PCL4-Michelle the Swimmer- Medical/Pharmacological Management

The first goal of treatment after a diagnosis of ‘Swimmer’s Shoulder’ is pain relief. This is done through rest. In most cases, athletes should stop or reduce swimming activities. Cold compression wraps should be used for 20 minutes every 2 hours on the first day of injury. Thereafter, they should be used 2/3 times a day, until swelling and pain diminishes. This is used both to help prevent inflammation and pain, through the ice, and a reduction in swelling through compression.

In addition, anti-inflammatory drugs should be given. Optimally, these should be non-steroidal, as these have more side-effects. Most Non-steroidal Anti-inflammatory drugs (NSAIDs), are taken orally, and are mostly free from side-effects. An example is Cerebrex. On the other hand, corticosteroids are more potent, can be taken orally or as an injection, and are seldom used unless there is a pressing need.

The second goal is to restore normal strength to the rotator cuff – regaining this strength can be accomplished through weight training using light weights, 1-2.5kg, with multiple repetitions, daily. The exercises should be designed to stretch the four muscles of the rotator cuff.

http://swimming.about.com/cs/shoulderinjury/a/endswimshoulder_4.htm

http://www.emedicine.com/sports/TOPIC125.HTM#section~Treatment

http://www.alexandriamasters.com/articles/shoulder.htm

Shoulder examination - Inspection and Feeling

A shoulder examination begins with history taking.

Some common signs and symptoms of rotator cuff tendinopathy:
-Pain and tenderness in your shoulder with overhead activities, reaching behind your back, lifting or pulling.
-Pain when sleeping on the affected side.
-Pain over deltoid muscle.
-Muscle weakness when lifting affected arm.
-Loss of shoulder range of motion.
-Inclination to keep your shoulder inactive.
-Cracking or clicking sounds when shoulder is moved.

Next, we want to inspect the affected shoulder, comparing it with the non-affected one. Ask the patient to undress. If possible, watch the movements of the patient as he/she undresses and note whether the movements are limited or cause pain. Some things to look for:
-Swelling and effusions
-Asymmetry
-Scars, lesions, bruises, redness, discolouration
-Deformity

After looking, we begin to feel the shoulder joint for:
-Tenderness, swelling and warmth
-Atrophy (in three particular sites: the supraspinatus fossa, infraspinatus fossa and deltoid)
-Assess the clavicle and the posterior joint line.
-Palpate the AC joint, then move along the clavicle to the SC joint.
-To palpate the rotator cuff bursa, extend the patient's arm backwards and internally rotate it. This brings the bursa anteriorly where it can be palpated by the index finger when the hand is placed across the upper aspect of the shoulder with the thumb posteriorly and the index finger anteriorly.

Upon completion of feeling, we then proceed to move the joint to test the range of passive and active movement (flexion, extension, rotation, lateral flexion), followed by some special tests.

Sources: Talley and O' Connor Clinical examination 5th ed.
http://www.nismat.org/orthocor/exam/shoulder.html

-Michelle

PCL 03- Investigations (Alan)

Investigations

l X-rays

n Anteroposterior, axillary (arm abducted at 90 degrees optimal) or outlet (directly facing the glenohumeral joint?)view of shoulder

n To rule out the possibility of the pain coming from bone related problems

u Stress fracture, infection, tumour…

l MRI

n Provides full spectrum view of the shoulder

u Clearer image of ligaments, tendons, muscles

l MRI anthrogram

n MRI but with a contrasting agent

u Like doing X-ray for lymph nodes, need a substance to highlight certain parts of the body

n Local anaesthetic, then needle injection of agent into joint

n Used to check for labral tear

l Musculoskeletal ultrasound

n Can check for muscle, tendon tears

n To check for bleeding, fluid collections in the shoulder joint

http://www.aafp.org/afp/20050901/811.html

http://www.emedicine.com/sports/TOPIC125.HTM

http://www.radiologyinfo.org/en/info.cfm?pg=musculous&bhcp=1

http://uwmedicine.washington.edu/PatientCare/MedicalSpecialties/SpecialtyCare/UWMEDICALCENTER/Radiology/mriarthrogram.htm

PCL 04 - Complications and Prognosis (Su-Wei)

Generally most people recover completely after correct treatment e.g. using medications, physical therapy. Without surgical intervention, and depending on the person’s age and injury, there is a 60-90% success of conservative treatment. Older people require longer to recover however.
Those who have surgery also have a high rate of successful recovery and report pain relief and recovery, or even improvement, of function. Time for recovery from surgery may be longer however, and results are injury dependent.
In some cases however, treatment fails to improve the symptoms, especially if the patient does not comply with stopping the activity causing the inflammation. If left untreated, the pain can worsen or cause rotator cuff degeneration and eventually complete rotator cuff tear. Another possibility is bursitis, inflammation of the bursa (common in shoulders) or progression to adhesive capsulitis .

http://www.nlm.nih.gov/medlineplus/ency/article/000438.htm
http://www.merck.com/mmhe/sec05/ch075/ch075j.html
http://www.emedicinehealth.com/rotator_cuff_injury/article_em.htm
http://www.emedicine.com/sports/topic124.htm

PCL 04 Definition and Incidence of Impingement - Myat

Description

• Impingement is pain on the shoulder resulting from pressure on the rotator cuff muscle from part of the scapula as the arm is lifted


• As the arm is lifted the Acromion rubs or "impinges" on the surface of the rotator cuff, this causes pain and restricts movement


• The impingement may occur be due to bursitis (inflammation of a small sack of synovial fluid called bursae) or tendonitis on the rotator cuff itself, or insome cases partial tear on the rotator cuff

Symptoms

• Minor pain that is present in both activity and rest


• Pain radiating from front of shoulder to the side of the arm


• Sudden pain with lifting and reaching movements


• Athletes in overhead sports when throwing or serving a tennis ball

Incidence

• Impingement is both common in young athletes and middle aged people


• Young athletes who use their arms overhead in sports e.g. tennis, basketball, swimming are particularly responsbile


• Studies have shown that shoulder pain was most prominant in volleyball athletes followed by swimmers while basketball, badminton and tennis players were equally affected


• Those who also do repetitive overhead activities using the arms e.g. paper hanging, construction or painting are particualry vulnerable

Causes and risk factors for rotator cuff tendinopathy

Causes of rotator cuff tendinopathy
- Over loading the shoulder either with repetitive activities or with weighted activities can cause injury or overuse of the tendons
- Altered or unfamiliar activities like starting a new sport or new program at the gym
- Chronic tears: usually in sports that entail a follow-through action such as repetitive throwing, overhead strokes, and swimming. The muscle or tendon tear is usually a result of joint imbalance that may be associated with looseness in the front of the shoulder caused by aweakness in supporting ligaments
- Acute tears: occur in instances of intense stress or pressure, such as lifting something extremely heavy
- The tendon becomes swollen and may become ‘impinged’ or caught between the bony structures of the shoulder during certain movements: namely the impingement of soft tissue against the coracoacromial arch.

Causes particular to swimmers
- 2 types of impingement: long head of the biceps against the anterior part of the coracoacromial arch, or supraspinatus muscle impinged between the greater tuberosity of the humerus and the middle and posterior portions of the coracoacromial arch. Both are caused by incorrect technique.
- Overtraining: if the swimmer continues to swim with fatigued muscles. As the muscles fatigue they will work less efficiently which has two poor consequences. First, the muscles will have to work harder in a weakened condition. Second, the swimmer will have to perform more strokes to cover the same distance, which is overusing already fatigued muscles. Together these two factors can result in swimmer's shoulder
- Unilateral breathing: swimmers who consistently turn their heads to the same side to breathe are risking shoulder pain in the opposite shoulder as it has to work harder to support forward movement with the head turned to the side.
- Overuse of certain training equipment: use of hand paddles that are much larger than the swimmer's hand, or those paddles that do not have drainage holes place great strain on the shoulder muscles during the pull-through phase of freestyle. Using a kickboard with arms fully extended in front of the swimmer can place the shoulder in a position of impingement. The longer the swimmer uses these items, or uses them incorrectly, the greater the risk of shoulder pain.

Risk factors
- Excessive repetitive motions of arms/ overhead activities: professional baseball players, swimmers, tennis players, for example, are at higher risk. Jobs involving overhead assembly, butchering also place people at greater risk.
- Age: incidence of tendinitis increases with age as muscles and tendons lose their elasticity, particularly when you are 40 and over
- Improper technique in any sport: can cause overload on the tissues in the shoulder, including tendons, contributing to tendinitis
- Shape/Thickness of the acromion : In some people the space between the undersurface of the acromion and the humeral head is very narrow, and thus is more likely to pinch the supraspinatus tendon.
- Bone Spur : Some people have bone spurs on the front of the acromion, which increases the risk of impingement syndrome.
- Muscle Imbalance : Either by injury or atrophy, the muscles in the shoulder may become imbalanced, which affects the shoulder motion, especially in the forward direction. Any change in motion increases the risk of impingement.

http://www.axisrehab.com.au/physio/case/case_rct.html
http://www.nismat.org/traintip/swimmershld
http://www.upmc.com/HealthManagement/ManagingYourHealth/HealthReference/Diseases/?chunkiid=22493
http://biomed.brown.edu/Courses/BI108/BI108_2004_Groups/Group01/mechRC.htm
http://www.uclahealth.org/body.cfm?xyzpdqabc=0&id=477&action=detail&AEProductIDSRC=Adam2004_1&AEArticleID=000438&AEProductID=Adam2004_1&AEProjectTypeIDURL=APT_1
http://www.riversideonline.com/health_reference/Disease-Conditions/DS00153.cfm

-Eunice

PCL 04 - Pathophysiology of Tendinopathy (Mamie)

Overloading crucial in development

Generally occurs near the insertion of a muscle where there is non-uniform strain on tendons and areas of stress concentration develops

No inflammation but initiators of tendinopathic pathway include proinflammatory agents such as cytokines, prostaglandins, growth factors and neuropathies
http://www3.interscience.wiley.com.ezproxy.lib.monash.edu.au/journal/119407081/abstract?CRETRY=1&SRETRY=0)

Histology - cells are
Rounder
More numerous
Abnormal regulation of apoptosis (most apoptotic cells identified as fibroblasts or fibroblast-like)
More evidence of oxidative damage
Abnormally plentiful tenocytes (often with alterations in size and shape of mitochondria and nucleus)

Histology - matrix is
Collagen degeneration
Thicker
Weaker
Higher water content
More immature, cartilage-like proteins
Less organised/disoriented fibres


http://www.mdconsult.com.ezproxy.lib.monash.edu.au/das/article/body/101401106-2/jorg=journal&source=&sp=14064019&sid=0/N/378936/1.html?issn=0278-5919

http://web.ebscohost.com.ezproxy.lib.monash.edu.au/ehost/detail?vid=1&hid=16&sid=dcb275f3-624c-407c-be23-008fabaf040c%40sessionmgr2&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=s3h&AN=15226347

http://www.springerlink.com.ezproxy.lib.monash.edu.au/content/g47505280228587w/

http://www3.interscience.wiley.com.ezproxy.lib.monash.edu.au/journal/119407081/abstract?CRETRY=1&SRETRY=0

Diagram: http://www.mdconsult.com.ezproxy.lib.monash.edu.au/das/article/body/101408767-2/jorg=journal&source=&sp=14064019&sid=0/N/378936/I9.fig

PCL Week 4 – Swimmer’s Shoulder - Frank

PCL Week 4 – Swimmer’s Shoulder
Examination – Frank

For patients with shoulder problems, pain is the most common symptom.
Typically it is felt over the front and lateral part of the joint. Other symptoms include deformity, stiffness, instability and loss of function.

Examination is usually a four step process: Watch, look, feel and move. Watch, look and feel is fairly straightforward, observing asymmetry, scars, limited or painful actions and swelling, and feeling for tenderness.

The main part of examination is regarding joint movements.
1. Abduction
2. Elevation
3. Adduction
4. External rotation
5. Internal roation
6. Flexion
7. Extension

For a quick assessment, the 3 step Apley scratch test is particularly helpful.
Stand behind the patient and ask them to scratch an imaginary itch over the opposite scapula, first by reaching over the opposite shoulder, next by reaching behind the neck and finally by reaching behind the back.

For shoulder stability, apply the apprehension test.
Stand behind the patient, abduct, extend and externally rotate the shoulder while pushing the head of the humerus forwards with the thumb. The patient will strongly resist this manoeuvre if there is impending dislocation. A similar response will be generated through adduction, internal rotation if posterior dislocation is impending.

As a general rule, intra-articular disease produces painful limitation of movement in all directions, while tendonitis produces painful limitation of movement in one plane only, and tendon rupture/neurological lesions produce painless weakness. E.g. if the abnormal sign is limited shoulder abduction in the middle range (45~135) this suggests rotator cuff problems rather than arthritis

For supraspinatus tendonitis, test by placing a finger over head of tendon (a little higher than bicipital groove and just under anterior surface of acromion) and extend the shoulder. As this pushes the tendon forwards against the examiner’s finger, the movement is painful. The pain is relieved by flexion.


http://www.nismat.org/orthocor/exam/shoulder.html
Talley and O’Connor – Clinical Examination

Issues for Patient - Sarah

Psychosocial factors
“Injury is often accompanied by depression, tension, anger and low self-esteem, particularly in competitive, seriously injured athletes. Mood disturbance seems to relate to the athlete's perceived progress in rehabilitation and has been shown to negatively relate to attendance at rehabilitation sessions.”

Impact of Michelle being a competitive swimmer
Michelle’s swimming is likely to be the cause of her injury, due to repetitive strain on the area, this means that it could become a recurrent disease, and inhibit her swimming abilities. Part of the treatment is to immobilise the arm, this could mean that Michelle will be unable to train and may lose her performance.

Issues with chronic and recurrent disease
If the shoulder does not completely heal then Michelle could end up with chronic tendonitis, continuing to swim could exacerbate this.

Problems with compliance
As previously mentioned part of the treatment of tendonitis is to immobilise the arm, this would have an affect on Michelle’s ability to train, this could lead her to discarding the treatment plan and continuing to train with her damaged shoulder, this could lead to long term damage and possibly chronic tendonitis. Adhering to rehabilitation has been shown to improve the outcomes for the patient.

References
o The Journal of the Royal Society for the Promotion of Health. London: Jul 2007. Vol. 127, Iss. 4; pg. 174, 7 pgs
o Wasley D. Lox CL. Self-esteem and coping responses of athletes with acute versus chronic injuries. [Journal Article] Perceptual & Motor Skills. 86(3 Pt 2):1402, 1998 Jun.
o Smith AM. Psychological impact of injuries in athletes. [Review] [78 refs] [Journal Article. Review] Sports Medicine. 22(6):391-405, 1996 Dec.
o Niven A. Rehabilitation adherence in sport injury: sport physiotherapists' perceptions. [Journal Article. Research Support, Non-U.S. Gov't] Journal of Sport Rehabilitation. 16(2):93-110, 2007 May.

ROTATOR CUFF TENDINOPATHY – SURGICAL TREATMENT

Surgery is an effective option in carefully selected patients who have failed three to six months of conservative therapy.

Although the mechanism of surgical healing promotion is not entirely understood, surgery is an effective treatment option in carefully selected patients. If pain persists despite a well-managed conservative treatment trial, referral to an orthopaedic surgeon for surgical evaluation may be warranted. Indications for operative treatment of rotator cuff disease include partial-thickness or full-thickness tears in an active individual who does not improve pain and/or function within 3-6 months with a supervised rehabilitation program.

Surgical techniques vary by tendinopathy location but typically include excision of abnormal tendon tissue and performance of longitudinal tenotomy (A surgical procedure that cuts the tendon of a contracted muscle to allow lengthening) to release areas of scarring and fibrosis. Longitudinal tenotomy is commonly used for tendinopathy of the lower limb (such as the knee and ankle).

An acromioplasty (An arthroscopic surgery involving the acromion) is usually performed in the presence of a type II (curved) or type III (hooked) acromion with an associated rotator cuff tear. Athletes with rotator cuff pathology secondary to GH instability also need to have this addressed.

In surgical candidates, early repair is useful to avoid fatty degeneration and retraction of the remnant rotator cuff musculature. Functional recovery should be stressed, and, in a patient who can achieve pain-free activities of daily living in the setting of a rotator cuff tear, surgical repair may be avoided. Surgeries including muscle transfers and debridement are generally reserved for massive, irreparable rotator cuff tears.

Acromioplasty and Subacromial smoothing

Arthroscopic acromioplasty is an operation designed to provide more room for your rotator cuff tendons to move.

Subacromial smoothing involves shaving bone or removing growths on the upper point of the shoulder blade. It removes scar tissue and damaged tendon and bursa from the joint. The surgeon may also remove small amounts of bone from the underside of the acromion and the acromioclavicular joint (acromioplasty). The goal is to take away roughness while keeping as much of the normal supporting structures as possible.

This surgery creates more room in the subacromial space so that the rotator cuff tendon is not pinched or irritated and can glide smoothly beneath the acromion.
Subacromial smoothing, acromioplasty, and rotator cuff repair may be done using arthroscopic surgery or open surgery.

1.Open-shoulder surgery involves making a larger incision in the shoulder, to open it and directly view the repair.

2.Arthroscopy uses a thin viewing scope called an arthroscope that is inserted into a joint through a small incision in the skin. Then the surgeon will remove loose fragments of tendon, bursa, and other debris from the shoulder (debridement). Additional instruments are then arthroscopically inserted to shave the bone or remove growths. This type of surgery is usually done on an outpatient basis.

www.webmd.com/a-to-z-guides/subacromial-smoothing-and-acromioplasty-for-rotator-cuff-disorders

www.aafp.org/afp/20050901/811.html

http://www.emedicine.com/sports/topic115.htm

Definition and Incidence of Tendinopathy

Definition
Tendinopathy: Literally means a disease of a tendon. It describes overuse tendon injuries characterized by a combination of pain, diffuse or localized swelling, and impaired performance. It includes tendinosis (non-inflammatory repetitive stress injury of tendon fibres) and tendonitis (inflammation of a tendon or tendon-muscle attachment).

(Distinguishing tendinosis from tendinitis is clinically difficult and can be made only after histopathological examination)

Incidence
In one UK study, supraspinatus tendinosis was seen in 67% of elite swimmers
->(four times more likely if more than 35km was swum per week, or swimmers trained over 15hours per week)
In the US 35% of swimmers are estimated to suffer from tendinopathy


References:
http://www.dentalarticles.com/dictionary/tendinopathy.html
http://medical-dictionary.thefreedictionary.com/Tendinosis
http://www.shoulderdoc.co.uk/article.asp?article=595http://www.emedicine.com/sports/TOPIC125.HTM

- Penny

Complementary Alternative Medicine - Bryn

For rotator cuff injuries there are no truly effective alternative remedies. However some studies have shown that acupuncture can be useful in decreasing pain and increasing function in the short term (2-4weeks). There are also courses of shoulder mobilization therapy that help to improve movement and reduce pain.

Two examples of complementary medicine techniques that deal with shoulder pain in general are:

Ayurveda, a form of traditional Indian medicine involving massaging the injury and the application of natural lotions and oil.
Reflexology, management of pain pathways through massage of different parts of the body.

There Glucose injections that supposedly strengthen the tissue around the injury site while reducing pain, but critics argue its just a placebo effect .

Sources
Shoulder pain: diagnosis and management in primary care
http://www.bmj.com/cgi/reprint/331/7525/1124.pdf

Shoulder immobilization therapy
http://www.sagerainbow.com/shoulder.html

http://www.onconurse.com/news/alternative.html

Patho - part 1 - PCL week 4

What is a joint:
- “the place of union, usually more or less movable, between two or more bones. Joints between skeletal elements exhibit a great variety of form and function, and are classified into three general morphologic types: fibrous joints; cartilaginous joints; and synovial joints.” – Stedman’s Medical Dictionary 2005.

Types of joint:
Fibrous joints.
- Solid with no joint cavity
- Types of fibrous joint
o Suture – “A form of fibrous joint in which two bones formed in membrane are united by a fibrous membrane continuous with the periosteum.” Eg between bones of the skull, which form a synostosis with age.
o Syndemosis – “A form of fibrous joint in which opposing surfaces that are relatively far apart are united by ligaments.” eg holds distal ends of tibia and fibula together with a strong interosseous ligament.
o Gomphosis – “A form of fibrous joint in which a peglike process fits into a hole, as the root of a tooth into the socket in the alveolus.”

Cartilaginous joints.
- Solid with no joint cavity
- Primary cartilaginous joints:
o Two areas of bone are bridged by hyaline cartilage.
o Don’t allow movement but do allow growth
o Include epiphysial plates during growth, costochondral joint.
- Secondary cartilaginous joints
o Thin layer of hyaline cartilage covers the bone with thick fibrocartilage in between.
o Also called symphyses
o Located exclusively in the midline of the body

Synovial joints.
- Allow for extensive movement
- Characterised by a joint cavity and hyaline cartilage covering bony surfaces
- Types of synovial joints:
o Plane – surfaces are almost flat and parallel. Movements are simple gliding movements
o Uni-axial – have a pair of movements around one axis. Can be either hinge (elbow) or pivot (radioulnar joints)
o Bi-axial – pair of movements around two axes which are usually perpendicular to each other. Can be condylar/ ellipsoid (wrist joint) or saddle (carpometacarpal joint of the thumb)
o Multi-axial/ ball and socket joints – two pairs of movement (as per bi-axial) and an extra pair of movements
- Simple and compound joints
o Simple = one pair of articular surfaces (most synovial joints)
o Compound = more than one pair (eg elbow and knee)
- Complex joints have a joint cavity subdivided into more than one compartment. Can be complete (by fibrocartilage) or incomplete (by menisci)

- Fern.