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A Conservative Approach to Treatment and Management of Rotator Cuff Impingement: a Literature Review

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A Conservative Approach to Treatment and Management of Rotator Cuff Impingement: a Literature Review A Conservative Approach to Treatment and Management of Rotator Cuff Impingement: A Literature Review By Brett Taylor Faculty Advisor: Rodger Tepe, PhD A senior research project submitted in partial requirement for the degree Doctor of Chiropractic March 11, 2011 ABSTRACT Objective: To present the various conditions of the shoulder/shoulder girdle, whether congenital, arthritis, muscle insufficiency or diversity of injuries and what, if any, conservative treatment can be applied by the chiropractic physician or physical therapist. Clinical Features: Patients with varied symptoms including: soreness, pain or insufficiencies of the rotator cuff manifesting from acromial spurring or diminished space for supraspinatus excursion between the humeral head and acromion, weakness of abductor, external or internal muscles of the cuff or rotator cuff injuries. Interventions and Outcome: Conservative treatment with spinal manipulative therapy, muscle stretching and strengthening, cryotherapy, ultrasound, range of motion exercises, taping and cross-friction massage have been shown to result in favorable outcomes in many patients, which eliminates the need for invasive surgery. Conclusion: This literature review shows the benefit of conservative care for rotator cuff impingement and rotator cuff tears. Persistence of the patient in following through with the proposed treatment plan before the decision of undergoing invasive surgical repair is an important component of successful outcomes. Key Indexing Terms: Shoulder, Shoulder Impingement Syndrome, Rotator Cuff Impingement, Rotator Cuff Injury. Taylor: Shoulder Impingement Syndrome: Literature Review 1 INTRODUCTION Shoulder impingement syndrome and rotator cuff conditions are among the most 1, 2, 3, 4, 5 common causes of shoulder pain and dysfunction in adults. Shoulder pain is the third most common musculoskeletal symptom encountered after back and neck pain 6 accounting for almost 3 million patient visits each year in the United States.7 Conditions affecting the shoulder are a common complaint presenting to the primary health care physician, particularly the chiropractor 8, 9 and are amendable through conservative treatment. Shoulder impingement syndrome and shoulder pain are third only to headache 8, 9 and back pain in frequency seen in the practitioner’s office, yet, despite this, there is lack of prior reporting of impingement syndrome in the chiropractic literature. Half of these patients have 1 episode of shoulder pain yearly.10 Studies show that conservative management of shoulder impingement syndrome resolves the problem in 70-90% of patients, 9, 11 although, in certain cases, surgical intervention is required. 5 Successful management of impingement syndrome is dependent on an accurate diagnosis, which is attained by knowledge of the regional anatomy, the biomechanics of shoulder motion and the correct interpretation of the pathology determined through a detailed history, physical examination and diagnostic studies. 12 The glenohumeral articulation has more overall movement than any other joint in the body due to the minimal bony stability in the shoulder permitting a wide range of motion (ROM). In order to achieve peak performance, there must be optimal balance between mobility and stability. 2, 12 Due to the limited bony structures, the shoulder is inherently Taylor: Shoulder Impingement Syndrome: Literature Review 2 unstable, thus the soft tissue structures (static and dynamic stabilizers) are the major 12 glenohumeral stabilizers. However, excessive or repetitive strain of the shoulder complex can impair the balance between mobility and stability, placing the shoulder at 3, 12, 13 risk for a variety of disorders. The purpose of this paper is to discuss the typical causes of shoulder pain and the conservative management in a chiropractic setting, common and beneficial exercises employed to strengthen and repair the rotator cuff, and when surgery is necessary/unnecessary. DISCUSSION Anatomical considerations: The shoulder joint is a multiaxial spheroid joint. The minimal bony stability in the shoulder permits the greatest range of motion of any other joint in the human body. The soft tissue structures are the major glenohumeral stabilizers. Stability is provided both statically by the capsule and labrum, and dynamically by the rotator cuff musculature. Dysfunction of any of these structures can lead to pain, weakness, and instability. Several interconnecting ligaments and layers of muscles join these bones, providing the rather unstable joint with a great amount of strength. 2, 12 Due to the curvature of the articular surfaces of the shoulder, the joint is not congruent and is referred to as “loose packed.” It is only when the humerus is abducted and externally rotated that it becomes “close packed” and a congruent joint. 2 The rotator cuff consists of four muscles, which reinforce the fibrous capsule and Taylor: Shoulder Impingement Syndrome: Literature Review 3 control three basic motions: abduction, internal rotation and external rotation. The supraspinatus lies above the joint providing abduction, while the infraspinatus and teres minor muscles cross the joint posteriorly allowing for external rotation; all three muscles insert onto the greater tubercle of the humerus. The subscapularis, allowing for internal rotation, is the fourth rotator cuff muscle, attaching from the anterior surface of the scapula, crossing the glenohumeral joint anteriorly and inserting onto the lesser tubercle of the humerus. 2, 9, 12 The muscles of the rotator cuff balance the forces of other shoulder muscles, most importantly the deltoid muscle. Contraction of the deltoid muscle in the absence of supraspinatus function leads to superior translocation of the humeral head, making wide abduction difficult. 14 Clark and Harryman reported that tendons of the rotator cuff muscles fuse into one structure near or at their insertion into the tuberosities of the humerus. Therefore, the contraction loads of one cuff muscle can effect the attachment of neighboring tendons. 15 This interconnection may be important in the pathogenesis of cuff tears. 15 It was also noted that the coracohumeral ligament and fibers from adjacent cuff tendons reinforce the supraspinatus tendon. 14 The vascular supply to the rotator cuff tendons is different from that of typical synovial avascular tendons or paretenon-covered vascular tendons. 16 The rotator cuff tendons receive their blood supply through the bursal surface, 16 musculotendinous junction, and the periosteum. A “critical zone” of decreased vascularity near the insertion of the supraspinatus tendon has been identified.8 However, other investigators have noted an adequate vascular supply on the bursal surface with relative hypovascularity on the articular surface of the rotator cuff Taylor: Shoulder Impingement Syndrome: Literature Review 4 Muscles. 16 This finding is consistent with reported higher incidence of the articular 17 surface tears of the cuff. In 1972, Neer 18 first introduced the concept of rotator cuff impingement to the literature, stating that it resulted from mechanical impingement of the rotator cuff tendon beneath the anterior/inferior portion of the acromion, especially when the shoulder is placed in the forward-flexed and internally rotated position. 19 He reported that about 90% of rotator cuff tears are a result of subacromial impingement from supraspinatus outlet narrowing. The supraspinatus outlet is a space formed on the upper rim, humeral head, and the glenoid by the acromion, coracoacromial arch and acromioclavicular joint. This outlet accommodates the passage and excursion of the supraspinatus tendon. Abnormalities of the supraspinatus outlet have been attributed as a cause of impingement syndrome and 20 21 rotator cuff disease, as has rotator cuff weakness. Anatomical variants of the acromion have been shown to correlate with impingement. 5, 22 The acromion has been classified into three types based on the shape of its inferior surface: flat (type I), curved (typed II) and hooked (typed III). 1 The latter two types have been implicated as a causative factor in the development of impingement syndrome leading to rotator cuff pathology. 17 Research carried out by Neer on impingement was based on cadaveric dissections and clinical and surgical experience. 18 ,3, 12 He established a classification system that defines three stages in the spectrum of rotator cuff impingement that follow a pattern of severity. Stage 1 is depicted by acute inflammation, edema and hemorrhage in the rotator cuff. In Taylor: Shoulder Impingement Syndrome: Literature Review 5 stage 2, the rotator cuff tendon progresses to fibrosis and tendinitis. As this condition progresses, it may lead to mechanical disruption of the rotator cuff tendon and to changes in the coracoacromial arch with osteophytes along the anterior acromion. These changes are consistent with stage 3 of the Neer classification. In all Neer stages, etiology is impingement of the rotator cuff tendons under the acromion and a rigid coracoacromial 18 arch, eventually leading to degeneration and tearing of the rotator cuff tendon. Stage II warrant a possibility of surgery. Stage III, surgery is crucial. Rotator cuff pain is frequently described as a dull ache of insidious onset, extending over the lateral arm and shoulder. Overhead activities exacerbate the pain, and the pain frequently increases at night and may awaken the individual from sleep. Weakness with the inability to abduct and elevate the arm
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