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