DETERMINING THE POTENTIAL SUCCESS OF CONSERVATIVE TREATMENT OF ROTATOR CUFF IMPINGEMENT / Sklaar BSc Physiotherapy (W itwatersrand). H onorary lecturer, Physiotherapy, University o f the W itwatersrand. Private Practitioner INTRODUCTION A clinical test is proposed w hich will end the dilem m a of w hether conservative treatm ent w ill be o f value in patients diag­ nosed w ith rotator cu ff im pingem ent syn­ drom e. To date there are no conclusive inva­ sive or non-invasive tests to d iagnose the stage of im pingem ent eg. arth rogram will only b e positive in a full thickness tear. If the m u scle is 99.9% torn the arthrogram result will be negative. It is im portant to d iagnose progressive im p ingem ent in order to prevent a con tin ­ uum o f the pathology. The prognosis after a decom pression or repair o f a sm all tear, is m uch m ore favou rable than if the tear is allow ed to enlarge. METHOD OF TEST A n objective test, called the " S " test, is described w hich is based on clinical obser­ vation w hich is d iagnostic and prognostic of early suprasp inatus tears. The physiotherapist and patient stand facing each other, w ith their arm s at their sides. Elbow s are flexed to 90° and fore­ arm s are m id w ay betw een supination and pronation. The physiotherapist places her hands laterally and proxim ally to the patients w rists and bilaterally applies a m edially directed force, w h ile the patient statically resists this force. This tests the static resis­ tance of external rotation and m ust be taken to breaking point to pick up sm all changes betw een the tw o arm s. The test is considered positive if there is even the slightest w eakness or pain and w eakness of the one arm com pared to the other. If a patient w ith signs and sym ptom s o f a Rotator C u ff Im pingem ent syndrom e is treated co n se rv a tiv e ly and recov ers fu lly , b u t th e " S " te s t r e m a in s e v e n slightly positive, then it is proposed that this is indicative of an early supraspinatus tear, partial or com plete. A lso if the " S " test gets w eaker, then it is proposed that this is indicative of a progressive tear. In either case, further tests are necessary as op erative intervention m ay be indicated rather than conservative treatm ent at this stage. , A positive " S " test signifies a suprasp i­ natu s tear. The a tm is in neutral for this test and therefore w hen tension is applied it tests the integrity of the supraspinatus m uscle itself, as opposed to the im pingem ent tests w hich are all done w ith the arm in >90°. This sandw iches the m uscle betw een the acrom ion, coraco-acrom ial ligam ent and hum erus. A ny stage of im pingem ent w ill test positive regardless of w hether there is true m uscle dam age or ju s t an oedem a or haem orrhage. There is no w ay of d iagnos­ ing the stage of im pingem ent w ith the standard im pingem ent tests. DISCUSSION W e have observed that a positive " S " test is indicative o f supraspinatus pathol­ ogy, and this gives rise to tw o questions: 1. B es id e s its tra d itio n a l ro le a s a n a b d u c ­ tor is s u p ra s p in a tu s an e x te rn a l ro ta to r in n e u tra l? 2. In addition or alternatively, does a torn s u p r a s p in a tu s re n d e r an in ta c t in ­ fr a s p in a tu s b io m e c h a n ic a lly in e ffi­ cient. Calliett (1981) view ed the action of su­ praspinatus in a unique w ay 1. H e looked at the supraspinatus from a superior view and m ade the interesting observation that the supraspinatus runs p o sterior to the axis o f rotation o f the h u m e ru s, on its w a y to a ttach to the greater tuberosity. Therefore w hen it con­ t r a c t s it m u s t e x t e r n a l l y r o t a t e th e hum erus. W ith the help o f an orthop aed ic su r­ geon w e conducted a cad aver stu d y and confirm ed C alliett's observation. W e also detached the m uscle from the su p rasp i­ natus fossa and pulled on the m u scle in order to sim ulate a contraction. W e noted a sm all b u t definite m ovem ent o f the arm into external rotation, this w as lim ited by the fact that the cad aver w as very rigid. Biom echanically therefore, it is p ossible for the suprasp inatus to b e an external rotator. W e then d ecided to sim u late a suprasp inatus tear. A t op eration s w e had noticed that w ith su p rasp inatu s tears the infraspinatu s fell into a postero-inferior p osition. W e felt that b ecau se anato m i­ cally the tendons blend ed into one cuff, if the suprasp inatus w as d isru pted then by virtu e of this fact the attach m en t o f in­ fraspinatu s w ill be loosened and therefore w eakened . Therefore the answ er to the second question, a tear of suprasp inatus c a n r e n d e r a n i n t a c t i n f r a s p i n a t u s b iom echan ically inefficient. Post et al (1983), review ed 59 patients w ith rotator cu ff tears confirm ed at op era­ tions and found that p atien ts w ith severe external rotator m u scle w eakness, loss of good elevation and increased crep itu s had larger tears2. Brem s (1988) reported hav ing d on e a stud y using a hand held digital strength analyser and found that external rotator w eakness w as proportional to the size of the tear3. N eviaser (1971) review ed 42 p atients w h o had confirm ed rotator cu ff tears and found that the p red om inant presen ting feature w as pain4. H e found in these pa­ tients that there w as no significant w e ak ­ ness in abduction and there w as an ab­ sen ce o f a po sitive d ro p -arm sign. All these stud ies supp orted our observations. 1. The " S " test is d iagnostic o f su p rasp i­ natus pathology. 2. The w eakn ess o f the " S " test is p ropor­ tional to the size o f the suprasp inatus tear. 3. Static resisted /active abdu ction is not conclu sive in tears o f supraspinatus. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DISCOVER AM ERICA 500 years ago Columbus discovered America. T o d a y , A c tio n M e d ica l is h e lp in g S o u th A fric a n physiotherapists and occupational therapists to make great discoveries of their own. You may be in te re s te d in e xp lo rin g th e co u n try, working on short assignments in a variety of locations on o u r D i s c o v e r A m e r i c a p ro g ra m , w h ich in addition to an excellent salary, offers you free housing, subsistence allowance, medical and dental insurance and a full range of other benefits. 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T e l: 4 4 2 - 7 5 7 8 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) STAGES OF IMPINGEMENT Neer (1983) has classified three stages of im p in g em en t w h ich are sim ila r to the stages o f pathology in all jo in ts5. W e have also added the fourth stage w h ich is a clinical entity p ecu liar to the gleno-hu- m eral jo in t described by N eer et a f . Stage One - Oedema and Haem orrhage T he patients w ith stage one are usually you nger than 25 years and p resen t w ith an arc o f pain after excessive overhead use in sport or w ork. The treatm ent is conserva­ tive and there is a good prognosis for total reversal. Stage Two - Fibrosis and Tendinitis/ A dhesions Stage tw o occu rs w ith rep eated ep i­ sod es o f m echanical im pingem ent. The b ursa and tendons becom e thickened and fibrotic and the problem m agnifies. It usu­ ally occu rs betw een 25 and 40 years. The shoulder functions satisfactorily fo r light activity b u t becom es painful 'locally after overhead use. Surgery is done only if con­ servative treatm ent fails. Stage Three - Bone Spurs and Tendon Ruptures (Partial or com plete) W ith fu rther im pingem ent w ear, com ­ plete o r incom plete tears of the rotator cu ff and biceps tendon occur. Patients are al­ m ost exclusively old er than 40 years. Bone changes m ay develop. The pain is referred d istally and there is night pain. The success o f conservative treatm ent at this stage is doubtful. Stage Four - Cuff Tear Arthropathy Full thickness tears o f 4% w ill progress to a cu ff tear arthropathy. This usually occurs in p atients over 50 years. T he p a­ tient p resen ts w ith constan t pain w h ich is severe at night and a progressive d isabil­ ity. A cu ff tear arthropathy results in se­ vere d isorganisation o f the gleno-hum eral jo in t w ith collapse o f the hu m eral head and the treatm ent is shou ld er replacem ent. In this case prevention is b etter than cure and perhaps w ith a d iagnosed full thick­ ness tear it is better to repair early. 1 am proposing that w ith the " S " test y ou will be able to diagnose an early stage 3. A lthough looking at the above it seem s our dilem m a w as senseless as a sim ple decision can be m ade ie., stage 1 and 2 are treated by the physiotherapist and stage three and four need further investigation and probable surgery. T his is deceptive. As stated initially there are no tests (be­ sides this one that 1 am proposing) to accu­ rately diagnose these stages. The sym p­ toms and physical signs o f all the stages overlap. Any one stage can present w ith signs and sym ptom s o f the other stages. N eer states that surgeons often erron e­ ously think that a tear has healed w h en it w as a stage one ie. an oedem a or haem or­ rhage. It is also possible to confuse a stage three that has settled for a stage one, thus partial or sm all tear can easily be missed. CONCLUSION If the "S test is positive and rem ains so despite all other signs and sym ptom s of a rotator cu ff synd rom e clearing w ith con­ servative treatm ent, then w e are propos­ ing that it is an accurate d iagnostic and prognostic test of supraspinatus tears and that the patient m ust be sen t to the ortho­ paed ic surgeon for further investigation and probable surgery. REFERENCES 1. Cailliet R. The Shoulder. F A Davis 1981;2:20. 2. Post M et al. Rotator Cuff Tear. Clinical Orth and Related Research March 1983;173. 3. Brems J J. Rotator Cuff Tear: Evaluation and Treatment. Orthopedics 1988;2:1. 4. Neviaser J S. Ruptures of the Rotator Cuff of the Shoulder. Arch Surg May 1971;102:483- 485. 5. Neer C S. Impingement Lesions. Clinical Ortho and related Research, March 1983;173. 6. Neer C S, Craig E W, Hiroaki H. Cuff-Tear Arthropathy. J o f Bone and Jnt Surg, December 1983;65A:9. RESEARCH vs CO NJECTURE A L e tte r to th e E d itor This letter is w ritten in reference to an article pu blished in the N ovem ber 1994 issue of the SA Jo u rn al of Physiotherapy. This article is referred to as "re se a rch " by the author. I do not see this term inol­ o g y b e in g a p p r o p ria te fo r an article w h ich is based entirely on subjective n o ­ tions and pu re conjecture. N o statistical e v id en ce is p re sen ted and the author bases the valid ity o f h er training regim en on one case stud y only - that o f A thlete B. W here references are used, they include one textbook dated 1991 to substantiate that w ater exercises are g aining "m o ­ m en tu m " at p resen t and references to the A kw a Letter (presu m ably a new sletter) can hard ly be recognised as legitim ate. W hen d escribing the im provem ents m ade by the tw o case studies, the author does not inform the read er o f any specific param eters by w h ich the im provem ents in physical fitness w ere m easured. Im ­ p ro v em en ts in a n a e ro b ic cap acity are also sited for A thlete B. H ow this w as m easured and to w h at extent the anaero­ b ic capacity im proved is sim ilarly not described. These are ju s t a few exam ples to illustrate w h y n o n e o f w h at is w ritten in this article is o f any value to the d is­ cerning professional. Tak ing the above factors into account, the extrap olatio n that "w a te r exercise is a crucial b reak throu gh in training sp orts­ m en and w o m e n " cannot be m ade. F u r­ therm ore, the b ackgrou nd sectio n used to substantiate the p hysiological effects o f w ater exercise is n o t referenced at all. This article can hard ly b e regard ed as professional literature. Is it not tim e that ou r jo u rn al started m eeting international standards? In view o f the above it is u n ­ likely that I and pro bab ly oth er m em bers o f the profession w o u ld consid er p u b ­ lishing in this jo u rn al in future. M r M ichael Barker, P ost-G radu ate S tu ­ dent, D epartm ent o f P hysiotherapy, U ni­ versity o f the W itw atersrand NOTE The Editor shares the concerns o f the w riter and w elcom es any constructive criticism from ou r readers. See the E d ito­ rial for som e clarification o f the problem s regard ing pu blication. H ow ever, threat­ ening to w ithho ld su b m ission o f articles to ou r Jo u rn al w ill n ot help to im prove stand ard s and h op efu lly the w riter w ill reconsider this option. / C B eenhakker V_____________________ J R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )