If we take a step back from considering the mechanism of tendon injury to considering whether all tendon irritation can be truly considered as a tendonitis / tendonosis in the true sense.  This is not simply an academic debate because it profoundly influences the direction in which therapeutic interventions are conducted.  Take for example a common clinical scenario of applying resisted tests to the rotator cuff in a neutral anatomical positions. The clinical interpretation of a negative response is that a tendonitis or partial tear can be excluded.  Similarly, of the multitude of orthopaedic tests which have been devised to test for impingement (with varying diagnostic sensitivity) it raises the issue of whether clinical treatment is directed towards reducing the sensitivity of the irritated tendon or focusing on the patho-mechanics as a primary treatment strategy.

When we consider our normal treatment strategies for tendonitis in other anatomical regions the currently accepted protocols are to apply selectively graded loading sufficient to produce a positive physiological response and staying short of inducing overload.  Obviously this is not an exact science and it is a fairly common clinical experience for increased pain levels of post treatment soreness to dictate a modification of loading.

A particularly useful classification of tendon irritation has been presented by Craig Allingham, Australian Physiotherapist, and discussed in an excellent text called “Sports Physiotherapy”.

He presented the argument that tendonitis should be classified as either:

1. Compressive tendonitis

2. Tensile tendonitis.

For the biomechanists amongst you, you will recall that the tensile load placed upon a structure is the force which tends to increase tension through it. When tendons have a limited capacity to tolerate tensile load the clinical management is usually to partially unload allowing healing to occur and then gradually increase graded loading within tolerance. In the lower limb, specifically in the case of Achilles and Patellar tendonopathies the concept on eccentric training programmes have been popularised originally by Kirwan and Stanish in the 1980′s and these principals hold true in cases of tensile tendonitis in the shoulder region.

Specifically with regard to functional impairment different components of the cuff maybe overloaded at different phases e.g. an overhead athlete in the terminal phase of a tennis serve, known as late cocking, requires deceleration by strong eccentric activity of the internal humeral rotators.  Patients who complain of symptoms at this phase of the movement may have a tensile overload phenomenon of the anterior shoulder structures.  Alternatively, patients who complain of symptoms at the end of follow through, when the ball has been struck or an implement thrown, place high eccentric load on the posterior cuff in order to decelerate the arm and thus may expose the posterior cuff elements to an excessive tensile load.  This conceptual framework allows the clinician to be more selective in identifying the mechanism of breakdown and implementing specifically relevant treatment programmes.

Therefore clinically we are looking at differentiating positive resisted tests in non-impinged positions and applying graded loading as tolerated from tendon sensitivity which is only elicited in positions of compression – “impingement”.

Enjoy the clinical challenge.

David.

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: Abduction, Allingham’s test, anterior instability, anterior instability.Jerk test, Apprehension Test, crank test, curwin & stanish, Dynamic impingement test, eccentric training programmes, GH translation (drawer), impingement syndrome, inferior instability, Intra-Articular Shoulder Pain, kinetic shoulder test, LHB impingement, Long head of Biceps, Ludlington’s test, orthopaedic tests, overhead athletes, plexus.flexion, posterior instability, primary impingement, Push – pull test, Relocation test, rotator cuff, secondary impingement, Speed’s test, steroid, sub-acromial bursa, Sulcus test, tendonitis, tendonosis, uni or multidirectional instability

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Format:

1. Initial impression
2. Inspection
3. Range of movement
4. Muscle strength tests
5. Stability assessment
6. Special tests
7. Palpation
8. Neurological assessment
9. Sports specific function

1.  Initial impression:

• general body condition
• systemic disease
• antalgic posture
• willingness to move
• level of distress

2.  Inspection:

• asymmetry
• swelling
• scapular position
• glenohumeral position
• orientation of dependent arm
• muscle wasting
• deformities

3.  Range of Movement

• examine in upright and supine with overpressure EOR as applicable.
• Look for quality & potential compensations

• Total elevation
• Abduction + / – differentiation
• External rotation
  • dependant
  • 90 º abduction
• Internal rotation (hand behind back)
• Horizontal flexion

4.  Muscle strength testing: (stand & supine)

• specific muscle weakness / neurological deficit ?
• strength through range.

Scapular control on thorax:

• Trapezius
• Serratus Anterior

Humeral control in glenoid:

• External rotation
• Internal rotation

5.  Stability assessment: may be unidirectional or multidirectional

• GH translation (drawer) test
  • uni or multidirectional
  • instability
• Sulcus test – inferior instability
• Apprehension (crank) test – anterior instability
• Relocation test – anterior instability.
• Jerk test – posterior instability
• Push – pull test – posterior instability

6.  Special tests:

• Impingements
  • multifactorial etiology, structures potentially involved – rotator cuff,
  • Long head of Biceps, sub-acromial bursa, plexus.
• Tests (specificity imprecise):
  • flexion (EOR)
  • Flexion / internal rotation
  • Speed’s test (LHB impingement)
  • Ludlington’s test (LHB impingement)
  • Abduction
  • Dynamic impingement test (Allingham’s test)
  • Impingement test with local steroid
• Neurodynamic test (ULTT1)
• Cervical screening:
  • physiological with overpressure
  • Combined movements

7.  Palpation:

• Rotator cuff, LHB, A/C joint, muscle tone.
• Accessory joint movement – 3 key movements
• Quadrant & locking positions

8.  Neurological:

• Reflexes.
  • C5 – Deltoid
  • C5&6 – Biceps
  • C6 – Brachioradalis
  • C7 – Triceps
  • C8 – Pronator Quadratus
• Power.
  • C1&2 – Occipital flexion /extension
  • C2&3 – Cervical flexion / extension
  • C3&4 -  Shoulder girdle elevation
  • C5      -  Shoulder abduction
  • C5&6 -  Elbow flexion
  • C6      -  Wrist extension / rad. Dev.
  • C7      -  Elbow extension
  • C8      -  Thumb distal phalanx extension
  • T1       -  Fifth finger abduction

9.  Sports specific function:

• Serving action
• Swimming action
• Throwing
• Lifting

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: Abduction, Allingham’s test, anterior instability, anterior instability.Jerk test, Apprehension Test, crank test, Dynamic impingement test, GH translation (drawer), inferior instability, LHB impingement, Long head of Biceps, Ludlington’s test, plexus.flexion, posterior instability, Push – pull test, Relocation test, rotator cuff, Speed’s test, steroid, sub-acromial bursa, Sulcus test, uni or multidirectional instability

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