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Differential Diagnosis of Shoulder Impingement

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Neer (1972), anatomical variations in build, strain and ... C. A. Speed, Rheumatology 2001; 40: 1331-1336, Therapeutic ultrasound in soft tissue lesions ... – PowerPoint PPT presentation

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Title: Differential Diagnosis of Shoulder Impingement


1
Differential Diagnosis of Shoulder Impingement
  • Charlie Cotterill
  • Junior Physiotherapist
  • Feb 2006

2
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3
AIMS
4
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5
Anatomy
  • Subacromial joint.
  • Subacromial space 9-10mm
  • Force couple to counteract downward pull of
    deltoid Thompson et al (1996)
  • Jarjavay (1867)
  • Neer (1972), anatomical variations in build,
    strain and repetitive microtrauma.
  • Degeneration of the rotator cuff, oedema,
    bleeding, fibrosis and calcification ? ruptures,
    osteophyte formation, and spur formation.

6
Aetiology
  • Primary/Secondary
  • Intrinsic/Extrinsic

Bigliani Classification (1991)
7
Aetiology
  • Aetiology of SIS is multifactoral (Lewis et al
    2001).
  • Mechanical/Anatomical
  • Primary mechanical impingement (Neer 1972, 1983)
  • Acromial bone spurs (Neer 1972)
  • Os acromiale (Neer 1972, 1983)
  • Corocoacromial ligament (soslosky et al 1994)
  • Postereosuperior glenoid impingement (Jobe 1997,
    Riand et al 1998)
  • Rotator cuff
  • RC overuse (Jobe and Jobe 1983, Meister and
    Andrews 1993, Frost et al 1999)
  • Degenerative tendinopathy (Ozaki et al 1988)
  • Instability/hypermobility
  • Secondary tensile disease (Meister and Andrews
    1993)
  • Secondary compressive impingement (Warner et al
    1990)

8
Aetiology
  • Restrictive processes
  • Restricted glenhumeral capsule (Harryman et al
    1990, Matsen and Arntz 1990)
  • Posture
  • Ayub 1991, Bowling et al 1986, Calliet 1991,
    Solem-Bertoft et al 1993)
  • Functional scapular instability
  • Kibler 1991, 1998, 2002, 2003, Warner et al 1992,
    Lukasiewicz 1999, Ludewig and Cook 2000,
    Wandsworth, Bullock Saxton 1997)
  • Lateral Kibler slide test

9
Scapula
10
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11
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12
Differential Diagnosis?
  • Labrum tear Cervical/Thoracic spine RA
    Bursitis
  • Polymyalgia Rheumatica Rotator cuff tear
  • Biceps tendon rupture/tendinopathy Calcific
    tendinitis
  • Adhesive capsulitis AC arthritis
    Glenohumeral arthritis
  • Septic arthritis Gout Lyme disease Long
    thoracic nerve injury
  • Visceral PE, pleuritis, pericarditis, angina,
    MI, cholecystitis, pancreatitis, adnexitis.
  • Lupus erythematosus Spondylo-arthropathy AVN
  • Cervical radiculopathy Tumor/Malignancy
    Thoracic outlet Brachial plexus neuropathy
    Trigger points Post CVA Glenohumeral instability
    Humeral subluxation

13
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14
Evidence
  • Evidence suggests that the condition is not
    self-limiting.
  • Systematic review of manual and physical therapy
    treatment in SIS by Desmeules et al. revealed
    only 7 RCTs Limited evidence to support the
    efficacy of physical therapy in SIS
  • Lack of uniformity in defining, evaluating, and
    treating SIS.
  • Supervised exercises appear to be preferable to
    arthroscopic surgery for patients with persistent
    shoulder impingement syndrome. Brox et al (1993)
  • A review of 8 RCTs evaluated the efficacy of
    corticosteroid injection in the rx of rotator
    cuff tendonitis (Koester et al). 2 of the 8
    trials showed clinically relevant improvements in
    pain and range of motion in the injection groups
    as compared with placebo.
  • Two systematic reviews found ultrasound to be
    ineffective in the management of pain in the
    shoulder (Green and Heijden

15
Scapula Rehab
Living within a window
16
CONCLUSION
17
REFERENCES
  • Neer CS. Impingement lesions. Clin Orthop Rel
    Res. 198317370 77.
  • Neer, C. S. II. Anterior acromioplasty for the
    chronic impingement syndrome in the shoulder. J.
    Bone Joint Surg. 54A4150, 1972 22.
  • Neer, C. S. II and R. P. Welsh. The shoulder in
    sports. Orthop. Clin. North Am. 8583591, 1977.
  • Hawkins RJ, Brock RM, Abrams JS, Hobeika P.
    Acromioplasty for impingement with an intact
    Rotator cuff. J Bone Joint Surg Br. 1988
    70795797.
  • Michael C. Koester, MD, Michael S. George, MD,
    John E. Kuhn, MD Shoulder impingement syndromeThe
    American Journal of Medicine (2005) 118, 452455
  • Brox JI et al Arthroscopic surgery compared with
    supervised exercises in patients with rotator
    cuff disease (stage II impingement syndrome) BMJ
    1993 Oct 9 307899-903.
  • Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman
    JD, Efficacy of injections of corticosteroids for
    subacromial impingement syndrome. J Bone Joint
    Surg Am. 1996 Nov78(11)1685-9. 
  • Downing DS, Weinstein A. Ultrasound therapy of
    subacromial bursitis. A double blind trial. Phys
    Ther1986661949.
  • Nykanen M. Pulsed ultrasound treatment of the
    shoulder. A randomised, double blind, placebo
    controlled trial. Scand J Rehabil
    Med1995271058.
  • Hasson S, Mundorf R, Barnes W, Williams J, Fujii
    M. Effect of pulsed ultrasound versus placebo on
    muscle soreness perception and muscular
    performance. Scand J Rehabil Med199022199205.
  • Green S, Buchbinder R, Glazier R, Forbes A.
    Systematic review of randomised controlled trials
    of interventions for painful shoulder selection
    criteria, outcome assessment and efficacy. Br Med
    J199831635460.

18
REFERENCES
  • Kibler, W. Ben MD a Uhl, Tim L. PhD, ATC, PT b
    Maddux, Jackson W. Q. MD c Brooks, Paul V. MD a
    Zeller, Brian MS, ATC d McMullen, John MS, ATC
    2002. a Qualitative clinical evaluation of
    scapular dysfunction A reliability study.
    Journal of Shoulder Elbow Surgery.
    11(6)550-556,
  • W. Ben Kibler, MD and John McMullen, ATC , 2003
    Scapular Dyskinesis and Its Relation to Shoulder
    Pain, J Am Acad Orthop Surg, Vol 11, No 2,,
    142-151.
  • Lewis. J, Green. A, Dekel. S, The Aetiology of
    subacromial impingement syndrome, Physiotherapy
    Sept 2001, vol 87, No 9, pg 453-468.
  • McKenna et al (2004) Inter-tester reliability of
    scapular pposition in junior elite swimmers,
    Physical therapy in sport 5, 146-155.
  • Van der Heijden GJMG, van der Windt DAWM, de
    Winter AF. Physiotherapy for patients with
    shoulder disorders a systematic review of
    randomised controlled clinical trials. Br Med
    J19973152530.
  • C. A. Speed, Rheumatology 2001 40 1331-1336,
    Therapeutic ultrasound in soft tissue lesions
  • P Frost and JH Andersen, shoulder impingement
    syndrome in relation to Shoulder intensive
    workOccup. Environ. Med. 199956494-498
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