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  1. #1
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    Brief Medical History Overview

    Age: 43, Female, Presenting Problem Since: 2 years, Symptom Behaviour: worse, Symptoms Worse (24hr Behaviour): night- if i sleep on my arm, aches at night too, all day whenever i use my arm, Aggravating Factors:: using my arm/shoulder, Easing Factors:: rest....sometimes, Investigations: small intrasubstance supraspinatus tendon tear and subacromial bursitis. Focal hypoechogenicity is demonstrated in the supraspinatus tendon measuring 0.6 x 0.4cm in size. located 1cm from the biceps tendon. No full thickness seen. Rotator cuff tendon in, No Diabetes, No history of High Blood Pressure, No Medications, No Osteoporosis, No Hx of Cancer, No Unexplained Weight Loss, No Bowel/Bladder issues, Other Info: no

    intrasubstance supraspinatus tendon tear

    Physical Agents In Rehabilitation
    An ultrasound of my right shoulder reported "small intrasubstance supraspinatus tendon tear. Subacromial bursitis."
    After massage, osteopathy and stretching exercises failed to ease the pain, I had cortisione injection. I started to feel a little less pain but after about 1 month, the pain is all back again. I would appreciate any advice as the pain and lack of normal arm movement without pain is really stopping me from everyday tasks. Please help as I'm happy to give anything a go at this stage!

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  2. #2
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    Re: intrasubstance supraspinatus tendon tear

    It is common condition seen by Physio.
    1. control the symptoms-use anti-inflammatory gel every night before go to sleep can help if do have inflammation happening, and maybe some pain control to help you go to exercises.
    2. correct contributing factors-forward shoulder, poor scapular control during movement, stiff thoracic spine, which can treated by exercises and mobilisation
    3. Eccentric exercises: use pulley to low down you arm slowly, it is an exercises with pain, and will take long period of time. would be better to have someone instruct you.

    Would suggest you to see physio to manage it.


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    M.C.1968 (28-09-2011)

  4. #3
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    Re: intrasubstance supraspinatus tendon tear

    Re: intrasubstance supraspintatus tendon tear

    Hello M.C. 1968
    You have a number of problems that inter relate. The first and most important area to address is the subacromial bursitis. This is a collection of fluid in a small sac that glides underneath the over hang of your shoulder, designed to protect the supraspinatus tendon when your arm is moved sideways away from the body. Reaching movements eg reaching into the back seat of a car when in the front will aggravate the shoulder.
    Self treatment to the sub deltoid bursa is difficult. I tend to disperse some of the fluid via mobilisation, although parts of the bursa cannot be reached due to bone coverage. It is also possible to mobilise the AC joint - where the clavicle (collar bone) and scapula (shoulder blade) join. The aim is to decompress the supraspinatus tendon as it moves through its tunnel.
    If not already ruled out, an x-Ray view to confirm no bony spurs under the acromion (top of shoulder bony overhang) should be undertaken. The spur, if present, will aggravate the tendon and the bursa causing ongoing mechanical problems / inflammation due to movement.

    Various other techniques include a specific shoulder exercise to control the shoulder movement and trigger point dry needling. Initial shoulder taping can improve range of movement and reduce night pain.

    I am probably too far away from your area as I am in Healesville, Yarra Valley (60 minutes from Melbourne through Ringwood, Lilydale on the Maroondah Highway). Let me know more details and I will try to assist further.
    Regards,
    MrPhysio+ Healesville


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    M.C.1968 (28-09-2011)

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    Re: intrasubstance supraspinatus tendon tear

    MC1968, you have to be careful when making a diagnosis based on an ultrasound report or examination as it is a very user dependant investigation. In fact a small intra-substance tear could just be an incidental finding or intrasubstance swelling but it is the overall rotator cuff tendinopathy or degeneration that may be contributing to a lack of shoulder performance and painful bursal involvement.

    On the other hand the ultrasound may be under reporting the pathology present...all dependent on the user?


    Tendons need appropriate mechanical stimulation for optimal health.

    However, if you have overloaded or in fact under loaded the tendon at some stage or are doing so right now during daily activity or at gym or sport then your problem is likely to persist. In your age group it is usually related to an overloading incident.

    The tendon gets overloaded, struggles to return to normal, the bursa gets involved (contributing to the night pain), injection therapy if successful can reduce the pain significantly if only for a short while indicating that the pain is more likely bursal related. More over the rotator cuff starts to fails in its humeral head control leading to further impingement and bursal irritation etc etc

    Controlling the overload and pain is very important and an injection could be repeated in your case to allow a relative pain free window to get the full benefit of what is most important...a specific and graduated shoulder physiotherapy program that gradually increases the activation of your rotator cuff muscles allowing hopefully a normalisation of the surrounding tendon structure and better shoulder performance.

    Only thing is you got to get in early and start the rehab asap.

    Good Luck!

    Luke

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    M.C.1968 (28-09-2011)

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    Re: intrasubstance supraspinatus tendon tear

    Thankyou for your reply. I will organize to see a physio soon but as far as the tear goes, i was a bit worried about having any work done on it in case more damage is done or the tear gets larger or worse. Can you please clear this up for me? Thankyou again. maria


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    Re: intrasubstance supraspinatus tendon tear

    Much appreciated your reply Luke. Your info and advice is quite helpful. I will go and see a physio and do rehab as you suggested. My only concern is that I am worried that if the shoulder is worked on, that the tear my get larger or worse. Was i wrong to think that I shouldnt have anyone "agrevate it" via massage or manipulation? Thanks again..Maria


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    Re: intrasubstance supraspinatus tendon tear

    Thankyou Mr Pysio+ for such clear and "easy to compehend" info and advice. Being far from where i live (about 2hrs away) i will try and find a physio closer for regular treatment. I can understand the treatment needed for the bursitis but i"m a bit scared about having anyone "work" on the shoulder out of fear that the tear may get bigger or worse. My thought was to not aggrevate it any further with further stretching and the like? Thanks again. Maria


  11. #8
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    Re: intrasubstance supraspinatus tendon tear

    Hello Maria,
    If you see a sports physio or shoulder specialist physio there is little chance any tear would be aggravated. Some interesting facts: on scanning 100% of 80 year olds, 80% of 70 year olds and 50% of 60 year olds have tears in the supraspinatus tendon whether or not they have symptoms. Also, up to 50% of ultrasound scans give incorrect results ie false positive, false negative or innaccurate estimate of tear size. It is quite possible to have a supraspinatus tear without symptoms, which means that even if a tear is confirmed there may be other reasons for the symptoms. Sometimes a tear can settle, but the muscles supporting the shoulder can be affected by the previous pain or swelling, creating a problem of shoulder joint stability and / or alignment that may be giving you the current problems, or at least contributing. A sub acromial bone spur can form to create problems and the supraspinatus tendon may become partially calcified due to ongoing trauma or initial trauma.

    All the above is written to show that shoulders are complex and the symptoms can be caused by many factors. Scans alone are insufficient to base treatment decisions upon. Proper diagnosis requires scans, physical assessment, history taking, possible cause and integrating response to treatment. Sometimes a diagnosis requires visualisation of the area via arthroscopy which may then proceed to repair. There are treatments that can be tried before surgery that can be effective in stopping the need for surgery. MRI is better than ultrasound for scanning. 3D CT scans are wonderful to visualise the bony structural alignments eg bone spurs.
    Once again, I hope this information helps.
    Cheers,
    MrPhysio+


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  13. #9
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    Re: intrasubstance supraspinatus tendon tear

    Maria, in the hands of someone who knows what they are doing and who has a good grasp on shoulder diagnosis and rehabilitation you will most likely have a successful outcome.

    The cuff is effectively intact (intrasubstance only) but degenerative. The bursa is, it seems irritated and reactive.

    It is highly likely that your rotator cuff and scapula muscles are dysfunctional but with a graduated physiotherapy program including massage, heat, trigger point therapy, mobilisation, postural correction, scapula stability and rotator cuff activation (loading) drills over an approximate 90 day period you should see some positive results if the diagnosis and therapy are accurate.

    However, as has been previously stated shoulder pain is complex and the root cause can be different to the presenting problem and unrelated to the presence of a cuff tear so a thorough assessment is essential.

    What we know about cuff tendons is they have a tendency to propagate and become larger tears over time. Likewise as previously stated they become more prevalent as we get older, whether we get symptoms or not is another thing (explanation) all together.

    Best thing... get in early, get educated, become more aware of how to engage the right muscles to improve the performance of your shoulder NOW because there are no guarantees. You're only young and have hopefully a healthy biology so you should do well.

    Good Luck!

    Luke

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    M.C.1968 (29-09-2011)

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    Re: intrasubstance supraspinatus tendon tear

    We recommend the Physio Shop - www.physioshop.co.uk
    Thankyou Luke, you have adressed my concerns and again given me great advice. thanks



 

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