rotator cuff tendonitis

[arifa]

hi all
Need help with a patient that i have been treating for more than seven sessions.
She is a 50 year old school teacher presenting with shoulder pain for the last 6 years, aggravated last couple of months. Subjectively pain not there at rest but comes on with hand behind back(HBB). On assessment she has a positive empty can test, limitation with HBB, pain from about 100 degreess abduction. Cervical movements fine and pain free.
My treatment has entailed shoulder mobs specifically GHJ A-P's in neutral, GHJ longitudinal caudad grIII. cross frictions over rotator cuff tendons, posterior and inferior capsule release(soft tissue work) trigger point therapy over upper traps, supraspinatus. Have had very little improvement with HBB. The last session i gave her external rotation exercise with theraband with shoulder in neutral position.
Improvement has not been significant at all.
I sent her for an u/s, results came back showing calcification at musculo-tendinous junction of subscap and supraspinatus. Infraspinatus is fine, biceps longhead is fine.

Next step would be referral to ortho specialist. Throughout treatment she has been on anti- inflamm drugs. Any suggestions? I am possibly missing something?

look forward to responses.

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[sharileedahl]

Based on what you have noted, I think my treatment would be similar (except for maybe cross-frictions...not because it's not an accepted and common treatment; just because it doesn't make sense in my "little brain").

Re. exercise: really look at where her weakness is; how she functionally moves throughout her shoulder girdle to decide what exercises to use

Considering the finding of calcification...
There has been some decent research in the past supporting the use of low intensity, pulsed ultrasound (which is nice considering there is not much other support for the modality).
If the area of calcification is palpable, it may be a good reason to discontinue cross-frictioning as I would think that would just irritate her symptoms.
Even if you addressed her biomechanics with exercise to minimize secondary impingement, some impingement may be difficult to avoid with the presense of some calcification. Have her be aware her ADLs (i.e. limit over-shoulder height lifting or activity) to limit repeated impingement.
I have used eccentric exercise for tendinopathies in the area however I don't know if the exercise directed specifically at the affected tendons would be of benefit when there is calcification.....maybe someone else can address that ????

[alophysio]

HI,

I would agree with the above.

I wouldn't friction the calcification but iwould be asking "why is the calcification there?"

HBB no doubt is aggravating the ssp tendon, not likely the subscap tendon.

Forget the GH joint mobes, they won't do much.

Check her serratus anterior status, her upper traps ability vs lev scap overactivity.

I had a patient with bad clacification - it just sat in there and pinched everything that was in the way. Personally i think my patient needs to have it cleared because anything above the head is physically impinged - and i can't do anything about that - it is chronically swollen and sore and a structural limitation - what is your patient's calcification like?

[arifa]

thanks for responses
Her X-Ray shows increased density in region of greater tuberosity, her ultrsound report reckons "soft calcification". No disruption of rotator cuff tendons.
She has no pain at rest, slight pain occurs with active abduction (over 100degrees).
She is able to get HBB to about T10, (T4 on the good side). This problems on going for 7 years. Why do you think GHJ mobs wont work, with the mobs mentioned, it stretches the post capsule.
I really feel quite helpless with her. I've had good responses with similar patients.

Really appreciate your responses.

Thanks guys

[sharileedahl]

I, like you, would tend to mobilize the GH joint too. If not to improve mobility, to assist with some kind of neuromuscular / proprioceptive input (i.e. mobs through range...). I feel it works well when there is impingement.

Do you know what the U/S report really means when it says, "soft calcification" with "no disruption to the r.c. tendons"? Because i'm not sure i really do.
Does it mean that the calcification is lower down on the greater tuberosity and therefore not affecting any area of the capsule? Could it then be affecting the deltoid? I can't imagine there being calcification in the shoulder girdle and it NOT affecting some of the musculature in the area.

However... because her pain seems to be quite mild (and perhaps unlike the pain usually associated with calcification) and comes on late in abduction, I would still look at her pattern of movement. Does she actually impinge? (Hawkin's test / Neer's test?) Does she hike her shoulder at 100 degrees of abd'n? Does the tone in her upper / middle / lower traps change as she goes through range and what happens at 100degrees? Any palpable tight bands in the deltoid or upper traps?

??........

[arifa]

hey there
thanks for your help.
Speeds test was fine for her, empty can produced her pain, hawkins produced her pain. She has a trigger point in upper traps, supraspinatus too (just localised pain on palpation). No winging scapula. no sh hiking through abduction range.
As for her ultrsound report i am not so sure what "soft calcification" means. The report specifically says "increased echogenicity in subscap at musculo-tendinous junction, could represent soft calcification" (same for suprspinatus). Have to assume that the calcification is not so bad, since she does not have any pain at all at rest and only feels it with HBB, feels "discomfort" with writing on board.
The mobs I have been doing are just accessory mobs at GHJ neutral and about 90degrees abduction(short of pain).
I will see her on Thursday and analyse her abduction again.
really appreciate your help

[alophysio]

Hi,

The reason i wouldn't do mobilisations is because stiffness doesn't seem to be a problem. Sharileedahl is right in that there might be other reasons to do it but after 6 years, there are bigger fish to fry...

1. Soft calcification - no idea what that means but if the calcification is in the tendon, then perhaps she has sustained repeated small traumas and there is calcification in the tendon INLINE with the tendon as opposed to the hard blobs we can sometimes see. In that case, it might be a stress reaction to tension as opposed to a reaction to a tear/other injury - hope you understand what i mean there!

2. If the pt's internal rotation is deficient, then the inferior band of glenohumeral ligament might be tight. For this, Burkhart recommends lying on the affected side in 90deg ABD with elbow at 90deg then internally rotating to stretch. See attached.

3. How is her serratus anterior function, upper traps function ?? A common mistake in these cases is to train the rhomboids with retraction which is terrible (IMHO) because the orientation and function of rhomboids is to downwardly rotate the scapula. Combine this with an overactive lev scap and suddenly you have a nice recipe for repeated impingement. Upper traps' function is to pull on the distal third of the clavicle and jam it onto the SC joint on the sternum. Then help the scapula upwardly rotate via the CLAVICLE (there is no upper traps attachment on the scapula). The axis of rotation starts from the base of the spine of the scap until EOR where the AoR is at the acromion part of the spine of the scap. Bogduk has a good paper from 1994 about it - see attached too!

Hope that helps. Don't forget to check her neck and her thoracic function. Basically, work on the dysfunctions that are leading to the reason why she is aggravating the pain producing structure. These dysfunctions are often not painful. I haven't mentioned things like lat length (or any other muscle length) or any of the other usual things that physios do.

personally i would get more active so she understands that the answer to her problems lie with her discipline in her exercises...you are there to do the things she can't - diagnose, observe, treat and correct problems she doesn't have the knowledge to do herself.

Good luck