Shoulder Impingement Syndrome

7/13/2019 Shoulder Impingement Syndrome

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SHOULDER IMPINGEMENTSYNDROME


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Definition:Shoulder impingement has been defined as

compression and mechanical abrasion of the supraspinatusas they pass beneath the coracoacromial arch duringelevation of the arm.

Related terms:

Rotator cuff tendinitis : It encompasses impingement, andresult from acute rotator cuff overload, intrinsic rotator cuff

degeneration, or chronic overuse.Rotator cuff syndrome: It is a term used to describe the

process whereby tendinitis and impingement are ongoingsimultaneously.

Painful arc syndrome: Pain in the shoulder and upper armduring the midrange of glenohumeral abduction, withfreedom from pain at extremes of the range due tosupraspinatus damage . The term shoulder impingementsyndrome has largely replaced what used to be called

painful arc syndrome.


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Functional anatomy:

The rotator cuff (Figure 21) comprises four muscles

The subscapularis, the supraspinatus, the

infraspinatus and the teres minor and their

musculotendinous attachments.

The subscapularis muscle is innervated by the

subscapular nerve and originates on the scapula. It

inserts on the lesser tuberosity of the humerus.

The supraspinatus and infraspinatus are both

innervated by the suprascapular nerve, originate in

the scapula and insert on the greater tuberosity.


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The teres minor is innervated by the axillary nerve,

originates on the scapula and inserts on the

greater tuberosity.

A bursa in the subacromial space provides

lubrication for the rotator cuff.


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The rotator cuff is the dynamic stabilizer of theglenohumeral joint. The static stabilizers are thecapsule and the labrum complex, including the

glenohumeral ligaments. Although the rotator cuffmuscles generate torque, they also depress thehumeral head. The deltoid abducts the shoulder.Without an intact rotator cuff, particularly during

the first 60 degrees of humeral elevation, theunopposed deltoid would cause cephalic migrationof the humeral head, with resulting subacromial

impingement of the rotator cuff.In patients with large rotator cuff tears, the

humeral head is poorly depressed and can migratecephalad during active elevation of the arm.


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Figure 21: Rotator cuff muscles


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Etiology:

1. Extrinsic causes:

A- Bony factors:

The type I acromion, which is flat, is the "normal"acromion.

The type II acromion is more curved and downward

dipping,The type III acromion is hooked and downward

dipping, obstructing the outlet for the supraspinatustendon and therefore may impinge on the rotator cuff

on elevation of the arm. Osteophytes under the acromioclavicular joint

reduces the subacromial space and can also lead tocuff impingement and therefore failure" '


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Type I Type II Type III

Figure 22 : Types of anatomical acromion variation: Flat

acromion, curved and hoocked


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B- Soft tissue factors Examples include Subacromial bursitis

Thickened coracoacromial ligament.

2. Intrinsic causesa. Degenerative cuff failure :

This constitutes the commonest cause of cuff failure andusually occurs in the older individual. Degeneration of the cuffmay later result in partial tears which may progress to complete

tears. The precise cause of degenerative cuff tear is unknown.One possible theory relates to the 'critical vascular zone' of thecuff tendon where the blood supply is precarious, and relativeischemia leads to degenerative changes.

b. Traumatic cuff failure:

This may occur when the upper limb is subject to a violentforce and the rotator cuff sustains a traumatic tear. In theyounger individual where the tendinous part of the cuff-bonecomplex is stronger than the bony part, the tendons may avulsewith a piece of bone.


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c. Reactive cuff failure:

Calcific rotator cuff tendinitis is an example of

reactive cuff failure. The calcifying mass inside the

tendon may give rise to a swellingwhich leads to

impingement under the subacromial arch, hence

resulting in cuff failure.


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Classification of the Impingement Syndrome

Neer divided impingement syndrome into three stages:

1. Stage Iinvolves edemaand/or hemorrhage. This stagegenerally occurs in patients less than 25 years of age

and is frequently associated with an overuse injury.

Generally, at this stage the syndrome is reversible.

2. Stage II is more advanced and tends to occur in

patients 25 to 40 years of age. The pathologic changes

that are now evident show fibrosis as well as

irreversible tendon changes.

3. Stage III generally occurs in patients over 50 years of

age and frequently involves a tendon rupture or tear.


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History :

1- Pain: It is exacerbated by overhead or above theshoulder activities. A frequent complaint is night pain,

often disturbing sleep, particularly when the patientlies on the affected shoulder. The onset of symptomsmay be acute, following an injury, or insidious,particularly in older patients, where no specific injury

occurs. In the acute stage I, there is a painful arc ofabduction between 60 and 120 degrees increasedwith resistance at 90 degrees.

2- Loss of motion : Prolonged shoulder pain causes the

patient to restrict instinctively the range of use andoften results in an initial adhesive capsulitis.

3- weakness and inability to raise the arm may indicate

that the rotator cuff tendons are actually torn.


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Physical examination:

1. Manual motor testing for the rotator cuff muscles:

Geber's lift-off test for subscapularisExternal rotation with adducted and elbow

flexed 90 degrees for test of the

infraspinatus and teres minor.

Arm abduction 90 degrees in the scapular plane

(30 degrees anterior to the coronal plane of the

body and internal rotation for test of the

supraspinatus.


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Figure 23: Lift off test for subscapularis, external rotation for

teres minor and infraspinatus and abduction with internal

rotation for supraspinatus test


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2. The key feature of the physical examination is an

assessment for signs of impingement:

a-Neer impingement sign: With the patient seated

or standing place one hand on the posterior aspect

of the scapula to stabilize the shoulder girdle, and,

with the other hand, take the patient's internally

rotated arm by the wrist, and place it in fullforward flexion. If there is impingement, the

patient will report pain in the range of 70 degrees

to 120 degrees of forward flexion as the rotatorcuff comes into contact with the rigid

coracoacromial arch.


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Figure 24:Neer impingement sign


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b-Hawkins impingement sign:

With the patient sitting or standing, the examiner

places the patient's arm in 90 degrees of forward

flexion and forcefully internally rotates the arm,

bringing the greater tuberosity in contact with the

lateral acromion. A positive result is indicated if

pain is reproduced during the forced internalrotation at the supraspinatus site.

C-AROM of shoulder : Forward flexion, abduction,

external rotation and internal rotation.


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Figure 25: Hawkin's impingement sign 3

f h ld fl bd


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Figure 26: AROM of shoulder flexion, abduction, ext.

rotation with 90 abduction and neutral the last is Apleys

scratch test for internal rotation.


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Management:

There are three ways of approaching

impingement syndrome:

-Physical therapy rehabilitation,

-subacromial injections of cortisone, and

-surgical intervention.-Physical therapy rehabilitation in :

1- Pain control and inflammation reduction by:

Relative rest: A sling may be used but it iscrucial that the sling be removed several times

daily to perform exercises.

Acute phase

I i (20 i 3 4 ti d ) It d th


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Icing (20 min, 3-4 times per day): It decreases thesize of blood vessels in the sore area.

Have the patient sleep with a pillow between the

trunk and arm to decrease tension on the;upraspinatus tendon (that is the arm is littleabduction, flexion and internal rotation) andprevent blood flow comprise in its watershedregion.

Patients are instructed to continue the paincontrol techniques at home, work, or vacation as

part of their exercise program. The home exerciseprogram builds on itself through each phase of therehabilitation process, and carry-over should bemonitored


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The recovery phase from a rotator cuff injurymust include several components to be successful.

These include the following:

(1) Restoration of shoulder ROM,

(2) Normalization of strength and dynamic muscle

control, and

(3) Proprioception and dynamic joint stabilization.

Recovery Phase

1 Restoration of shoulder range of motion


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1-Restoration of shoulder range of motionAfter the pain has been managed, restoration of

motion can be initiated:

Codman pendulum exercises. Wall walking

Stick or towel exercises

Address any posterior capsular tightness because this

can lead to anterior and superior humeral headmigration, resulting in impingement:

Stretching of the posterior capsule. The focus oftreatment in this early stage should be on improving

range, flexibility of the posterior capsular posturalbiomechanics, and restoring normal scapular motion.Each stretch should be held for a minimum of 30seconds, although stretching for 1 minute is

encouraged.

2 Normalization of strength and dynamic muscle control


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2-Normalization of strength and dynamic muscle control

a. Perform strengthening in a pain-free range only. Beginwith the Scapulothroracic stabilizers to help returnsmooth motion allowing normal rhythm between scapula

and GH joint. The scapular stabilizers include therhomboids, levator scapulae, trapezius, and serratusanterior.:

Shoulder shrugs.

push-ups.b. Then, turn attention toward strengthening the rotator cuff

muscles. Position the arm at 45 and 90 of abduction forexercises to prevent the wringing out phenomenon, inwhich hyperadduction can be caused, stressing thetenuous blood supply to the tendon of the exercisingmuscle. Avoid the thumbs down position with the arm ingreater than 90 of abduction and internal rotation tominimize subacromial impingement.

M t t th l il bl Th


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Many ways to strengthen muscles are available. The

rehabilitation program usually starts with isometric

progresses to concentric contractions, and finally

incorporates eccentric contractions as part of thepreparation for return to sports.

Additional strengthening techniques that can be used are

progressive resistive exercises (PREs), Thera-Band, and

plyometrics.Use of isokinetic exercises has been debatedbecause they are not performed in a functional manner.

Probably the best use for isokinetic exercise machines is

for objective side-to-side comparison of strength and

progress made in strength rehabilitation. Incorporate

endurance training into the program as it advances.

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Stick exercise

Figure 27: Shoulder stretching exercises include gentle pendulum

exercises, stick exercises, the use of overhead pulley.


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Flexion Extension Internal Rotation


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Overhead Bar Pulley


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Wail Walking Posterior Stretching Door Handing

i 28 h h ld h i i d i d i h i h


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Figure 28:The shoulder strengthening program is designed to improve strength in the

remaining rotator cuff and improved strength of the deltoid. The five theraband exercises

provide resistance against internal rotation and external rotation , abduction, adduction,

extension and forward flexion to strengthen the rotator cuff muscles and the three distinct

portions of the deltoid muscle.


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Shoulder strengthening exercise


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1-Wall Push-Up 2-Knee Push-Up

Shoulder press up ups


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Shoulder press up ups

Figure 29: Scapular stabilizer are strengthened by shoulder shrug,

push-up and shoulder press

3-Proprioception


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3-Proprioception

Proprioceptive training is important to retrain

neurologic control of the strengthened muscles,providing improved dynamic interaction and

coupled execution of tasks for harmonious

movement of the shoulder and arm. Begin taskswith closed kinetic chain exercisesto provide joint

stabilizing forces. Then as the muscles become

reeducated, one can progress to open chain

activities, In addition, proprioceptive

neuromuscular facilitation (PNF) is designed to

stimulate muscle/tendon stretch receptors for

reeducation.

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Return to task-specific or sport-specific

activities is the last phase of rehabilitation. Thisphase is an advanced form of proprioceptivetraining for the muscles to relearn prior activities.

It is an important phase of rehabilitation andshould be supervised properly to minimize thepossibility of re injury. At the conclusion of formaltherapy sessions, patients should be independent

in a ROM and strengthening program and shouldcontinue these exercises. Athletes are oftentempted to return to their overhead throwingsport too soon after recovery of the acute phase.

Maintenance Phase

Subacromial injections of cortisone:


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-Subacromial injections of cortisone:

Although these injection do not cure the

underlying pathology, they decrease swelling of

the inflamed bursa and rotator cuff tissue and

allow for more room in the sudacromial space for

the rotator cuff to move.

Corticosteroids delivered directly to the

subacromial space via injection can be considered.

Surgical Intervention


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-Surgical Intervention

Indications for operative treatment of rotator

cuff disease include partial-thickness or full-

thickness tears in an active individual who does

not improve pain and/or function within 3-6

months with a supervised rehabilitation program.

An acromioplasty is usually performed in thepresence of a type II (curved) or type III (hooked)

acromion with an associated rotator cuff tear.

In surgical candidates, early repair is useful to avoidfatty degeneration and retraction of the remnant

rotator cuff musculature

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Shoulder Impingement Syndrome