Injured Rotator Cuff of the Shoulder

The shoulder joint (and its connective muscles, tendons, and ligaments) has a greater range of motion than all other joints. It can allow your arm to move outward to the side, forward and back, do circles in a windmill fashion, and rotate your arm from palm up to palm down. No other joint allows all these movements.

However, the complex anatomical structure that allows such flexibility of movement also makes the shoulder joint somewhat susceptible to injury. The cluster of muscles and connections that facilitates this movement is called the rotator cuff. 

    The muscles of the rotator cuff are:

• Teres minor 
  
• Subscapularis

• Infraspinatus  

•    Supraspinatus (SITS) muscles, helps stabilize the humeral head in the glenoid fossa of the scapula during overhead arm motions (eg, pitching, swimming, weightlifting, serving in racket sports)

 These muscles control the shoulder girdle and its movement. Injury can occur when muscles are strained, torn, or inflammation occurs in the joint as a result of damage.

Description:

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved.

There are different types of tears.

• Partial Tear. This type of tear damages the soft tissue, but does not completely sever it.
   
• Full-Thickness Tear. This type of tear is also called a complete tear. It splits the soft tissue into two pieces. In many cases, tendons tear off where they attach to the head of the humerus. With a full-thickness tear, there is basically a hole in the tendon
  
  
  
  
  

           A rotator cuff tear most often occurs within the tendon.

Cause:

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear:

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear:

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater risk for a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

• Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.

• Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.

• Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

      

 Tendinitis  typically results from chronic impingement of the supraspinatus tendon between the humeral head and coracoacromial arch (the acromion, acromioclavicular joint, coracoid process, and coracoacromial ligament). Activities that require the arm to be moved over the head repeatedly, such as pitching in baseball, lifting heavy weights over the shoulder, serving the ball in racket sports, and swimming freestyle, butterfly, or backstroke, increase the risk. 

·                                         The resultant inflammatory reaction and edema further narrow the subacromial space, accelerating tendon irritation or damage. If the process is not interrupted, the resulting inflammation can lead to partial or complete tear of the rotator cuff. Degenerative rotator cuff tendinitis is common among older (> 40 yr) people who are not athletes for the same reason.

·        

        subacromial bursitis  (inflammation, swelling, and fibrosis of the bursal area above the rotator cuff) commonly results from tendinitis of the cuff.

Risk Factors

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms and signs:

The most common symptoms of a rotator cuff tear include:

• Pain at rest and at night, particularly if lying on the affected shoulder
• Pain when lifting and lowering your arm or with specific movements
• Weakness when lifting or rotating your arm
• Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

A rotator cuff injury can make it painful to lift your arm out to the side.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm to the side, or pain that moves down your arm.

 At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night.

 The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult

Subacromial bursitis, rotator cuff tendinitis, and partial rotator cuff tears cause shoulder pain, especially when the arm is moved overhead. 

The pain usually is worse between 60° and 120° (painful arc of motion) of shoulder abduction or flexion and is usually minimal or absent at < 60° or > 120°. The pain may be described as a dull ache that is poorly localized. Complete rotator cuff tears result in acute pain and weakness of the shoulder. In larger tears of the rotator cuff, weakness of external rotation is particularly apparent.

Suspected rotator cuff injury can be further evaluated with MRI, arthroscopy, or both Medical History and Physical Examination

Diagnosis is by history and physical examination, including provocative maneuvers. The rotator cuff cannot be palpated directly, but it can be assessed indirectly by provocative maneuvers that test its individual components; significant pain or weakness is considered a positive result

Other areas that may be the source of shoulder pain include the acromioclavicular and sternoclavicular joints, cervical spine, biceps tendon, and scapula. These areas should be assessed for any tenderness or deformity indicating a problem in those areas.

The neck is examined as part of any shoulder evaluation because pain can be referred to the shoulder from the cervical spine (particularly with C5 radiculopathy).

 Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

• X-rays. The first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur.

• Magnetic resonance imaging (MRI) or ultrasound. These studies can better show soft tissues like the rotator cuff tendons. They can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how "old" or "new" a tear is because it can show the quality of the rotator cuff muscles.

please refer  my next blog:

Prevention and Treatment of the rotator cuff Injuries to the Shoulder.........

Tips to get rid of vertigo......

Conservative Treatment:

Vertigo treatment focuses on treating the underlying condition.

• If caused by drugs, stop using them is usually enough to relieve vertigo.

• If caused by benign paroxysmal positional vertigo (BPPV)., the most effective treatment is through canalith repositioning procedure, also known as Epley maneuver. This procedure involves a series of maneuvers (moving) head to remove calcium deposits from the posterior semicircular canal to the other parts in the ear canal.

• Vertigo can also be treated with vestibular rehabilitation therapy which involves a series of specific exercises guided by a physical therapist that is designed to minimize dizziness. The effectiveness of treatment depends on many factors, including age and health condition of the patient, the severity of the condition, and the patient's cognitive function.

• If vertigo is caused by a bacterial infection, antibiotic ear drops may be prescribed.

• If caused by Meniere's disease, taking diuretics and reducing salt intake can help reduce complaints.

• Additionally vertigo disorders can be reduced by taking enzyme Bromelain, Magnesium, Vitamin B12 which serves to regulate the balance of the nervous system. Ginger and Ginko is also very useful to improve circulation to and within the brain.

• For the case of vertigo that still light, aromatherapy is helpful to stabilize the nervous system, both inhaled (breathed in) or massage.

• Have a healthy diet that is low in sodium and sugar. Make sure you get your essential vitamins and minerals. If you are doing salads, add lemon peel to boost that vertigo-fighting meal.

• Lastly, talk to your doctor about the best treatment. Each individual may have a different case and require different types of treatment

• Suppression of the vestibular system by Labyrinthine sedatives.

•  Suppression of patient’s emotional reaction by mild tranquilizers.

• Wait for compensation. Compensation can be hastened by specific vestibular exercises.

•  Acceptance of the problem and using appropriate aids like walking stick.

Tips to overcome the vertigo attacks quickly

1. Sleep with your head a little high
 
2. Get up slowly and sit down before you got up from the bed
 
3. Avoid bending position when lifting objects
 
4. Avoid tilting the head position, for example to take an object from a height
 
5. Move your head carefully if your head in a flat position (horizontal) or when the neck in up position

physical therapy,goals,outcomes,and interventions:

• bed rest: brief ,useful during initial stages only;prolonged bed rest may delay recovery.

• implement safety measures;teach sensory substitution,compensatory strategies ;provide ambulatory aids as indicated;eg:cane ,walker.

• provide active exercises to promote vestibular adaptation[recalibration of system]

1.  habituation training:  repetition of movements and positIons that provoke dizziness and vertigo.

encourage movement; engage VOR and VSR as much as possible.  

                        

• eye and head exercises:eg; eye movements up and down,side to side;head movements up and down,side to side progressing slow to fast .                                                                                            

• exercises to improve postural stability;sitting and standing ,static and dynamic activities.eg:bending forward,turning,swiss ball exercises.

• emphasize functional mobility skills;walking,turning,stairs,community activities,activities with spatial and timing  constraints.

• relaxation training; decrease anxiety levels

• begin conservatively ,avoid excessive exacerbation of symptoms.

• recovery is better,generally faster in unilateral than bilateral vestibular dysfunction

• provide psychological support and reassurance. 

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness, most often 
 experienced when patients lies down.

Because BPPV is not intrinsically life threatening and symptoms are usually self limiting patient is usually kept under watchful wait but as BPPV can last for much longer than 2 months, it is better to treat it actively by Epley maneuvers or Semont Maneuver.

The Semont and Epley maneuvers may improve or cure benign paroxysmal positional vertigo (BPPV) with only one procedure however some people may need multiple sittings.

CRP / Epley maneuver/  Canalith repositioning procedure




The Canalith Repositioning Procedure (CRP) or epley’s maneuver is a rehabilitation treatment for Benign positional vertigo.  CRP is very effective, with an approximate cure rate of 80%. The recurrence rate for BPPV after these maneuvers is low. However, in some instances additional treatment may be necessary.

Canalith/otolith/or otoconia are small crystals of calcium carbonate attached to the otolithic membrane in the utricle of the inner ear. Because of trauma, infection, or aging, canaliths can detach from the utricle and collect within the semicircular canals. Here these canaliths shift with the head movement  and stimulate sensitive nerve endings to cause dizziness.

Epley’s maneuvers 

 involve a series of specifically patterned head and trunk movements performed by a trained professional. This head position change, moves the canaliths from the problematic location in one of the semicircular canal to the utricle.

Procedure: The procedure takes approximately 20-30 minutes.

You will be placed on a table and then laid back with your head hanging over the end of the table.

If you have a “positive” response in this position you will then be moved through the procedure.



A. Patient is placed in sitting position on the edge of the examination table (Position A).

B. Head is rotated 45° towards the affected ear, and the patient is swiftly placed in lying position with the head hanging 30° below the horizontal over the table edge (Position B). Positive response (primary stage nystagmus) is observed position is maintained for 1-2 minutes.

C. The head is rotated 90° towards the opposite ear while maintaining the head hanging position. (Position C)

D. Patient is turned further 90° towards the unaffected side to face the floor. (Position D)
The patient’s eyes are observed for secondary-stage nystagmus, it should be in the same direction as the primary-stage nystagmus.

E. Position is maintained for 30 to 60 seconds, and then again laced in sitting position (Position E). Upon sitting, there should be no vertigo or nystagmus in a successful maneuver.


Instructions Following the Canalith Repositioning Procedure

Wait for 10 minutes after the maneuver is performed before going home. Don’t drive yourself home.
For first 48 hours–

1. Do not tip your head up or down or bend at the waist. Use of the cervical collar will help prevent you from tipping your chin down.

1. Do not visit the places that require you to lie down or tilt your head (hairdresser, dentist, chiropractor or barber).

1. Avoid tipping your head up or down when brushing teeth, shaving or washing your hair.

1. Sit down and get up from chairs while keeping your back straight, without bending forward and avoid tilting your head forward.

1. Housework such as cooking or cleaning should be avoided for the next 48 hours.    

Do Not Lie Flat in Bed: 

 

Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and 

upright (a 45 degree angle) by using a recliner chair or by using pillows arranged on a couch

 
 The Following Week:

• Do Not Sleep on your treated side

• Use two pillows when you sleep.

• Avoid sleeping on the “bad” side.

• Don’t turn your head far up or far down

(Like head extended positions at the beauty parlor, dentist’s office, and while undergoing minor surgery).

• No “sit-ups” for at least one week and no “crawl” swimming.

After 1 week you can resume your daily activities without any restrictions. Move around as you wish.

 
Contraindications to perform Epley Maneuver

• Unstable heart disease

• High grade carotid stenosis,

• CNS disease (stroke or Transient Ischemic Attack),

• Physical limitation– neck disease (rheumatoid arthritis, cervical radiculopathies, ankylosing spondylitis, cervical spine fracture or surgery)

• Pregnant women beyond the 24th week of pregnancy  

 

 

 

 

 

 

 

Semont Maneuver

The Semont maneuver (liberatory” maneuver) involves a procedure whereby the patient is quickly moved 

from lying on one side to lying on the other side.

Position 1. Patient is made to sit on the examination table with legs hanging over the edge and head turned 45 degrees horizontally towards the unaffected ear.

Position 2. While maintaining head rotation patient’s upper body is swiftly moved to side lying position on the affected side with head resting on examination table and nose pointed upwards. Position is maintained for 3 minutes or till vertigo and nystagmus subsides. This step moves the debris to the apex.

Position 3. Patient is rapidly moved through the sitting position (Position 1) to lying on the opposite or unaffected side (maintaining same head rotation) with nose pointed to the ground. Position is again maintained for 3 minutes or till the vertigo and nystagmus subsides. This maneuver moves the debris towards exit of the canal.
Idea is to move the debris into the utricle where it will no longer cause vertigo.
Semont maneuver is 90% effective after 4 treatment sessions


 Home exercise:

Brandt daroff exercises:

                   

 
                              

 vestibular suppressant medications :prolonged use may delay recovery ;severe cases may require ablative surgery

Surgical:

It is rarely used. It also depends on the cause of Vertigo. It is indicated in cases resistant to Conservative management. The various options available are Vestibular nerve section, and destruction of balance organ in the inner ear (labyrinthectomy) by chemical or surgical method. If the cause of Vertigo is an Intracranial then the disease is treated accordingly

Disclaimer: This information might have been copied from different sources to give the best accessible...

Know Vertigo, Causes and How to Overcome It....

      

There are a few tips to get rid of vertigo. Vertigo is a symptom of a medical condition characterized by the sensation of  moving around in space or  having objects move around a person ; tends to come in attacks;if severe,accompanied  by nausea and vomiting.

Causes of Vertigo

 There are a number of different causes of vertigo. Vertigo can be defined based upon whether the cause is peripheral or central.

 Central causes of vertigo arise in the brain or spinal cord while peripheral vertigo is due to a problem within the inner ear.

                                 

Brain or sensory nerve disturbance:


Central vertigo

  is a term that collects together the central nervous system causes - involving a disturbance to one of the following two areas:

• The parts of the brain (brainstem and cerebellum) that deal with interaction between the senses of vision and balance, or

• Sensory messages to and from the thalamus part of the brain.

The central nervous system regulate a sense of balance. Disruption by diseases of the central nervous system such as multiple sclerosis, tumors, neck damage, or stroke can cause vertigo

Uncommon causes are stroke and transient ischemic attack, cerebellar brain tumor, acoustic neuroma (a non-cancerous growth on the acoustic nerve in the brain) and multiple sclerosis

Inner ear disturbance:

 

 unilateral vestibular disorder:[UVD]

 

Peripheral vertigo 

 is a term that collects together the inner ear causes.

The labyrinth of the inner ear has tiny organs that enable messages to be sent to the brain in response to gravity. By telling our brains when there is movement from the vertical position, we are able to keep our balance, maintain equilibrium.
Disturbance to this system therefore produces vertigo and can be created by inflammation among other causes. Viral infection is behind the inflammation seen in the following two conditions:

• Labyrinthitis - this is inflammation of the inner ear labyrinth and vestibular nerve (the nerve responsible for encoding the body's motion and position

• Vestibular neuronitis - this is thought to be due to inflammation of the vestibular nerve. an acute infection with prolonged attack of symptoms,persisting for several days or weeks;caused by viral or bacterial infection.
  Infections such as colds, flu, or other inflammation can affect the inner ear and cause vertigo.

• Ménière's disease

        This form of vertigo is thought to be caused by high pressure of a fluid in a compartment of the inner ear (a swelling that is also known as endolymphatic hydrops).

As well as infection, Meniere's disease can result from metabolic and immune disorders.

 recurrent and usuallay progressive vestibular disease;episodic attacks may last from minutes to several hours with severe symptoms ;usually associated with tinnitus ,deafness,sensation of pressure/fullness with in ear;etiology:unknown,edema of membranous labyrinth is a consistent finding

 

Benign paroxysmal positional vertigo

Benign positional vertigo is due to a disturbance within the inner ear. The inner ear has fluid-filled tubes called semicircular canals. The canals are very sensitive to movement of the fluid, which occurs as you change position. The fluid movement allows your brain to interpret your body's position and maintain your balance.

Benign positional vertigo develops when a small piece of bone-like calcium breaks free and floats within the tube of the inner ear. This sends the brain confusing messages about your body's position.

                             

Benign paroxysmal positional vertigo (BPPV) is the most common disorder of the inner ear’s vestibular system, which is a vital part of maintaining balance. BPPV is benign, meaning that it is not life-threatening nor generally progressive. BPPV produces a sensation of spinning called vertigo that is both paroxysmal and positional, meaning it occurs suddenly and with a change in head position. - See more at: http://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo#sthash.ipE9F7RB.dpuf