes associated with growth and development -Poor posture with depressed shoulders and protracted scapula , -trauma to the shoulder girdle, and body composition have all been identified as contributing to the development of TOS. The human upright posture has contributed to the development of TOS because gravity pulls on the shoulder girdle creating traction on the structures. Additionally, congenital factors that affect the bony structures, such as a cervical rib or fascial bands, also compress the neurovascular bundle

Shoulder instability anterior instability posterior instability inferior instability

Anterior instability usually occurs with forces against the arm when it is in an abducted and externally rotated position, resulting in anterior humeral head translations. If these forces occur with enough frequency and force to compromise anterior GH joint structures, instability results. ■ Posterior instability is much less common but can occur from repetitive forces against a forward-flexed humerus, translating the humeral head posteriorly. There is a positive posterior drawer sign. ■ Inferior instability is typically the result of rotator cuff weakness/paralysis and is frequently seen in patients with hemiplegia. It is also prevalent in patients who repetitively reach overhead (workers or swimmers, for example) and those with multidirectional instability. This is detected with a positive sulcus sign

Carpal tunnel syndrome description

Carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and arm. In carpal tunnel syndrome, pain and paresthesias occur in the median nerve distribution of the hand, which includes the lateral three digits.----------------------------------------The condition occurs when one of the major nerves to the hand — the median nerve — is squeezed or compressed as it travels through the wrist. In most patients, carpal tunnel syndrome gets worse over time, so early diagnosis and treatment are important. Early on, symptoms can often be relieved with simple measures like wearing a wrist splint or avoiding certain activities. If pressure on the median nerve continues, however, it can lead to nerve damage and worsening symptoms. To prevent permanent damage, surgery to take pressure off the median nerve may be recommended for some patients.

cause

Cause Medial epicondylitis is caused by repeated wrist flexion or bending the wrist, particularly against resistance such as holding a golf club. It can also occur from throwing actions, as well as in occupations such as through manual jobs like carpentry or working at a computer work station. It tends to occur after a period of repeated overuse. Mechanism of injury - valgas stress on the medial epicondyle Commonly involves the pronator teres and flexor carpi radialis tendons

cause

Cause • individuals participating in activities that require excessive overhead activities such as swimming, tennis, baseball, painting and other manual labor activities are at increased risk for rotator cuff tendinitis. • Excessive use of the upper extremity following a prolonged period of inactivity also can produce the condition.

Impingement syndrome

Classification • is caused by the tendons of the rotator cuff (supraspinatus, infraspinatus, teres minor and subscapularis muscle) becoming irritated or inflamed as they pass through a narrow bony space called the Subacromial space. This can lead to thickened of the tendon which may cause further problem because there is very little free space, so as the tendons become larger, they are impinged further by the structures of the shoulder joint and the muscles themselves With repetitive pinching, the tendons become irritated and inflamed. Individuals participating in thrown activities, swimming and racquet sports are particularly susceptible to impingement syndrome

Symptoms

Clinical Manifestations • Signs and symptoms reflect the structures that have been compressed. • When the nerves are compressed: o most people report paresthesias and pain in the neck, shoulder, arm, or hand Other symptoms may include pain, tingling, and paresis. o If the upper nerve plexus is involved (C5 to C7), pain is reported in the neck; this may radiate into the face (sometimes with ear pain) and anterior chest as well as over the scapulae. Symptoms may also extend over the lateral aspect of the forearm into the hand. o If the lower plexus is compromised (C7 to T1), pain and numbness occur in the posterior neck and shoulder, medial arm and forearm, and radiate into the ulnarly innervated digits of the hand. Weakness is usual in the muscles corresponding to nerve root innervation, and atrophy occurs in severe cases. • Vascular symptoms may include o coldness, edema and redness in the hand or arm, Raynaud's phenomenon (cyanosis), fatigue in hand and arm, and superficial vein distention in the hand Overhead activities are particularly difficult because they worsen both types of compression. There may be a depression in your shoulder, or swelling or discoloration in your arm. Your range of motion may be limited.

exercise

Exercise • including ROM/flexibility, RTC strengthening, and scapular strengthening/stabilization. • Other exercises can include isokinetic strengthening, plyometrics, and sports specific exercises. Phase 2 • ROM and flexibility exercises are initiated in phase II of rehabilitation. The patient is initially instructed to limit shoulder movement to a pain-free range which is usually below shoulder level, therefore, the program can start with Codman's pendulum exercises (Figure 8.1) and wand exercises without elevation. ROM with elevation can be added as tolerated by pain. o Stretches o Stretches should also be introduced early in the exercise program and can be added by instructing the patient to apply slight pressure at the end range during the wand exercises. Two areas where tightness can predispose patients to shoulder impingement include the pectoralis minor muscle and posterior/inferior capsule resulting in GIRD. For the pectoralis minor muscle, the most effective stretch has been shown to be the unilateral self stretch (Figure 8.2) (41) while for patients with GIRD, two particularly good stretches include the cross body adduction (Figure 8.3) and the sleeper stretch (Figure 8.4) to increase internal rotation • based upon physical findings, include the UT, levator scapulae, scalenes, and suboc- cipital muscles. Strengthening • Strengthening can start with isometrics without shoulder elevation. Isometric strengthening for internal and external rotators can be per- formed against a static body. • Once ROM has improved and pain decreased, isotonic RTC strengthening can be added. This phase of strengthening can be done with the use of either dumbbells or resistance tubing or bands. Ini- tial isotonic RTC strengthening should emphasize cuff function without elevation to minimize discomfort. • Strengthen external rotation, internal rotation, and extension, flexion Scapula strengthening • Scapular rehabilitation addresses impaired scapular mechanics early in the rehabilitation program. The initial goal is to normalize the resting position of the scapula without putting high demands on the shoulder joint. Var- ious exercises have been shown to be helpful during this phase, including inferior glide, low row, lawnmower, and robbery exercises (47). scapula The next phase of scapular stabilization involves correcting muscle imbalances of the scapular stabilizers. These imbalances occur as a result of weaker scapular stabilizers, namely the middle trapezius stabilization involves correcting muscle imbalances of the scapular stabilizers. These imbalances occur as a result of weaker scapular stabilizers, namely the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) along with overactivity of the UT (20,48-50). Forward flexion in side lying and side lying external rotation exercises (51) are optimal for restoration of UT/MT and UT/LT imbalance whereas the push up plus exercise (Figure 8.6) (48) is optimal for restoration of UT/SA imbalance. The side lying external rotation exercise is an espe-cially good exercise since it has the added advantage of strengthening the supraspinatus, infraspinatus, teres minor, and posterior deltoid muscles (52,53). • Once muscle balance is restored, general scapular strengthening exercises may be used to increase muscle strength. During this phase, exercises that maximally activate the targeted muscles can be used. They include overhead arm raise in line with the LT with dumbbell, which maximally activates MT and LT, and a diagonal exer- cise with a combination of shoulder flexion, horizontal flexion, and external rotation with dumbbell or rubber tubing bands that maximally activates SA Ex Therapeutic exercise: - • ROM: start with pendulum, Codman, and wall climbing exercises in pain-free ROM, P/A/ AAROM at shoulder in all planes - Stretching: especially pectoralis minor - Strengthening: • Scapular stabilizers including lower trapezius, middle trapezius, and SA should be initial focus of strengthening program

The thoracic outlet definition 395 KISEAR

Definition TOS is an entrapment syndrome caused by pressure from structures in the thoracic outlet the narrow space between clavicle and 1st rib.

The thoracic outlet Description 395

Description The thoracic outlet is the space between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. If the shoulder muscles in your chest are not strong enough to hold the collarbone in place, it can slip down and forward, putting pressure on the nerves and blood vessels that lie under it and cause irritation . This causes a variety of symptoms which together are known as thoracic outlet syndrome.

Shoulder instability

Description Spontaneous subluxation/dislocation of the glenohumeral joint, Glenohumeral instability- refers to excessive translation of the humeral head on the glenoid during active rotation. Instability- involves varying degrees of injuries to dynamic and static structures that function that contained the humeral head in glenoid subluxation -refers to joint laxity allowing for more than 50% of the humeral head to pass passively translate over the glenoid rim without dislocating dislocation- is the complete separation of the articular surface of the glenoid at the humeral head

effects

Effects • Elbow pain with lifting, and gripping • Loss of grip strength • Point tenderness at the lateral epicondyle • Pain that increases with resisted wrist extension

Adhesive capsulitis cause

Etiology -the onset may be related to a direct injury to the shoulder or begin insidiously. -Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, -a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder

Etiology

Etiology Arterial compression: <5% Venous compression: <5% neurologic compression: <5% The anatomy of the region of the thoracic outlet is extremely complex. Spinal nerve roots of the brachial plexus interact with surrounding bony ribs, muscles, and tendons (subclavius, anterior and middle scalene, and pectoralis minor) and the vascular supply (subclavian artery and vein) to the region. In addition to neurologic structures becoming entrapped, arterial and venous structures also may be affected individually or in combination. Thus multiple specialists may be involved in a person's care. Practically, TOS can be divided into three groups: neurogenic (compression of brachial plexus), vascular (compression of subclavian artery and/or vein), and disputed (nonspecific TOS with chronic pain and symptoms of brachial plexus involvement).12,67

Medial epicondylitis Characteristic

Medial epicondylitis, Characteristic • often referred to as golfer's elbow, is characterized by pathologic changes to the musculotendinous origin of the common flexor tendon and pronator teres at the medial epicondyle (1). • The pronator teres and the flexor carpi radialis both attach to the anterior aspect of the medial epicondyle, caused by repetitive stress and overuse leading to tendinosis

Muscles that run through the carpal tunnel (DDP) And muscles that are affected by carpal tunnel (BAO)

Muscles that pass Through the tunnel flexor digitorum superficialis flexor digitorum profundus flexor pollicis longus(thumb flexor) and the median nerve The median nerve runs from the It controls sensations to the palm side of the thumb and fingers causes atrophy of the thenar eminence WEAKNESS IN flexor pollicis brevis, abductor pollicis brevis opponens pollicis

Special test

Neer and Hawkins impingement test

Pathogenesis of thoracic outlet syndrome

Pathogenesis ---Compression of the lower trunk of the brachial plexus and/or subclavian vessels as they course through three narrow passageways from the base of the neck toward the axilla and the proximal arm --the most common sites of compression are the costo-clavicular space between clavicle and first rib the triangle between anterior scalene muscle and upper border of first rib , and between the coracoid process and the pectoralis minor insertion ---Poor posture with protracted scapula and depressed shoulders can decrease diameter of cervicoaxillary canal --Congenital abnormalities can compress the neurovascular bundle ---Traumatic fracture of clavicle with subsequent malunion, exuberant callus formation, or crush injury of upper thorax can also lead to neurovascular compromise

treatment

Phase 1 Phase I is comprised of pain relief and activity modification. Conservative management of medial epicondylitis typically includes protection, relative rest, ice, and avoiding tasks that provoke discomfort at the elbow. Clinicians also need to modify their patient's daily activities if these tasks provoke symptoms Phase 2 After the pain is well controlled, phase II is initiated and includes stretching the involved musculature and ROM exercises. Stretching of the wrist flexors is performed by gently moving the wrist into extension Phase 3 the strengthening phase (phase III) can now be initi- ated. Initially, pain-free, isometric exercises with gentle wrist, forearm, and elbow ROM are performed. Again, the elbow should be flexed during the early stages and progressed toward extension as the patient improves. If discomfort does not occur, the patient can perform progressive resistive exercises (PREs) starting with light-weight concentric contrac- tions, then progressing to eccentric exercises (30).

Prevention THO

Prevention If you have symptoms of thoracic outlet syndrome, avoid carrying heavy bags over your shoulder because this depresses the collarbone and increases pressure on the important structures in the thoracic outlet. You should also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try—10 repetitions of each exercise should be done twice daily: Corner Stretch - Stand in a corner (about 1 foot from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds. Neck Stretch - Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction. Shoulder Rolls - Shrug your shoulders up, back, and then down in a circular motion. Neck Retraction - Pull your head straight back, keeping your jaw level. Hold for 5 seconds

Adhesive capsulitis exercises

Rehab Exercises Pendulum, active assistive, and active exercises in the pain-free range Four-direction shoulder-stretching program that includes passive forward elevation, passive external rotation, passive internal rotation, and passive horizontal adduction Mobilization techniques Scapular muscle strengthening Rotator cuff strengthening o Ex of exercises http://orthoinfo.aaos.org/topic.cfm?topic=A00071 Treatment includes therapeutic modalities to decrease pain and inflammation, to promote relaxation, and increase tissue extensibility and therapeutic exercise and manual therapy to improve tissue extensi- bility, ROM, and to reestablish force couples to normalize scapulohumeral rhythm See chart pg 76

symptoms

Symptoms Presents with tenderness to palpation over the common flexor tendon and pain is reproduced with resisted wrist flexion,resisting pronation or rotating the wrist inwards.

Adhesive capsulitis symptoms

Symptoms • insidious onset of pain often extended down the arm • Restricted active and passive range of motion in all directions, including forward flexion, abduction, external, and internal rotation • however • Lateral (external) rotation is the most limited motion in a patient with adhesive capsulitis

Symptoms of carpal tunnel

Symptoms • Numbness, • tingling, • burning, and pain Pain or tingling that may travel up the forearm toward the shoulder Weakness and clumsiness in the hand—this may make it difficult to perform fine movements such as buttoning your clothes Dropping things—due to weakness, numbness, or a loss of proprioception (awareness of where your hand is in space) • muscle atrophy is often noted in the abductor pollicis brevis muscle and progress to the thenar muscles universe

Rotator cuff tendinitis symptoms

Symptoms • difficulty with overhead activities • dull ache following periods of activity • feeling of weakness and identified the presence of a painful motion most commonly occurring between 60 - 120° of active abduction • pain with palpation of the musculotendinous junction of the involve muscle and or with stretching or resistive contraction of the muscle. • Pain often increase at night resulting in difficulty sleeping on the affected side. • Difficulty with dressing and repetitive shoulder motions such as lifting, reaching, throwing, swinging or pushing and pulling with the involve upper extremity

tennis elbow description

Tennis elbow, also called lateral epicondylitis • Irritation or inflammation of the wrist extensors at their orgin at the lateral epicondyle of the humerus • Indivudula that play racket sports or activities that require throwing are at greater risk • The primary muscle affected is the extensor carpi radialis brevis, although other wrist extensors may be involved such as the extensor digitorum communis or the extensor carpi radialis longus

Etiology

The combination of forces stressed anterior capsule ligament and rotator cuff, causing the humerus to move anteriorly out of the glenoid fossa. an anterior dislocation is the most common and usually associated with shoulder abduction and lateral rotation

Medical management

The focus of the treatment is on -increasing range of motion with glenohumeral mobilization, -rage of motion exercises, -and modalities. The therapist and patient should avoid overstretching and elevating pain since this can result in further loss of motion. Surgical options include suprascapular nerve block and close manipulation under anesthesia

exam

Tinel sign Press down or tap along the median nerve at inside of your wrist to see if it causes any numbness or tingling in your fingers (Tinel sign) PHALENS maneuver Bend and hold your wrists in a flexed position to test for numbness or tingling in your hands

Treatment

Treatment Management is divided into conservative and surgical approaches. The initial treatment of the person with TOS is conservative when symptoms are mild to moderate in severity. Postural and breathing exercises and gentle stretching are the cornerstones of the initial conservative program. This is followed by strengthening exercises for shoulder girdle musculature, especially the trapezius, levator scapulae, and rhomboids. Initially, overhead exercises should be avoided because they tend to evoke symptoms. PTAs are cautioned against forceful stretching to mobilize the first rib.88,166 Focuses on "opening up" thoracic outlet by correcting abnormal posture Initially correct protracted and depressed shoulders with aggressive pectoralis and scalene stretching combined with correction of any scapulothoracic dysfunction Manual medicine to focus on: soft tissue mobilization, mobility of first rib, and resorting motion to sternoclavicular and acromioclavicular joints Side bending and cervical retraction can correct head forward posture by stretching soft tissues of lateral cer- vical spine Thoracic extension and brachial plexus stretching as tolerated Weight loss, stress reduction, and aerobic fitness have been shown to be beneficial

treatment

Treatment Rest. The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks. Non-steroidal anti-inflammatory medicines. Drugs like aspirin or ibuprofen reduce pain and swelling. Tennis elbow brace/splint-to decrease tension and pain Exercise • Strength training with emphasis in eccentric component of wrist extensors • Stretching of wrist flexors and extensors • Strengthening of shoulder and core muscles is required for return to overhead sports • wrist/forearm ROM exercises Modalities • Ice in acute phase(ice pack, ice massage) • Heat • Ultrasound has thermal and mechanical (nonthermal) effects (mixed results in the medical literature) • Electrotherapy • Mobilization • Deep transverse friction massage

tenis elbow anatomy

Your elbow joint is a joint made up of three bones: your upper arm bone (humerus) and the two bones in your forearm (radius and ulna). There are bony bumps at the bottom of the humerus called epicondyles. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle. Muscles, ligaments, and tendons hold the elbow joint together. Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of your forearm. Your forearm muscles extend your wrist and fingers. Your forearm tendons — often called extensors — attach the muscles to bone. They attach on the lateral epicondyle. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). Your arm is kept in your shoulder socket by your rotator cuff. These muscles and tendons form a covering around the head of your upper arm bone and attach it to your shoulder blade. There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. Impingement. When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or "impinge" on) the tendon and the bursa, causing irritation and pain.

Cause of carpal tunnel

any condition that produces inflammation of the carpal tunnel • Repetitive hand use. • Pregnancy. o Hormonal changes during pregnancy can cause swelling. • Health conditions. Such as o Diabetes, o rheumatoid arthritis, o trauma disorders, o tumors, o hypothyroidism, o wrist sprain or fractures

cause

cause • Overuse • Overuse injury and eccentric loading that involves the origin of the wrist • extensors at the lateral epicondyle • Associated with repetitive wrist extension • tennis elbow is often due to damage to a specific forearm muscle. The extensor carpi radialis brevis (ECRB) resulting in microtrauma. The lateral epicondylitis can be precipitated by poor mechanics or faulty equipment such as tennis racket with a handle that is too small or with strings that possess too much tension.

Cause

cause • Rotator cuff pain is common in both young athletes and middle-aged people. Young athletes who use their arms overhead for swimming, baseball, and tennis are particularly vulnerable. Those who do repetitive lifting or overhead activities using the arm, such as paper hanging, construction, or painting are also susceptible. • Pain may also develop as the result of a minor injury. Sometimes, it occurs with no apparent cause. Impingement syndrome is caused by the humeral head and associated rotator cuff muscles migrating proximately and become impinge on the undersurface of the acromion and acromion ligaments (Subacromial space)

Adhesive capsulitis description

is a condition of the shoulder characterized by pain and subsequent gradual loss of shoulder motion. due to soft-tissue contracture. The condition is caused by adhesive fibrosis and scarring between the capsule, rotator cuff, subacromial bursa and deltoid.

Medical management

physical therapy aspect • splinting- The patient with carpal tunnel syndrome may be fitted with a splint to keep the wrist in extension but leave the metacarpophalangeal and interphalangeal joints free • carpal mobilization • gentle stretching • biomechanical analysis and adoption of the patient occupation, workplace leisure activities, and living environment • if conservative treatment fails patient may require surgery to release the carpal ligament and decompress the median nerve post surgery • intervention includes moist heat with electric stem • iontophoresis • cryotherapy • gentle massage • desensitizationof the scar, • tendon glide exercise and active range of motion o patient should initially avoid wrist flexion and a forceful grasp o after four weeks a patient can progress with active reflection gentle stretching, putty exercise, light progressive resistive exercise and continue modification of body mechanics. o Radial deviation against resistance should be avoided due to the tendency of irritation and inflammation.

symptoms

symptoms • pain within the shoulder , pain with overhead activity • painful arc of motion (70-120 abduction) • positive impengment sign tenderness over the greater tubersity and biciptal grove

cause

• often cause through overhead activity and motion • there usually direct trauma to the tendon at the shoulder motion approaches excessive abduction and lateral rotation • hi risk athletes include baseball pictures, tennis players

Clinical Features

• Laxity of the glenohumeral joint: either unidirectional or multidirectional • subluxation - feeling the shoulder popping out and back into place, pain • Paristhesis, sensation of the arm feeling dead, • positive apprehension tests, • capsular tenderness, • swelling, • dislocation - severe pain • Paristhesis limited range of motion • weakness visible shoulder fullness, • arm supported by contralateral limb

BICIPITAL tendinitis

• an inflammatory process of the tendon long head of the biceps o impingement or an inflammatory injury of shoulder pain, can result in symptoms of shoulder pain o repeated full abduction and lateral rotation of the humeral head can lead to irritation that produces inflammation, edema, microscopic tears within the tendon and degeneration of the tendon itself an injury was most likely sustained to which structure • continuous overhead activity of shoulder motion can cause overuse of the bicep tendon. The cells within the tendon not have time to heal, leading to tendinitis. • This is common in sports or work activities that require frequent and repeated use of the upper extremity, especially when the motions perform overhead. At least to throw, swim or swing a racket or club our greatest risk

effects

• deep ach directly in front and on the top of the shoulder. • The ach may spread down into the bicep muscle and usually made worse with overhead activities or lifting heavy objects. • Resting the shoulder reduces the pain • Catching or slipping sensations of the biceps muscles may indicate a tear of the transvers humeral ligament • pain to palpation over the anterior shoulder the area of the bicipital groove • pain with the biceps resistance test • a positive yergonson or speeds tests

Management for rotator cuff tendinitis

• physical therapy interventions should include cryotherapy, • activity modification, • range of motion and rest. • As the acute phase supside the patient is often instructed in strengthening exercises. • Since the rotator cuff muscles are dependent on adequate blood supply and oxygen, it is essential that all range of motion and strengthening exercise are pain-free. • Range of motion exercises using a pulley system or a cane can serve as an effective intervention. • Strengthening exercise are initiated with the arm at the patient side in order to prevent the possibility of impingement. • Elastic tubing or handheld weights are often the preferred equipment of choice. • It is important for the entire rotator cuff to be strong prior to initiating overhead activities. • Shoulder shrugs and push up with the arm abducted to 90° can effectively be used to strengthen the upper trapezius and serratus anterior. This type of activity promotes elevation of the achromium without direct contact with the rotator cuff

management

• the primary goal of medical management is to releave pain reduce inflammation and regain full available range of motion. Rest/immobilization using a splint or a removable brace may be indicated initially for a brief period of time • patient should avoid all overhead movement, reaching and lifting of objects. • NASIDS to reduce pain and inflammation • active physical therapy is not often initiated immediately however the patient may be referred for instructions in patient education, guidelines for restriction, pendulum exercise use of TENS • application of heat or cold to the affected area can also assist with relief of pain. • Acute phase of physical therapy should focus on exercise program that stretches and strengthens the affected muscle groups.