SHOULDER IMPINGEMENT SYNDROME

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SHOULDER IMPINGEMENT SYNDROME
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• Definition
• Shoulder impingement has been defined as
  compression and mechanical abrasion of the
  supraspinatus as they pass beneath the
  coracoacromial arch during elevation of the arm.
• Related terms
• Rotator cuff tendinitis It encompasses
  impingement, and result 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 ongoing simultaneously.
• Painful arc syndrome Pain in the shoulder and
  upper arm during the midrange of glenohumeral
  abduction, with freedom from pain at extremes of
  the range due to supraspinatus damage . The term
  shoulder impingement syndrome 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
  the glenohumeral joint. The static stabilizers
  are the capsule and the labrum complex, including
  the glenohumeral ligaments. Although the rotator
  cuff muscles generate torque, they also depress
  the humeral head. The deltoid abducts the
  shoulder. Without an intact rotator cuff,
  particularly during the first 60 degrees of
  humeral elevation, the unopposed deltoid would
  cause cephalic migration of 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 migrate
  cephalad 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
  supraspinatus tendon 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
  to cuff impingement and therefore failure" '

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Type I Type II Type
IIIFigure 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 causes
• a. Degenerative cuff failure
• This constitutes the commonest cause of cuff
  failure and usually occurs in the older
  individual. Degeneration of the cuff may 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 the cuff
  tendon where the blood supply is precarious, and
  relative ischemia leads to degenerative changes.
• b. Traumatic cuff failure
• This may occur when the upper limb is subject
  to a violent force and the rotator cuff sustains
  a traumatic tear. In the younger individual where
  the tendinous part of the cuff-bone complex is
  stronger than the bony part, the tendons may
  avulse with 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 swelling
  which 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 I involves edema and/or hemorrhage. This
  stage generally 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
  the shoulder activities. A frequent complaint is
  night pain, often disturbing sleep, particularly
  when the patient lies on the affected shoulder.
  The onset of symptoms may 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 of
  abduction between 60 and 120 degrees increased
  with resistance at 90 degrees.
• 2- Loss of motion Prolonged shoulder pain
  causes the patient to restrict instinctively the
  range of use and often 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 subscapularis
• External 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 full forward flexion. If there is
  impingement, the patient will report pain in the
  range of 70 degrees to 120 degrees of forward
  flexion as the rotator cuff comes into contact
  with the rigid coracoacromial arch.

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Figure 24Neer 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 internal rotation 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
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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 is
  crucial that the sling be removed several times
  daily to perform exercises.

Acute phase
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• Icing (20 min, 3-4 times per day) It decreases
  the size 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)
  and prevent blood flow comprise in its watershed
  region.
• Patients are instructed to continue the pain
  control techniques at home, work, or vacation as
  part of their exercise program. The home exercise
  program builds on itself through each phase of
  the rehabilitation process, and carry-over should
  be monitored

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• The recovery phase from a rotator cuff injury
  must include several components to be successful.
  These include the following
• Restoration of shoulder ROM,
• Normalization of strength and dynamic muscle
  control, and
• Proprioception and dynamic joint stabilization.

Recovery Phase
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• 1-Restoration of shoulder range of motion
• After 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
  head migration, resulting in impingement
• Stretching of the posterior capsule. The focus
  of treatment in this early stage should be on
  improving range, flexibility of the posterior
  capsular postural biomechanics, and restoring
  normal scapular motion. Each stretch should be
  held for a minimum of 30 seconds, although
  stretching for 1 minute is encouraged.

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• 2-Normalization of strength and dynamic muscle
  control
• a. Perform strengthening in a pain-free range
  only. Begin with the Scapulothroracic stabilizers
  to help return smooth motion allowing normal
  rhythm between scapula and GH joint. The scapular
  stabilizers include the rhomboids, levator
  scapulae, trapezius, and serratus anterior.
• Shoulder shrugs.
• push-ups.
• b. Then, turn attention toward strengthening the
  rotator cuff muscles. Position the arm at 45 and
  90 of abduction for exercises to prevent the
  wringing out phenomenon, in which hyperadduction
  can be caused, stressing the tenuous blood supply
  to the tendon of the exercising muscle. Avoid the
  thumbs down position with the arm in greater than
  90 of abduction and internal rotation to
  minimize subacromial impingement.

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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 the preparation 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 debated because 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 exerciseFigure 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
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Figure 28The 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
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Shoulder press up upsFigure 29 Scapular
stabilizer are strengthened by shoulder shrug,
push-up and shoulder press
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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 tasks
  with closed kinetic chain exercises to 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.
  This phase is an advanced form of proprioceptive
  training for the muscles to relearn prior
  activities. It is an important phase of
  rehabilitation and should be supervised properly
  to minimize the possibility of re injury. At the
  conclusion of formal therapy sessions, patients
  should be independent in a ROM and strengthening
  program and should continue these exercises.
  Athletes are often tempted to return to their
  overhead throwing sport too soon after recovery
  of the acute phase.

Maintenance Phase
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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.

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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 the
  presence of a type II (curved) or type III
  (hooked) acromion with an associated rotator cuff
  tear.
• In surgical candidates, early repair is useful to
  avoid fatty degeneration and retraction of the
  remnant rotator cuff musculature