Management of Rotator Cuff Tendinopathy
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Rotator Cuff and Subacromial Impingement Syndrome: Anatomy, Etiology, Screening, and Treatment
Rotator Cuff and Subacromial Impingement Syndrome: Anatomy, Etiology, Screening, and Treatment The glenohumeral joint is the most mobile joint in the human body, but this same characteristic also makes it the least stable joint.1-3 The rotator cuff is a group of muscles that are important in supporting the glenohumeral joint, essential in almost every type of shoulder movement.4 These muscles maintain dynamic joint stability which not only avoids mechanical obstruction but also increases the functional range of motion at the joint.1,2 However, dysfunction of these stabilizers often leads to a complex pattern of degeneration, rotator cuff tear arthropathy that often involves subacromial impingement.2,22 Rotator cuff tear arthropathy is strikingly prevalent and is the most common cause of shoulder pain and dysfunction.3,4 It appears to be age-dependent, affecting 9.7% of patients aged 20 years and younger and increasing to 62% of patients of 80 years and older ( P < .001); odds ratio, 15; 95% CI, 9.6-24; P < .001.4 Etiology for rotator cuff pathology varies but rotator cuff tears and tendinopathy are most common in athletes and the elderly.12 It can be the result of a traumatic event or activity-based deterioration such as from excessive use of arms overhead, but some argue that deterioration of these stabilizers is part of the natural aging process given the trend of increased deterioration even in individuals who do not regularly perform overhead activities.2,4 The factors affecting the rotator cuff and subsequent treatment are wide-ranging. The major objectives of this exposition are to describe rotator cuff anatomy, biomechanics, and subacromial impingement; expound upon diagnosis and assessment; and discuss surgical and conservative interventions. -
Gluteal Tendinopathy
Gluteal Tendinopathy What is a Gluteal Tendinopathy? In lying Up until recently hip bursitis was diagnosed as the main Either on your bad hip or with bad cause of lateral hip pain but recent studies suggest that an hip hanging across body like so irritation of the gluteus muscle tendon is the likeliest cause. The tendon attaches onto a bony prominence (greater trochanter) and it is here that the tendon is subject to All these positions lead to increase friction of the tendon, compressive forces leading to irritation. can cause pain and slow the healing process. This can result in pain over the lateral hip which can refer down the outside For sleeping you might like to try these positions: of the thigh and into the knee. How common is it? Gluteal tendinopathy is relatively common affecting 10-25% of the population. It is 3 times more prevalent in women than men and is most common in women between the ages of 40 and 60. One of the reasons for this is women It is also important to modify your activity. Avoid or reduce tend to have a greater angle at their hip joint increasing things that flare up your pain, this could be climbing stairs compressive forces on the tendon. or hills or those longer walks/runs. Signs and Symptoms Exercise Therapy • Pain on the outside of your hip, can refer down outside of the thigh to the knee This is best administered by a Physiotherapist to suit the • Worse when going up and/or down stairs individual but below is a rough guide to exercises which • Worse lying on affected side (and sometimes on the can help a gluteal tendinopathy. -
Current Trends in Tendinopathy Management
Best Practice & Research Clinical Rheumatology 33 (2019) 122e140 Contents lists available at ScienceDirect Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh 8 Current trends in tendinopathy management * Tanusha B. Cardoso a, , Tania Pizzari b, Rita Kinsella b, Danielle Hope c, Jill L. Cook b a The Alphington Sports Medicine Clinic, 339 Heidelberg Road, Northcote, Victoria, 3070, Australia b La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Corner of Plenty Road and Kingsbury Drive, Bundoora, Victoria, 3083, Australia c MP Sports Physicians, Frankston Clinic, Suite 1, 20 Clarendon Street, Frankston, Victoria, 3199, Australia abstract Keywords: Tendinopathy Tendinopathy (pain and dysfunction in a tendon) is a prevalent Management clinical musculoskeletal presentation across the age spectrum, Rehabilitation mostly in active and sporting people. Excess load above the ten- Achilles tendinopathy don's usual capacity is the primary cause of clinical presentation. Rotator cuff tendinopathy The propensity towards chronicity and the extended times for recovery and optimal function and the challenge of managing tendinopathy in a sporting competition season make this a difficult condition to treat. Tendinopathy is a heterogeneous condition in terms of its pathology and clinical presentation. Despite ongoing research, there is no consensus on tendon pathoetiology and the complex relationship between tendon pathology, pain and func- tion is incompletely understood. The diagnosis of tendinopathy is primarily clinical, with imaging only useful in special circum- stances. There has been a surge of tendinopathy treatments, most of which are poorly supported and warrant further exploration. The evidence supports a slowly progressive loading program, rather than complete rest, with other treatment modalities used as adjuncts mainly targeted at achieving pain relief. -
Evaluation and Management of Elbow Tendinopathy
vol. XX • no. X SPORTS HEALTH Evaluation and Management of Elbow Tendinopathy Samuel A. Taylor*† and Jo Hannafin† Context: Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic sur- geons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment out- comes will enable the appropriate management of patients and their expectations. Evidence Acquisitions: The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy. Results: Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments. Conclusions: Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate bene- fit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diag- nosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury. -
Equinus Deformity in the Pediatric Patient: Causes, Evaluation, and Management
Equinus Deformity in the Pediatric Patient: Causes, Evaluation, and Management a,b,c Monique C. Gourdine-Shaw, DPM, LCDR, MSC, USN , c, c Bradley M. Lamm, DPM *, John E. Herzenberg, MD, FRCSC , d,e Anil Bhave, PT KEYWORDS Equinus Pediatric External fixation Achilles tendon lengthening Gastrocnemius recession Tendo-Achillis lengthening Different body and limb segments grow at different rates, inducing varying muscle tensions during growth.1 In addition, boys and girls grow at different rates.1 The rate of growth for girls spikes at ages 5, 7, 10, and 13 years.1 The estrogen-induced pubertal growth spurt in girls is one of the earliest manifestations of puberty. Growth of the legs and feet accelerates first, so that many girls have longer legs in proportion to their torso during the first year of puberty. The overall rate of growth tends to reach a peak velocity (as much as 7.5 to 10 cm) midway between thelarche and menarche and declines by the time menarche occurs.1 In the 2 years after menarche, most girls grow approximately 5 cm before growth ceases at maximal adult height.1 The rate of growth for boys spikes at ages 6, 11, and 14 years.1 Compared with girls’ early growth spurt, growth accelerates more slowly in boys and lasts longer, resulting in taller adult stature among men than women (on average, approximately 10 cm).1 The difference is attributed to the much greater potency of estradiol compared with testosterone in Two authors (BML and JEH) host an international teaching conference supported by Smith & Nephew. -
Achilles Tendon Injury
Achilles Tendon For further information contact injury Sports Medicine Australia www.sma.org.au www.smartplay.com.au A guide to prevention References and management For a full list of references, contact Sports Medicine Australia. Acknowledgements Sports Medicine Australia wishes to thank the sports medicine practitioners and SMA state branches who provided expert feedback in the development of this fact sheet. Images are courtesy of www.istockphoto.com ALWAYS CONSULT A TRAINED PROFESSIONAL The information in this resource is general in nature and is only intended to provide a summary of the subject matter covered. It is not a substitute for medical advice and you should always consult a trained professional practising in the area of sports medicine in relation to any injury. You use or rely on information in this resource at your own risk and no party involved in the production of this resource accepts any responsibility for the information contained within it or your use of that information. © Papercut 719/2010 The Achilles tendon is a large tendon at the back of the ankle. The tendon is an extension of the gastrocnemius and Achilles Tendinopathy is a chronic, yet common soleus (calf muscles), running down the back of the lower leg condition in sports people and recreational athletes. attaching to the calcaneus (heel bone). The Achilles tendon In the past treatment options have been limited due Anatomy connects the leg muscles to the foot and gives the ability to a poor understanding of its cause; however recent to push off during walking and running. research has revealed valuable information that has provided further treatment options. -
Achilles Tendonopathy
Achilles Tendinopathy Mid–portion (non-insertional) and Insertional Tendinopathy (Haglunds deformity) Achilles mid portion Achilles insertion Calcaneous/heel bone What is the Achilles tendon? Your Achilles tendon is an important part of your leg. It is found just behind and above your heel. It joins your heel bone (calcaneum) to your calf muscles. The function of your Achilles tendon is to help in bending your foot downwards at the ankle: this movement is called plantar flexion. Source: Trauma & Orthopaedics Reference No: 6456-1 Issue date: 01/03/2021 Review date: 4/1/21 Page: 1 of 13 What is Achilles tendinopathy and what causes it? Two types of Achilles tendinopathy are commonly described: 1. Non–insertional Achilles tendinopathy, where the mid portion (2-6cm from the insertion to the calcaneous/heel bone) is affected. 2. Insertional Achilles tendinopathy, tendinopathy up to 2cm from the Achilles tendon insertion to the calcaneous/heel bone is affected. This leaflet describes both conditions and their treatment options. Achilles tendinopathy is a condition that causes pain, swelling and stiffness of the Achilles tendon. It is thought to be caused by repeated tiny injuries (known as micro-trauma) to the Achilles tendon. After each injury, the tendon does not heal completely, as should normally happen. This means that over time, damage to the Achilles tendon builds up and Achilles tendinopathy can develop. There are a number of things that may lead to these repeated tiny injuries to the Achilles tendon, for example: • Overuse of the Achilles tendon. This can be a problem for people who run regularly. -
Tendinopathy: Tackling Troubled Tendons
Tendinopathy: Tackling Troubled Tendons Deepak Patel, MD, FAAFP, FACSM ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. 1 DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. -
Achilles Tendinopathy: Some Aspects of Basic Science and Clinical Management
239 REVIEW Br J Sports Med: first published as 10.1136/bjsm.36.4.239 on 1 August 2002. Downloaded from Achilles tendinopathy: some aspects of basic science and clinical management D Kader, A Saxena, T Movin, N Maffulli ............................................................................................................................. Br J Sports Med 2002;36:239–249 Achilles tendinopathy is prevalent and potentially and the outcomes of management protocols were incapacitating in athletes involved in running sports. It is carefully scrutinised. Case reports were excluded, unless they mentioned a specific association with a degenerative, not an inflammatory, condition. Most the condition that was thought to be relevant to patients respond to conservative measures if the the discussion. Only papers that made a signifi- condition is recognised early. Surgery usually involves cant contribution to the understanding of this condition were included in the review. This left a removal of adhesions and degenerated areas and total of 347 publications, of which 135 were decompression of the tendon by tenotomy or measures directly related to the topic of this review. that influence the local circulation. .......................................................................... ANATOMY OF THE ACHILLES TENDON The gastrocnemius muscle merges with the In the past three decades, the incidence of over- soleus to form the Achilles tendon in two use injury in sports has risen enormously,1 not different ways. In the more common type 1 junc- Ionly because of the greater participation in rec- tion, the two aponeuroses join 12 cm proximal to reational and competitive sporting activities, but their calcaneal insertion. In type 2, the gastrocne- mius aponeurosis inserts directly into the also as a result of the increased duration and 9 intensity of training.23 Excessive repetitive over- aponeurosis of the soleus. -
The Use of Dehydrated Human Amnion/Chorion Membrane Allograft Injection for the Treatment of Tendinopathy Or Arthritis: a Case Series Involving 40 Patients
PM R XXX (2017) 1-8 www.pmrjournal.org Original Research The Use of Dehydrated Human Amnion/Chorion Membrane Allograft Injection for the Treatment of Tendinopathy or Arthritis: A Case Series Involving 40 Patients Alfred C. Gellhorn, MD, Alex Han, BA Abstract Background: Degenerative joint and tendon injuries remain difficult to treat, with few effective conservative treatment options available. Regenerative approaches aim to promote the inherent healing capacity of injured tissues. Micronized dehydrated human amnion/chorion membrane (dHACM) injection is an emerging regenerative option with promising preclinical results. Objective: To test the clinical effectiveness of dHACM injection in patients with chronic tendinopathy and arthropathy. Design: Case series. Setting: Academic medical center outpatient sports medicine clinic. Patients: A total of 40 patients with chronic tendinosis or arthropathy who received dHACM over a period of 9 months. Methods: A structured interview was administered to patients by telephone to supplement the clinical information available in the medical chart. All patients received an ultrasound-guided injection of dHACM. Main Outcome Measures: The primary outcome was change in pain level, and the secondary outcome was change in activities of daily living (ADLs) and sports/recreation function. More than 30% improvement in average pain and function was considered a successful outcome. Results: Patient pain and function were measured at 1, 2, and 3 months after the procedure. Patient-reported average pain scores decreased from a baseline value of 6.4 (95% confidence interval [CI] ¼ 5.7-7.0) to 2.7 (95% CI ¼ 2.1-3.3; P < .001) at 1 month, 1.7 (95% CI ¼ 1.1-2.2; P < .001) at 2 months, and 1.4 (95% CI ¼ 0.9-1.9; P < .001) at 3 months. -
Inferior Heel Pain Is Not Necessarily Plantar Fasciitis
Agenda . -Plantar fasciitis / heel pain -Achilles tendinopathy Plantar fasciitis -Flatfoot -2nd MP synovitis -Morton’s neuroma [email protected] Plantar fasciitis Old Definition: acquired inflammatory condition characterized by inflammation Inferior heel pain at the origin of the plantar fascia is not necessarily plantar fasciitis New Definition: “fasciosis” with degeneration, inelasticity, and Differential . microscopic tears Plantar fasciitis Plantar fasciitis Clinical presentation: Differential: - inferior heel pain with insidious onset - entrapment neuropathy - fat atrophy - first-step / morning pain - worsens as day progresses - tarsal tunnel - neoplasm - alleviated with rest - calcaneal stress fracture - plantar fibroma - plantar fascia rupture - Achilles Physical exam . Physical exam . Take home . Take home . Plantar Nerve Lateral wall tenderness . calcaneal stress fx Fascia entrapment Imaging . Plantar fasciitis - X-rays if sx’s > 6 weeks Non-operative Rx: - MRI if stress fx - Shoewear modification - Achilles / plantar fascia stretching - Night splint - NSAIDs Plantar fascia specific stretching . Custom orthotics Take home . - No better Take home . Plantar fasciitis Other options: Take home . - Walking cast/boot - Steroid injection (x 1) Refer for surgical evaluation if symptoms persists after - Shockwave 6 months of non-operative treatment Surgical release for recalcitrant disease What about the heel spur? Leave it alone Achilles Tendinopathy Definition: Tendinosis and/or peritendonitis Achilles Tendinopathy Etiology: - Inelasticity - Hypovascularity - Overuse / Age - Fluoroquinolones - Constrictive shoes - Inflammatory arthropathy Achilles Tendonitis/osis Achilles Tendonitis/osis Peritendinitis: inflammation involving peritendinous structures. In acute setting, symptoms typically last less than 2 weeks; in Insertional disease Non-insertional subacute setting, symptoms last 2 to 6 weeks; with chronic disease peritendinitis, symptoms are present 6 weeks or longer. Chronic peritendinitis may be associated with tendinosis. -
Standard of Care: Shoulder Impingement ICD 9 Codes
BRIGHAM AND WOMEN’S HOSPITAL Department of Rehabilitation Services Physical Therapy Standard of Care: Shoulder Impingement ICD 9 Codes: 726.10 - Rotator cuff syndrome of shoulder and allied disorders 840 - Sprains and strains of shoulder and upper arm Case Type / Diagnosis: Shoulder impingement. Indications for Treatment: Subacromial impingement with rotator cuff tendinopathy is a very common condition seen by both orthopedic surgeons and physical therapists. 23, 4, 18 Impingement syndrome as defined by Neer refers to a pathological condition in which the suprahumeral structures are compressed against the anteroinferior aspect of the acromion and/or the coracoacromial ligament. 23, 4, 17, 34 Impingement can also occur internally between the humerus, glenoid rim, and labrum. 9 The structures most often involved are the rotator cuff tendons, the long head of the biceps and the subacromial bursa.4 Rotator cuff syndrome is a term that is often used to describe the process when both rotator cuff tendinitis and impingement are thought to be occurring simultaneously. 23 There are four major causes of rotator cuff tendinopathy: external impingement, internal anatomical impingement, functional overload and intrinsic tendinopathy. 23 Rotator cuff tears can occur either traumatically or by the result of the degenerative process of tendinosis. Rotator cuff tears (RCT) are frequent and increase with age, yet the varying functional implications of a tear can have a unique and dramatic impact on a patient’s daily life. The presence of a RCT can cause a vast array of impairments and associated dysfunctions. This can be the result of many variables including: age of the individual, activity level of an individual, size of the tear, location of tear, number of tendons involved, and overall rotator cuff tissue quality, as well as the presence or absence of other pathology within the shoulder complex.