Question A patient presents with a chronic injury to the tendon of supraspinatus following a fall onto the point of shoulder several months earlier.
Supraspinatus A muscle that connects the scapula to the humerus Origin: Supraspinous fossa of the scapula Insertion: Greater tuberosity of humerus Action: Abduction of the arm (early range & following that is done by anterior fibers of deltoid) Also stabilizes shoulder joint as it is part of the rotator cuff muscles
Supraspinatus as a Rotator cuff Muscle Tendon fuse into the underlying capsule of the shoulder joint Plays an important role in stabilizing the shoulder joint Tone of muscle assists in holding the head of humerus in the glenoid cavity of scapula during shoulder joint movements
How long has the pain been Onset- Months What movements trigger pain To confirm that the movement is abduction of arm as it is the specific movement carried out What daily activities trigger pain To find out what ADL(s) it affects Find out if patient plays sports and if it is swimming or throwing sports Pain Intensity To plan out type of exercise and treatment Questions to ask the patient/ Complaints
Objective Assessment Look out for Swelling or Oedema AROM/PROM- AROM first, then PROM. Assess if movement inhibited by pain, impingement, tightness etc Pain Rating Muscle Strength Palpation- Check for painful spots, muscle tightness, muscle wasting
Goals Short-term goal Increase range of motion (abduction); active range Pain relief Long-term goal Restore to full range of motion (abduction) Permanent pain relief
Selection of Modalities Cryotherapy VS Heat Therapy Injury is chronic Cryotherapy is more suited for acute and sub-acute stage Heat therapy is more suited for chronic stage as… Useful for pain relief, swelling and inflammation in the chronic stage Therefore, heat modalities are recommended
Advantages of thermal effects Promotes relaxation Relief pain Increase blood flow Facilitate healing Prepare stiff joints and tight muscles for exercise
Modalities Temperature Change Penetration Depth Heat pack 2-5 Degrees 1-2 cm (Max) Paraffin Wax 2-5 Degrees 1-2cm (Max) Infra-red 5-6 Degree 1-2mm 3mm on sole and palm SWD Condensor- 5 Degrees Inductor- 7-8 Degrees Depend on arrangement MWD 5-7 Degrees 3 cm Ultrasound 8 Degrees 3MHZ- 16mm 1MHZ- 50mm
Possible modalities Ultrasound Short wave Diathermy Microwave Nature of modality Conversive heat modalities Penetration Depth Depth of 5cm or more 4cm is the greatest absolute heating of deep tissues More superficial than SW; 3-4cm Temperature change Up to 8 deg 5 (condensor) 7-8 (inductor) 5-7 deg Duration of Temperature Change about 30-45 minutes for alll Physiological effects Reduce pain & muscle spasm Reduce pain, muscle spasm, stiffness, oedema Reduce pain, muscle spasm, soften tissues, accelerate healing
Best Modality of Choice Ultrasound Thermal effect as patient presents chronic injury Has deep penetration depth Long Duration of temp change High absorption by tendons Easy to be match contours of shoulder Provides sufficient coverage for a small tissue like a tendon
List of Contraindications Cardiac pacemakers Patient is expecting Area is ischemic Thrombosis Phlebitis Metallic implants in treatment area Metallic effects on or near treatment area
Before treatment Hot/Cold Test and sharp/blunt test Give patient standard warning During treatment, all you should feel is a mild comfortable warmth. If you feel, any thing hotter, if you feel the heat concentrating in one area, or a sharp pain, you are in danger of being burnt. Alert me when this occurs and during treatment, don’t move, don’t fall asleep and don’t touch anything. Got it?
Method of Application Direct Contact using ultrasound gel as a coupling medium Soundhead is in contact with skin Suitable for treating area where surface being treated is larger than soundhead Not using immersion technique as it is not convenient to be used on the shoulders Not using gel pads (as another medium) as effects are superficial.
Area applied As tendon of supraspinatus is at the greater tuberosity of humerus, the area of modality applied will be at that area.
Duration & Dosage As it is a chronic condition, 0.8-3.0 W/cm2 1mHz (for deep penetration) Continuous for 7 minutes mild to comfortable warmth.
Desired Physiological effects Increase vasodilatation; promotes blood flow and facilitate healing Decrease pain; by decreasing nerve conduction velocity
Progression of Treatment Recommend patient to come on a weekly basis Each visit, we’ll take note of patient’s ROM and pain rating If shows improvement, we’ll continue with treatment.
Progression of Treatment Encourage mobility exercises (targeting the shoulder abduction) to the limit of motion before onset of pain Prevent further decrease in active range of motion.
Progression of Treatment Once pain subsides, we will recommend stretching and strengthening exercises to increase ROM as much as possible and restore functional strength Ie. Using therapy bands and light weights for shoulder abduction