1. Supraspinatus TendinitisRAHILA NAJIHAH ALIDPH/0102/1130th MAY 2013

2. Skeletal Structure 3. Humans have a strong andwell developed clavicle thatacts as a lateral strut(support) to the scapula andthe humerus. This increase glenohumeralmobility to permit reaching& climbing activitiesLaura K.Smith, 1995, Brunnstroms Clinical Kinesiology, 5thEdition, Book Promotion & Service LTD 4. Scapulo-Humeral rhythm describes the timing of movement at thesejoints during shoulder elevation1st 30 of shoulder elevation :glenohumeral jt. : largescapulothoracic jt. : small & inconsistentafter 1st 30 of shoulder elevation :glenohumeral jt. & scapulothoracic jt. movesimultaneouslyratio : 2 : 1 Function :1) preserves the length-tension relationships ofthe glenohumeral muscles2) Prevent impingementLaura K.Smith, 1995, Brunnstroms Clinical Kinesiology, 5th Edition, BookPromotion & Service LTDhttp://moon.ouhsc.edu/dthompso/namics/scapryme.htm 5. Ligament & Capsule 6. Muscles 7. Supraspinatus Muscle Origin - supraspinous fossa of scapula Insertion - greater tubercle of humerus Action Assists deltoid muscle inabducting arm at shoulder jointJoseph E. Muscolino, . The Muscle and Palpation Manual with TriggerPoints, Refferal Patterns, and Stretching 8. Supraspinatus Tendon Most frequently irritated tendon of mostsuperior tendons of glenohumeral joint Vulnerability of this tendon toinflammation is due to its anatomicallocation 9. Supraspinatus Tendinitis Inflammation ofsupraspinatus tendon Most common affectedstructure in rotator cuffmuscle that lead todevelopment of pain dueto impingement inshoulder 10. Impingement Occur beneath coraco-acromialarch Most vulnerable structuresbetween undersurface ofacromion and head of humerusare greater tuberosity, theoverlying supraspinatus tendonand long head of biceps Major site of compression is slightlyanterior to angle of acromion Proper term is painful arcsyndromeJohn Ebnezar,2011, Essential of Orthopaedics for Physiotherapy, 2ndedition,India, Jaypee Brother 11. Painful Arc Syndrome painful arc occur on resistedabduction between 60 and120 degrees when theinflamed tendon pressesagainst the acromium outside of thisrange, abduction is painlessPatricia A.Downie,1983, Cashs textbook of Orthopaedics andrheumatology for physiotherapists, London, JP 12. Causes Repeated use of arm overhead inoccupation, functional or sports stresses Arm kept at the side or moved withhorizontally adducted position Over stress to tendon due to muscleweakness, tight muscle, tight capsule, orbony impingement Poor posture like kyphosis and shouldercomplex protraction Poor body mechanicOtto D.Payton, 1989, Manual of Physical Therapy, NewYork, Edinburgh, London, Churchill Livingstone 13. Signs Active movement produce painful arcwith coronal abduction Patient complain of pain discomfortwhen therapist do passive stretching ofsupraspinatus tendon Patient complain of pain when therapistdo resisted isometric contracture ofexternal rotation and both diagonal andcoronal abductionOtto D.Payton, 1989, Manual of Physical Therapy, NewYork, Edinburgh, London, Churchill Livingstone 14. Symptoms Pain or limited of ROM Pain at rest with highly reactivecondition Example- lying on side of dysfunction- sit in chair with too high arm rest Limitation of function with elevateddiagonal movementOtto D.Payton, 1989, Manual of Physical Therapy, NewYork, Edinburgh, London, Churchill Livingstone 15. Radiograph X-ray MRI 16. Treatment Transverse friction massage to thesupraspinatus tendon Use modalities to reduce inflammation likeultrasound, iontophoresis, phonophoresis, IFT andhigh voltage stimulation Educate in posture and body mechanics Stretch tight muscle Strengthen weak muscle Manipulate thigh capsuleOtto D.Payton, 1989, Manual of Physical Therapy, NewYork, Edinburgh, London, Churchill Livingstone 17. Transverse Friction MassagePosition of patient : sitting with hand ofinjured shoulder placed behind the backand relax the armPosition of therapist: Stand in behind ofthe clients shoulder to find thesupraspinatus tendonProcedure : videoVal Robertson, 2009, Electrotherapy Explainedprinciples and practise, 4th edition, China, Elsevier 18. Strengthening weak muscle Muscle that need to be strengthen:-external and internal rotators-deltoid-scapular stabilizers(rhomboids, trapezius, serratusanterior, latissimus dorsi) Do the proprioceptive neuromuscularfacilitation (PNF)http://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis 19. D1 Flexion pattern: shoulder flexion, elbow flexion, forearmsupination, wrist flexion, and finger flexion. D1 Extension pattern: shoulder extension, elbow extension, forearmpronation, wrist and finger extension. D2 Flexion pattern: shoulder flexion, elbow extension, forearmsupination, wrist extension, and finger extension. D2 Extension pattern: shoulder extension, elbow flexion, forearmpronation, wrist and finger flexionhttp://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis 20. Increase ROM pendulum exercises active assisted ROM exercises active exercises in all planes self-stretches concentrating mainly onposterior joint capsulehttp://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis 21. Manipulate tight capsule Joint mobilization of the shoulder joint inferior, anterior, and posterior glides ofshoulderhttp://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis 22. CASE STUDYSOAPIER 23. SubjectiveNAME : Madam YAGE : 63 years oldGENDER : FemaleOCCUPATION : HousewifeDOMMINANT HAND: Left handDATE OF ASSESSMENT : 22nd Mei 2013CHIEF COMPLAINT : Patient complaint pain at her leftshoulder when lifting up the left hand above the headlevel and try to lift heavy things. Patient also complaindifficulty in dressing especially when trying to wear braand take out her cloth. 24. PRESENT HISTORY : Patient had fall down about 4 weeks agodue to wet floor at a bank. She fall with outstretched lefthand. She only felt pain after 3 days prior to the injury. Shewent to traditional Chinese doctor and did massage but thepain became worse.PAST HISTORY : NILSOCIAL HISTORY : She stays with her husband and daughterat a terrace house in Kuala Lumpur. She takes care of herhusband that has Alzheimers disease since 12 years and alsodoes a lot of housework. Sometimes she takes her husbandfor morning walk around her housing area. Patient is a non-smoker and doesnt consume alcohol. 25. SPECIAL QUESTIONGeneral health : High blood pressure and depressionPMHx/Surgery : ankle sprain on 2006 and low back pain since2008Lx/X-Ray/MRI :i) X-Ray for ankle on 2006ii) MRI for whole body on 2008MEDICATION/STEROID : under medicationi) Patenolol 100mg 1 tablet, 2 times per day for high bloodpressureii) Patient taking another type of high blood pressuremedicine but does not remember its nameiii) Lexapio 5mg 2 tablet per day for depression 26. Pain assessmentSite : Anterior and posterior shoulder near to glenohumeral jointPain scale :4/10 when rest6/10 when lift up the hand above head level and carry heavythingsNature of pain : Pulling painAggravating factor : Lift up the hand above head level and carryheavy thingsEasing factor : Resting hand on the abdomen in internal positionof shoulderIrritability : Medium24 hours :am : No painpm : sometime disturb sleepOnset : Gradual 27. Body Chartxx X 28. Objective On observation- Body built : Medium- Deformities : NIL- Swelling : mild swelling around the left shoulder- Posture : Slightly kyphotic On palpation- Spasm : on the anterior and posterior part of leftshoulder- Warmth : no- Tightness : on anterior part of left shoulder 29. On examination (Range of motion )1) Shoulder*( )-degree where patient start feel painpatient feel pain when do the flexion, extension, abduction and medialrotation of left shoulderall action of right shoulder is FROMACTIVE PASSIVE ACTION ACTIVE PASSIVE0-180 0-180 Flexion 0-160 (150) 0-1700-60 0-60 Extension 0-50 (30) 0-600-180 0-180 Abduction 0-165 (70-120)0-170Adduction0-80 0-80 MedialRotation0-70 (60) 0-800-90 0-90 LateralRotation0-90 0-90Right Left 30. 2) ElbowThe ROM of right and left elbow joint is FROMTheres no complain of pain when do all the movementACTIVE PASSIVE ACTION ACTIVE PASSIVE0-140 0-140 Flexion 0-140 0-140140-0 140-0 Extension 140-0 140-00-80 0-80 Pronation 0-80 0-800-80 0-80 Supination 0-80 0-80Right Left 31. 3) WristThe ROM of wrist joint is FROMtheres no complain of pain when do all themovementsACTIVE PASSIVE ACTION ACTIVE PASSIVE0-70 0-70 Flexion 0-70 0-700-60 0-60 Extension 0-60 0-600-20 0-20 Ulnar dev. 0-20 0-200-30 0-30 Radial dev. 0-30 0-30Right Left 32. Muscle girth*Differences of the muscle girth are 0.5 cm. Theres no musclewastingMUSCLE MEASUREMENT (RIGHT) MEASUREMENT (LEFT)DELTOID 31.5 CM 31.0 CMBICEPS 30.5 CM 30.0 CMTRICEPS 29.5 CM 29.0 CMBRACHIALRADIALIS 23.0 CM 22.5 CM 33. Muscle Power (Shoulder)MUSCLE ACTION RIGHT LEFTAnterior Deltoid &CoracobranchialisFLEXION 4/5 3/5Latisimus Dorsi,Teres Major,Posterior DeltoidEXTENSION 4/5 3/5Middle Deltoid &SupraspinatusABDUCTION 4/5 3/5Pectoralis Major ADDUCTION 4/5 3/5Subscapularis MEDIALROTATION4/5 3/5Infraspinatus &Teres MajorLATERALROTATION4/5 3/5 34. Special TestTEST RESULTNeer Impingement Test NegativeHawkins-kennedy Impingement Test NegativeEmpty Can Test Positive 35. Analysis Physiotherapy impression- pain at the anterior and posterior site of left shoulder-reduce full ROM of left shoulder due to pain-reduce muscle power in left hand due to weakness-left Supraspinatus tendinitis GoalsShort Term Goal- To reduce pain at the left shoulder- To increase range of motion of flexion, extension, abduction and medialrotation of left shoulder- Improve the muscle power of left shoulderLong Term Goal- To improve functional activity of daily life ( patient can take care of herhusband and able to do housework with no pain ) 36. Plan of treatment- Pain relief- Soft tissue manipulation- Home program exercise- Patient education 37. Intervention1) Pain releif Interferential therapysite : around the left shoulderposition of patient : sitting with shoulder in relax positionprocedure : apply 4 pole at left shoulderduration: 10 minutespurpose : relieve pain Ultrasoundsite : anterior site of the left shoulderposition of patient : sits with his arm behind the back in medial rotationduration : 5 minutespurpose : promote healing process Crayo cuffsite : left shoulderposition : sit with the shoulder in relax positionduration :10 minutespurpose : to reduce swelling 38. 2) Soft tissue manipulation Superficial soft tissue manipulationsite: around the left shoulderprocedure : apply Repairil and Ultimax gel around the leftshoulderpurpose : relaxing the muscle Transverse friction massageSite : anterior to acromion processDuration : 5 minutesPosition of patient : patient sits with his arm behind the back inmedial rotationProcedure : index finger of the ipsilateral hand, reinforced by themiddle finger. The thumb should be placed quite far down thearm. So that a downward pressure is exerted on the greatertuberosity, the index finger-nail remaining horizontal.Purpose : to break the adhesion around the joint 39. Contd.3) Home program exerciseStretching the Supraspinatus muscleposition of patient : sitting or standingaction : patients left hand is extended andadducted behind the bodyrepetition : 10 repetition 3 times daily 40. 4) Patient education Put ice on swelling part of the shoulder Avoid heavy lifting Rest the affected shoulder Dont lean on affected side duringsleeping Avoid sudden movement of the affectedshoulder 41. Evaluation Patient fell better after do thetreatments Patient able to lift up the hand over thehead with less pain after TransverseFriction Massage at the shoulder jointReview Reassess ROM , muscle girth for next visit Review the muscle power 42. First follow up 43. Date of assessment : 27th may 2013Complain : patient is complain of pain increase due to lift the wheel chairinto the carPain scale :5/10 when rest7/10 when lift up the hand above head level and carry heavy thingsOn observationSwelling : mild swelling around the left shoulderOn palpation- Warmth : no- Tightness : on anterior part of left shoulder 44. On examination (Range of motion )1) Shoulderright left*( )-degree where patient start feel painpatient feel pain when do the flexion, extension, abduction and medial rotationof left shoulderall action of right shoulder is FROMACTIVE PASSIVE ACTION ACTIVE PASSIVE0-180 0-180 Flexion 0-160 (150) 0-1700-60 0-60 Extension 0-50 (30) 0-600-180 0-180 Abduction 0-165 (70-120)0-170Adduction0-80 0-80 MedialRotation0-70 (60) 0-800-90 0-90 LateralRotation0-90 0-90 45. 2) elbow-the movements are FROM-theres no complain of pain when do themovements 3) wrist-the movements are FROM-theres no complain of pain when dothe movements 4) Spasm : on the anterior and posteriorpart of left shoulder 46. Muscle Power (Shoulder)MUSCLE ACTION RIGHT LEFTAnterior Deltoid &CoracobranchialisFLEXION 4/5 3/5Latisimus Dorsi,Teres Major,Posterior DeltoidEXTENSION 4/5 3/5Middle Deltoid &SupraspinatusABDUCTION 4/5 3/5Pectoralis Major ADDUCTION 4/5 3/5Subscapularis MEDIALROTATION4/5 3/5Infraspinatus &Teres MajorLATERALROTATION4/5 3/5 47. Analysis Physiotherapy impression- pain at the anterior and posterior site of left shoulder-reduce full ROM of left shoulder due to pain-reduce muscle power in left hand due to weakness-patient did not do the stretching that had taught by therapist Goalsshort term goal- To reduce pain of the left shoulder- To increase range of motion the flexion, extension, abduction and medialrotation of left shoulder- Improve the muscle power of the left shoulderLong Term Goal- To improve functional activity of daily life ( patient can take care of herhusband and able to do housework with no pain ) 48. Plan of treatment- Pain relief- Soft tissue manipulation- Home program exercise- Patient education 49. Intervention1) Pain relief Interferential therapysite : around the left shoulderposition of patient : sittingprocedure: apply 4 pole at left shoulderduration: 10 minutespurpose : relieve pain Ultrasoundsite : anterior site of the left shoulderposition of patient : sittingduration : 5 minutespurpose : promote healing process Crayo cuffsite : left shoulderposition : 10 minutespurpose : to reduce swelling 50. 2) Soft tissue manipulation Superficial soft tissue manipulationsite: around the left shoulderprocedure : apply Repairil and Ultimax gel around the leftshoulderpurpose : relaxing the muscle Transverse friction massageSite : between glenohumeral jointDuration : 5 minutesPosition of patient : patient sits with his arm behind the back inmedial rotationProcedure : index finger of the ipsilateral hand, reinforced by themiddle finger. The thumb should be placed quite far down thearm. So that a downward pressure is exerted on the greatertuberosity, the index finger-nail remaining horizontal.Purpose : restoring mobility to muscles 51. Contd.3) Home program exerciseStretching the Supraspinatus muscleposition of patient : sitting or standingaction : patients left hand is extended andadducted behind the bodyrepetition : 10 repetition 3 times daily 52. 4) Patient education Avoid heavy lifting Rest the affected shoulder Dont lean on affected side duringsleeping Avoid sudden movement of the affectedshoulder Therapist emphasize the importance ofstretching 53. Evaluation Patient fell better after do the treatment Patient able to lift up the hand over thehead with less pain after TransverseFriction Massage at the shoulder jointReview Reassess ROM , muscle girth for next visit Review the muscle power 54. Second follow up 55. Date of assessment : 29th may 2013complain : patient fell pain decreasePain scale :3/10 when rest5/10 when lift up the hand above head level and carry heavy thingsOn observationSwelling : mild swelling around the left shoulderOn palpation- Spasm : on the anterior and posterior part of left shoulder- Warmth : no- Tightness : on anterior part of left shoulder 56. On examination (Range of motion )1) Shoulderright left*( )-degree where patient start feel painpatient feel pain when do the flexion, extension, abduction and medial rotationof left shoulderall action of right shoulder is FROMACTIVE PASSIVE ACTION ACTIVE PASSIVE0-180 0-180 Flexion 0-160 (150) 0-1700-60 0-60 Extension 0-50 (30) 0-600-180 0-180 Abduction 0-165 (70) 0-170Adduction0-80 0-80 MedialRotation0-70 (60) 0-800-90 0-90 LateralRotation0-90 0-90 57. 2) elbow-the movements are FROM-theres no complain of pain when do themovements 3) wrist-the movements are FROM-theres no complain of pain when dothe movements 58. Muscle Power (Shoulder)MUSCLE ACTION RIGHT LEFTAnterior Deltoid &CoracobranchialisFLEXION 4/5 3/5Latisimus Dorsi,Teres Major,Posterior DeltoidEXTENSION 4/5 3/5Middle Deltoid &SupraspinatusABDUCTION 4/5 3/5Pectoralis Major ADDUCTION 4/5 3/5Subscapularis MEDIALROTATION4/5 3/5Infraspinatus &Teres MajorLATERALROTATION4/5 3/5 59. Analysis Physiotherapy impression- pain at the anterior and posterior site of left shoulder-reduce full ROM of left shoulder due to pain-reduce muscle power in both hand due to weakness- patient did not do the stretching that already taught by therapist Goalsshort term goal- To reduce pain- To increase range of motion- Improve the muscle powerLong Term Goal- To improve functional activity of daily life 60. Plan of treatment- Pain relief- Soft tissue manipulation- Home program exercise- KIV shoulder exercise- Patient education 61. Intervention1) Pain relief Interferential therapysite : around the left shoulderposition of patient : sittingprocedure: apply 4 pole at left shoulderduration: 10 minutespurpose : relieve pain Ultrasoundsite : anterior site of the left shoulderposition of patient : sittingduration : 5 minutespurpose : promote healing process Crayo cuffsite : left shoulderposition : 10 minutespurpose : to reduce swelling 62. 2) Soft tissue manipulation Superficial soft tissue manipulationsite: around the left shoulderprocedure : apply Repairil and Ultimax gel around the leftshoulderpurpose : relaxing the muscle Transverse friction massageSite : between glenohumeral jointDuration : 5 minutesPosition of patient : patient sits with his arm behind the back inmedial rotationProcedure : index finger of the ipsilateral hand, reinforced by themiddle finger. The thumb should be placed quite far down thearm. So that a downward pressure is exerted on the greatertuberosity, the index finger-nail remaining horizontal.Purpose : restoring mobility to muscles 63. Contd.3) Home program exerciseStretching the Supraspinatus muscleposition of patient : sitting or standingaction : patients left hand is extended andadducted behind the bodyrepetition : 10 repetition 3 times daily 64. 4) Patient education Avoid heavy lifting Rest the affected shoulder Dont lean on affected side duringsleeping Avoid sudden movement of the affectedshoulder 65. Evaluation Patient fell better after do the treatment Patient able to lift up the hand over thehead with less pain after TransverseFriction Massage at the shoulder jointReview Reassess ROM , muscle girth for next visit Review the muscle power 66. Reference Laura K.Smith, 1995, Brunnstroms Clinical Kinesiology, 5thEdition, Book Promotion & Service LTD Joseph E. Muscolino, . The Muscle and Palpation Manualwith Trigger Points, Refferal Patterns, and Stretching John Ebnezar,2011, Essential of Orthopaedics forPhysiotherapy, 2nd edition,India, Jaypee Brother Patricia A.Downie,1983, Cashs textbook of Orthopaedicsand rheumatology for physiotherapists, London, JP Otto D.Payton, 1989, Manual of Physical Therapy, NewYork, Edinburgh, London, Churchill Livingstone Val Robertson, 2009, Electrotherapy Explained principlesand practise, 4th edition, China, Elsevier http://morphopedics.wikidot.com/physical-therapy-management-of-supraspinatus-tendinitis http://moon.ouhsc.edu/dthompso/namics/scapryme.htm