​Kembara Xtra - Medicine -Rotator Cuff Impingement Syndrome

​Kembara Xtra - Medicine -Rotator Cuff Impingement Syndrome 
The most frequent cause of non-traumatic shoulder discomfort in those over 25 is compression of the rotator cuff tendons and subacromial bursa between the humeral head and the components of the coracoacromial arch and proximal humerus.
The "painful arc"—a range of arm abduction between 60 and 120 degrees—is when pain is felt the maximum. Traditionally broken down into three stages:
- Stage I: Acute inflammation, edema, or bleeding of the underlying tendons as a result of overuse (mostly affects those under 25 years old)
- Stage II (often affecting people between the ages of 25 and 40): progressive tendinosis that causes a partial rotator cuff tear and underlying thickening or fibrosis of the surrounding structures.
- Stage III: complete thickness tear (common in patients older than 40 years)

 Incidence
1% of all visits to the doctor for primary care are for shoulder pain.
Patients between the ages of 42 and 46 had a peak incidence of 25/1,000 patients each year.
 Impingement is the diagnosis for 18–74% of shoulder pain cases.
Prevalence
In the general population, shoulder pain can occur anywhere between 7% and 30% of the time.

Risk factors include shoulder trauma, thickened coracoacromial ligament, repetitive overhead motions (throwing, swimming), glenohumeral joint instability, muscle imbalance, acromioclavicular arthritis, and smoking.


Prevention
Proper lifting and throwing mechanics, and balanced rotator cuff and scapula stabilizer muscle development are all important.


Increasing shoulder pain gradually with overhead activity is the diagnosis
(A tear is suggested by a sudden start of intense pain.)
Night pain is frequent and made worse by sleeping with the affected arm over the head or laying on the affected shoulder.
 Anterior shoulder soreness when performing overhead motions
If the shoulder is not used through its entire range of motion, it could lead to weakness and limited range of motion.


Clinical evaluation 
Check the patient for asymmetry or atrophy. Watch the patient remove his or her shirt during the examination.
Neer impingement test: The scapula is stabilized while the afflicted upper extremity is moved in an arc of flexion by the examiner. Positive is shoulder flexion-related pain.
78% sensitivity. Particularity: 58%
The Hawkins-Kennedy impingement test involves the examiner flexing the arm 90 degrees forward before gradually rotating the arm internally. When the patient experiences discomfort or the examiner feels or observes the scapula rotating, that is the internal rotation's end point. When the patient feels discomfort while performing the test, it is considered positive. 74% sensitivity. Particularity: 57%


Empty can test (supraspinatus): The patient is instructed to elevate and internally rotate their arm while pointing their thumbs in the direction of their scapula. Elbow should be extended all the way. The examiner presses downward on the arm's top surface. When the patient expresses pain while showing resistance, the test is affirmative.
69% sensitivity. 62% specificity



The lift-off test (subscapularis) requires the patient to internally rotate their shoulder while placing the back of their hand on the buttock on the opposite side, and then to raise that hand off against resistance. This motion becomes weak when the subscapularis muscle is torn. 42% sensitivity. 97% specificity 



Patient fully rises arm and then gently reverses motion in the drop-arm test. The test is positive for a potential rotator cuff tear if the patient experiences severe discomfort or drops their arm abruptly. 21% sensitivity. 92% specificity


Resisted external rotation: teres minor and/or infraspinatus tendon involvement-related weakness
. 


Test for anterior glenohumeral joint instability using apprehension-relocation: Have the patient lie on his or her back or sit as the examiner slowly rotates the humerus (pushing the hand posteriorly while the patient resists and then anteriorly while the patient resists). The test is positive if the patient has any anxiety or worry as a result of this movement, indicating instability and a potential for dislocation. Instead of focusing on instability if pain is present, think about labral tears and/or impingement syndrome.
To rule out cervical pathology as the cause of shoulder pain, examine the cervical spine.
 Upper-limb neurovascular examination


Multiple Diagnoses 
Labral injury
The pain when the affected arm is fully adducted across the chest in a horizontal plane is a sign of acromioclavicular arthritis, which is more common in elderly people.
 
Adhesive capsulitis (rotator cuff tendonitis causes the muscles in the rotator cuff to become less active, atrophy, and eventually constrict; associated with diabetes and maybe previous trauma)
Anterior shoulder instability (previous trauma; individuals under 25 are more likely to have it)
 Instability in multiple directions
.Perform the Speed and Yergason tests and search for a visible or palpable deficiency in the biceps, often known as the "Popeye sign."
Calcific tendinitis and cervical radiculopathy (which can be tested with the Spurling maneuver if there is spinal or foraminal stenosis)
Glenohumeral arthritis (Question using simple films.)
 
Suprascapular nerve entrapment (observe focal infra- or supraspinatus muscle atrophy).
 
Rotator cuff tear caused by trauma

Initial test results from the laboratory and imaging
 
Anteroposterior, axillary, and scapular Y views of the shoulder on plain-film radiographs.
Plain films may show: - Acromioclavicular and glenohumeral joint osteoarthritis - Superior migration of the humeral head (a sign of a significant rotator cuff injury)
- Cystic alteration of the humeral head and inferior acromion sclerosis (signs of chronic rotator cuff illness)
- Tendinitis calcific

MRI is utilized to conclusively assess partial tears, full tears, and tendinopathy of the rotator cuff.
Ultrasound is sensitive and selective for rotator cuff injuries but is extremely operator dependant. MR arthrogram is preferable for labral disease.
For patients who cannot receive an MRI or who have bone disease, a CT scan is suggested.


Lidocaine injection test: Inject lidocaine into the subacromial region as part of diagnostic procedures or other:
Repeat the impingement tests; if the pain is fully gone and your range of motion increases, it's probably impingement syndrome and not a rotator cuff injury.
- Makes physical examination strength testing more accurate:
If strength is intact, a rotator cuff tear can be ruled out. If range of motion does not improve in any plane, adhesive capsulitis is more likely to be the cause. After a lidocaine injection with some improvement in range of motion
.A lack of pain alleviation may indicate additional origins (such as cervical radiculopathy) or ineffective injection placement. Glenoid labral tear; capsular strain; glenohumeral osteoarthritis; glenohumeral instability.
Interpretation of Tests
may have a muscle or tendon injury, tendonitis, or tendinosis.


Management 

Most patients' rotator cuff tendonitis improves and completely cures with pain management and vigorous therapy.


Ice or heat for discomfort alleviation; rest initially; afterwards, physically supervised rehabilitation is required for 6 to 8 weeks; activity modification with avoidance of aggravating activities, particularly overhead motions;
Strengthening the muscles around the rotator cuff will improve stability and help to prevent further injuries. Range of motion exercises.

First-line treatment with NSAIDs or another analgesic, often for 6 to 12 weeks


Referral 

failure of conservative therapy, ongoing discomfort, weakened condition, or rotator cuff injury in its entirety



Exercise programs under supervision or performed at home significantly reduce pain and enhance function. Physical therapy is successful for both short- and long-term function rehabilitation.
After the pain has subsided, gradually strengthen the rotator cuff muscles that control internal rotation, external rotation, and abduction.


Surgical Procedures 
Although they do not appear to have a substantial long-term impact, steroid injections may significantly improve pain and function in the short term.
There is no proof that surgery is better for impingement syndrome than conservative therapy or that one surgical technique is superior to another. Platelet-rich therapy for soft tissue musculoskeletal injuries are becoming more and more popular.
- The use of platelet-rich plasma during arthroscopic rotator cuff surgery does not appear to have any impact on overall retear rates or shoulder-specific results.
Extracorporeal shock wave therapy is a newly discovered method of treating calcific tendinitis, and it is actively being researched.

Healthcare Alternatives 
Acupuncture may help with pain management and function enhancement, especially when combined with physical therapy.


Constant Care 
Physical therapy, home exercises, and surgical intervention all require physical rehabilitation. This is true for both conservative and surgical treatment modalities.
Prior to comprehensive testing or surgical intervention, an intensive trial of rehabilitation should be recommended.
Getting rid of discomfort before starting a physical therapy program enhances compliance and results because symptoms frequently return if not entirely treated.

Variable prognosis that relies on the underlying pathology
.The majority of patients get better with conservative treatment.
Recovery may take time.
Patients who have had more severe symptoms for longer than a year are less likely to benefit from conservative therapy.

Tendon retraction in a full rotator cuff tear is one of the complications. Injury progression is another.

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