Rotator Cuff Tendinopathy - Physiotherapy Alberta Rotator Cuff Tendinopathy Tendinopathy Partial thickness

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  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    1

    Lori Michener, PhD, PT, ATC, SCS, FAPTA Director of Clinical Outcomes and Research

    Director – COOR Lab University of Southern California; Los Angeles, CA

    lmichene@pt.usc.edu http://pt.usc.edu/COOR/

    Differential Diagnosis of Rotator Cuff Disease

    COOR Lab

    @LoriM_PT

    Rotator Cuff Tendinopathy Tendinopathy  Partial thickness RC tear  Full Thickness RC tear • Tendinopathy • Partial thickness RC tear

    – Articular, bursal, mid-substance • Full-thickness RC tear

    – Complete rupture superior to inferior – Not necessarily side to side – “Hole’ in the sock

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    2

    Rotator Cuff Tendinopathy

    • Full-thickness RC tear

    • Partial thickness RC tear

    • Tendon pathology without tear

    • Subacromial impingement

    Single clinical  diagnostic category:

    Subacromial  pain syndrome

    COOR Lab @ USC @LoriM_PT

    Tendon  Pathology

    What’s in a name…. • ‘subacromial impingement’

    – Limited support for compression mechanism – Perpetuates flawed reasoning & treatment

    • Subacromial Pain Syndrome (SPS) – Allows for uncertainty of the pain generator:

    tendons, bursae, biceps, CNS, other… – Allows for mechanisms other than impingement

    • Other names – ex: RC Related Shoulder Pain

    COOR LabCOOR Lab @ USC @LoriM_PT

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    3

    Supraspinatus Tendon

    Tendon overload & Degeneration

    Mechanical Compression in

    SA Space

    Subacromial Impingement Syndrome RCT 2 predominant theories

    If mechanical compression is the predominant mechanism, then….

    … ALL would benefit from an acromioplasty • Acromioplasty + rehab was not clinically more

    beneficial than rehab alone in multiple trials (Brox et al; 1993, 1999; Haahr, 2005, 2006; Ketola S, 2009, 2013)

    • Bony pathology is not the only mechanism • ‘Impingement’ – May not be an appropriate

    label (Cools AM and Michener LA, BJSM, 2017)

    COOR LabCOOR Lab @ USC @LoriM_PT

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    4

    Mechanisms of RC (Tendon) Disease

    • Mechanisms: – Overload and Compression

    • Factors contributing to the mechanisms: – Intrinsic factors – within the tendon – Extrinsic factors – external to the tendon – Other factors –

    • Personal and Environmental factors

    COOR LabCOOR Lab @ USC @LoriM_PT

    Intrinsic factors: Within the tendon

    Vascularity Morphology Mechanical

    Aging Genetics

    SA space- impingement??

    RCD

    Extrinsic factors: Strength/ m. control Tightness & Laxity Posture: spine, sh Bony abnormalities

    Scap & GH kinematics Neurophysiological

    Brain / CNS

    Load Load

    COOR Lab @ USC

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    5

    Tendon overload • Neovascularization?

    • Conflicting evidence (Lewis J, 2009; Kardouni JR, 2013)

    • Is the tendon painful?

    Tendon Degeneration with Overload • Inflammation present (Dean BJ, BJSM; 2015) • Abnormal collagen laydown • Tendon thickens initially  then thins

    • Thicker in SPS (Michener LA, 2015; Joensen J, 2009; Leong HT, 2012) • Thins with progressive tendon disease • *Thickens response to use

    Overhead athletes, Spinal Cord Injuires (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    6

    Is compression in the SA Outlet causing tendon changes?

    Compression or ‘impingement’ of RC tendons

    - Subacromial (SA) space

    SA space measured

    Scapular al, 2012)

    AHD= acromiohumeral distance 10 – 15 mm in healthy

    AHD

    Tendon compression – is it possible?

    SA space and shoulder pain: – Space is smaller:  AHD in ‘impingement’

    (Hekimoglu B, 2013; Leong H-T, 2012; Seitz AL, 2011, Hebert LJ, 2003, Graichen H, 1999)

    – Tendon is thicker: initially with disease & ‘overuse’ – Occupation ratio > : supraspinatus tendon: AHD

    • ‘Impingement’: tendon occupies > amount of AHD (Michener LA, 2013)

    • Overhead athletes & Spinal Cord Injury (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)

    COOR Lab @ USC @LoriM_PT

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    7

    Tendon compression – is it possible?

    • Compression observed– cadaveric (Hughes PC, et al, 2012) • Compression risk:

    – Smallest AHD: supraspinatus tendon 0 - 60° Smallest AHD: tendon footprint 30 - 90° (Lawrence R, JOR, 2017)

    – Tendon is not ‘available’ for compression (under the acromion) above ~ 70 elevation (Giphart JE, 2012; Thompson MD, 2011; Bey MJ, 2007)

    Tendon compression may occur @ < 70°

    COOR Lab @ USC @LoriM_PT

    Glenohumeral impingement

    • Posterior / Internal – Compression between the

    posterior glenoid and the humeral head

    – Described in overhead athletes

    – Recent evidence – maybe in non-overhead athletes (Lawence R, Ludewig P, et al; CSM, 2017)

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    8

    European Society of MSK Radiology: Shoulder MSK Technical Guidelines

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    9

    So is it compression or is it degeneration?

    • Both compression AND degeneration are causes – Less support for compression

    COOR LabCOOR Lab @ USC @LoriM_PT

    Rotator Cuff Tendinopathy: What’s the Evidence for Diagnosis?

    • Subacromial Pain Syndrome (SPS) – SPS – Partial- thickness RC tears

    • Full-thickness Rotator Cuff Tear (FT-RCT)

    COOR LabCOOR Lab @ USC @LoriM_PT

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    10

    Key Metrics for Dx Accuracy

    • Diagnostic Accuracy values: – Sensitivity – Specificity – PPV: Predictive value of a positive test – NPV: Predictive value of a negative test – LR+: Positive likelihood ratio – LR- Negative likelihood ratio

    COOR Lab

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    11

    Sensitivity and Specificity • Sensitivity

    • SnNOut = When Sn is high, a Negative test rules Out the disease

    • Specificity (SpPIn) • SpPIn = When Sp is high, a Positive test rules In the

    disease.

    • Interpretation: • Indicates if a test s or s disease probability • BUT: No set cut-off to quantify shift in probability

    COOR Lab

    Likelihood Ratios

    • More helpful for Dx • Indicate by how much a given diagnostic test

    result will  or  the probability of the disease. • Quantify shifts in probability of the diagnosis

    • Ex: +LR= 5: a patient with a + test is 5x more likely in a patient with the disease as compared to a patient without the disease

    • Minimal affect of prevalence

    COOR Lab

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    12

    Likelihood Ratio “+” “—”

    Interpretation

    >10

  • Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

    2/12/2018

    13

    Recommendations for Diagnostic Values Interpretation

    Screen