Rotator Cuff Strain and Carpal Tunnel Syndrome

  5 minutes: Attendance and Breath of Arrival

  50 minutes: Problem-Solving: SG, Arms, and Hands

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o  Be ready to learn by the start of class, we'll have you out of here on time

o  Tardiness: arriving late, late return after breaks, leaving early

The following are not allowed:

o  Bare feet

o  Side talking

o  Lying down

o  Inappropriate clothing

o  Food or drink except water

o  Phones in classrooms, clinic or bathrooms

You will receive one verbal warning, then you'll have to leave the room.

Rotator Cuff Strain and Carpal Tunnel Syndrome

What four muscles could be involved in a rotator cuff strain?

o  Supraspinatus, infraspinatus, teres minor, and subscapularis

What are two onset patterns for rotator cuff strain?

o  Chronic onset: progressive degeneration. Partial-thickness tears

o  Acute onset: high force loads. Full-thickness tears

How many muscles can be involved in a rotator cuff strain?

o  Usually just one or two

o  Rarely are all four are involved

o  Subscapularis is rarely involved because there are several larger

muscles that perform the same actions and provide support

How is a strain assessed in the rotator cuff?

o  Suprapinatus: pain during resisted glenohumeral abduction

o  Infraspinatus / Teres minor: pain during glenohumeral lateral rotation

o  Subscapularis: pain during glenohumeral medial rotation

What are some traditional treatments for a rotator cuff strain?

o  Physical therapy (stretching, strengthening, and ultrasound)

•  Variable effectiveness

o  Corticosteroid injection

•  Variable effectiveness

o  Surgery

•  Most common is subacromial decompression for supraspinatus

Which muscles should be addressed for strain of any rotator cuff muscle?

o  All four rotator cuff muscles in a combined protocol

What bony structures may be involved in a supraspinatus strain?

o  Underside of the acromion process

o  Superior surface of the humerus

What are the results of subacromial compression?

o  Tendinosis of the supraspinatus

How does naturally decreased vascularity near the supraspinatus

insertion effect a strain?

o  Slower healing time

o  Increased risk of tendinosis

Calcific tendinitis Calcium deposits in the tendon. Tendinosis may allow

this to occur. Most common in supraspinatus.

What action commonly leads to an infraspinatus and teres minor strain?

o  During throwing motions involving medial rotation of the glenohumeral

joint, the infraspinatus and teres minor eccentrically contract to decelerate the

arm after release of the ball.

What can lead to tendinosis of the infraspinatus and teres minor muscles?

o  Overuse

o  Overloading

o  Strain

What serious injury often accompanies a subscapularis strain?

o  Glenohumeral dislocation

Prone Upper back myofascial release Deep effleurage Trapezius and deltoid Swedish Supraspinatus, infraspinatus, and teres minor stripping Infraspinatus and teres minor AMT stripping Trigger point deactivation Supraspinatus insertion tendon deep transverse friction Infraspinatus and teres minor stretching

Supine Deep Massage Anterior deltoid Swedish Subscapularis trigger point deactivation and friction Subscapularis stretching

Upper back myofascial release

o  Arms crossed: place hands 10 inches apart on either side of the spine

o  Apply a light degree of pulling force between the hands o  Hold this position and wait for a subtle sensation of tissue release or a

working sign

o  Slowly release and repeat (between the T1 and T10)

Deep effleurage

o  Trapezius: use one loose fist to work origins to insertions

o  Posterior deltoid: use two fists to work transversely and laterally

o  Infraspinatus and teres minor: use two loose fists toward insertions

o  Repeat to treat all fibers of all three muscles

Trapezius and deltoid Swedish

o  Effleurage

o  Pulling and wringing

o  Kneading (upper trapezius and deltoid)

o  Raking (middle trapezius)

o  Shoulder mobilization BMT

o  Longitudinal stripping

Supraspinatus, infraspinatus, and teres minor stripping

o  Use thumbs, fingertips, or loose fists

o  Strip longitudinally from origins to insertions

Infraspinatus and teres minor AMT stripping

o  Bring the client into “Cactus position” on one side:

•  Shoulder abducted 90°, elbow flexed 90°

•  Shoulder laterally rotated as far as comfortable

o  Instruct the client:

•  “Hold this position for 5 seconds”

•  “Medially rotate the shoulder slowly”

o  As the client does this, strip longitudinally origin to insertion o  Repeat Hold-Rotate-Strip to address all fibers

Trigger point deactivation

o  Hang the client’s arm off the side of the table

o  Use fingertips or thumbs

o  Target areas of tension that were palpated or reported by the client

o  Use the steps of the fulcrum to melt for about 10 seconds each

o  Variation: add slight passive medial and lateral shoulder rotation

Supraspinatus insertion tendon deep transverse friction

o  Use fingertips or thumb

o  Work just inferior to the lateral edge of the acromion process o  Use moderate pressure, for 1 minute

Infraspinatus and teres minor stretching

o  Joint mobilization: particularly medial and lateral rotation

o  Instruct the client:

•  “Place the back of your hand on your low back”

•  “Adduct your arm so that it is touching your torso”

•  “Let me know when you feel a good stretch”

o  Gently but firmly press the scapula so that it lies flat on the ribcage with one

hand

o  Press elbow toward the floor with the other hand

o  Hold for three of your breaths and slowly release

Deep Massage o  Trapezius (addressing supraspinatus)

o  Pectoralis major

Anterior deltoid Swedish

o  Effleurage, kneading, fulling, stripping longitudinally and distally

Subscapularis trigger point deactivation and friction o  Bring the client into this position:

•  Abduct the shoulder 90° •  Flex the elbow 90° with hand pointing toward the ceiling

o  Hold the client’s arm in this position with one hand o  Work on the accessible distal fibers in the posterior axilla

•  Contact the lateral surface of the ribs near the axilla •  Move posteriorly and medially onto the subscapularis fibers •  Press posteriorly into the fibers compressing the subscapularis into the

scapula. o  Use the steps of a fulcrum to hold points for 10 seconds each o  Variation: client may perform small active medial and lateral shoulder

rotation movements while pressure is maintained on the muscle o  Finally, perform deep transverse friction with emphasis on longer duration,

but moderate pressure

Subscapularis stretching

•  Mobilize the shoulder joint

•  Bring client into this position:

•  Abduct shoulder 90°

•  Flex elbow 90°

•  Instruct the client:

•  “Let me know when you feel a good stretch”

•  Traction the humerus distally with one hand

•  Laterally rotate shoulder with the other hand

•  Hold for three of your breaths and slowly release

o  First assess which muscle or muscles are torn. Accurate assessment is

essential to determine the severity. Avoid vigorous deep friction on a recent

or severe injury.

o  Advise the client to cease or rest from any offending activities.

o  Treat all muscles of the shoulder area to regain biomechanical balance.

o  Supraspinatus is more difficult to access, but can be addressed.

o  Subscapularis is rare and mostly inaccessible. The distal tendon is an

accessible and common site of strain.

o  Stretching, joint mobilization, and activity modifications can reduce stress on

damaged tissues allowing the soft tissue techniques to succeed.

o  Topical thermotherapy is not effective for the deeper supraspinatus and

subscapularis, but can be effective for infraspinatus and teres minor.

o  If the client is receiving other treatment methods such as physical therapy,

injections, or surgery, communicate with the other practitioners to ensure that

the treatment plans are all compatible.

What structures form the carpal tunnel?

o  Proximal row of carpals from lateral to medial:

•  Scaphoid, lunate, triquetrum, pisiform

•  “Steve Left The Party”

o  Distal row of carpals from lateral to medial:

•  Trapezium, trapezoid, capitate, hamate

•  “To Take Cathy Home”

o  Transverse carpal ligament (AKA: TCL, or wrist flexor retinaculum)

What structures pass through the carpal tunnel?

o  Flexor pollicis longus (1 tendon)

o  Flexor digitorum superficialis (4 tendons)

o  Flexor digitorum profundis (4 tendons)

o  Median nerve

Explain the causes of carpal tunnel syndrome.

o  Overuse of extrinsic finger and wrist flexors leading to tenosynovitis

o  Adhesion or inflammation between a tendon and its synovial membrane

increases the size of the tendon sheath causing compression of the median

nerve

What occupations increase risk of carpal tunnel syndrome?

o  Data entry

o  Factory worker

o  Packaging worker

o  Janitorial and cleaning jobs

What are some symptoms of carpal tunnel syndrome?

o  Paresthesia (sensation of pins and needles), numbness, and pain in the skin of

the first three and a half fingers

o  Clumsiness (when severe)

o  Loss of dexterity (when severe)

o  Weakening of grip strength (when severe)

Why are symptoms often exacerbated at night?

o  Wrist flexion while sleeping increases carpal tunnel compression

What are some traditional treatments for carpal tunnel syndrome?

o  Ergonomic intervention

•  Effective: wrist braces and supports, altered work schedules, variety of

work activities, and tool design

o  Reduction of offending activities

•  Effective

What are some traditional treatments for carpal tunnel syndrome? o  Pharmaceuticals (corticosteroid injection, oral steroids, NSAIDs,

diuretics)

•  Variable effectiveness

o  Wrist splints at night

•  Effective

o  Surgery •  Variable effectiveness: incision on the flexor retinaculum to

relieve compression on the median nerve

Seated during intake Transverse carpal ligament myofascial release

Prone Forearm flexor deep massage Forearm flexor Swedish

Supine Forearm flexor stripping Forearm flexor stripping with active movement Flexor pollicis brevis stretch Median nerve mobilization

Transverse carpal ligament myofascial release

•  Only for conditions with mild to moderate symptoms

•  Begin to full the TCL

•  Stop just beyond the scaphoid/trapezium and pisiform/hamate and

hold it for 20 seconds

•  Monitor for a subtle sensation of release that you feel or that is

reported by the client.

Forearm flexor deep massage

o  Place the arm palm up with slight flexion in the elbow

o  Support the elbow by holding it in one hand and rest it on the table

o  Use a loose fist to effleurage myofascially and distally

o  Lighten up on distal 1/3 of forearm

o  Repeat. Progress from light to moderate to firm pressure

Forearm flexor Swedish o  Effleurage (upbeat, hand-over-hand ), fulling and kneading

Forearm flexor stripping o  Strip longitudinally by pulling distally using thumbs

Forearm flexor stripping with active movement

o  Begin using a loose fist. Progress to fingertips or thumbs

o  Lie forearm on the table palm up with hand hanging off the side

o  Instruct the client: “Slowly alternate between finger and wrist flexion

and extension”

o  During extension, strip longitudinally and proximally

o  Cover only 2-4 inches per extension

Flexor pollicis brevis stretch

o  Pull the client’s wrist into hyperextension with one hand

o  Stretch the client’s thumb into full extension with the other

o  Hold for three of your breaths, slowly release

Median nerve mobilization

o  To allow free movement of the nerve in the carpal tunnel

o  Only do this in the later stages of rehabilitation

o  Bring client into this position:

•  Abduct shoulder 90°

•  Fully extend the elbow

•  Hyperextend the wrist

o  Slacken the nerve slightly and return it to a fully stretched position

o  Do not hold this stretch, but repeat the activity multiple times

o  Symptoms may recur at the fully stretched position

o  Treat the hypertonicity in wrist and hand flexors, and avoid any aggravating

pressure to the median nerve.

o  Stretch forearm flexor muscles to reduce hypertonicity and overuse irritation.

o  Treat the entire upper extremity to reduce tension that may contribute to

biomechanical dysfunction.

o  Nerve damage is slow to heal. Immediate or rapid relief can occur, but

complete resolution of the condition can be slow and gradual.

o  If the condition is severe or symptoms are magnified, adjust the pressure,

duration, and intensity of the treatment to avoid exacerbating the condition.

o  Use caution with any technique that aggravates symptoms.

Rotator Cuff Strain and Carpal Tunnel Syndrome