Common shoulder pathologies Impingement Syndrome

Question 1

Impingement Syndrome
p. 438 -Clinical Massage Therapy - Rattray and Ludwig, p.303 - Management of Common Musculoskeletal Disorders -Kessler and Randolph, p.217 - Orthopedic Physical Assessment – 4th Edition Magee)

Answer 1

• This is an inflammatory condition that involves the coracoacromial arch and the space between the acromioclavicular and glenohumeral joints. As it implies, the rotator cuff muscles, subacromial bursa and biceps tendon are pinched or ‘impinged’ between the coracoacromial arch and the proximal portion of the humerus.
• The condition may range from supraspinatus tendonitis to boney changes and even rotator cuff tears.

Question 2

Impingement Syndrome Etiology: In Kessler there are three theories:

Answer 2

mechanical-anatomic theory, vascular compromise theory, a theory implicating that kinesiological factors limit scapular rotation or promote uncoordinated movement
- Coracoacromial arch = Roof of the shoulder – the acromial arch – this may be shaped differently in individuals which predispose them to this lesion Coracoacromial and anterior acromioclavicular ligaments Coracoid process
- The rotator cuff tendons (especially the supraspinatus), biceps tendon and subacromial bursa undergo trauma and wear & tear when the head of the humerus is repeatedly being pushed up into the coracoacromial arch.
- Factors that may cause this repeated trauma include:
I. A failed muscle force-coupling where the infraspinatus and teres minor don’t depress humeral head to clear the acromion with abduction
II. Hyperkyphosis – Relatively constant internal rotation therefore decreased external rotation which equates to compression
- Supraspinatus and bicipital tendonitis, subacromial bursitis, calcific tendonitis
- Poor vascularity in the rotator cuff muscles especially supraspinatus and infraspinatus
- Age and gender (more prevalent in older Patients and females)
- Sports with repeated upper limb movements or occupation/activities that require working with the arm in a horizontal or higher position

Question 3

The Stages of Impingement Syndrome:

Answer 3

Stage 1
- Self-limiting, over-use syndrome
- Supraspinatus mostly involved; lesser extent: the biceps tendon
- Pain with activities and progresses to ADLs
- Edema and hemorrhaging of the subacromial bursa
Stage 2
- Tendinitis and bursitis persist
- Fibrosis occurs with repeated episodes of stage 1
Both stages are reversible with manual treatment, rest, stretching and progressive strengthening exercises
Stage 3
- Development of boney changes = bone spur formation and even eburnation of the humeral tuberosity, or associated bony changes to the acromion and AC joint
- Tears or ruptures may occur with the tendons (complete or incomplete)
- Surgery is indicated (arthroscopy, sutures, debridement of spurs)

Question 4

Signs and Symptoms:

Answer 4

• Insidious onset of tooth-ache like pain over the lateral brachial region with sharp twinges felt on certain movements (ADL’s involving abduction)
• AROM = earlier stages have a painful arc but relatively full range, this may decrease in the later stages
• PROM = in the earlier stages there may be full ROM with most pain present with full elevation, painful arc with rotation and abduction and pain with stretch the tissues involved.
• Later stages may yield empty end feels b/c of pain or abnormal hard end feel b/c of boney changes
• RROM = pain when relevant muscles contract maximally.
• Strong but painful with an intact tendon, weak and painful indicates a tear
• Holding patterns and postural changes may be present

Question 5

Special tests: (p.215-218 -Orthopedic Physical Assessment – 4th Edition Magee, Appendix C: Special orthopedic testing, p.1062 -Clinical Massage Therapy - Rattray and Luwig)

Answer 5

1. Hawkins-Kennedy Impingement Test
2. Neer Impingment Test
3. Drop Arm test
4. Empty can test
5. Speed’s test

Question 6

Treatment planning:

Answer 6

Stage 1 and 2
- Circulatory strokes, lymphatic drainage to address inflammation
- Manual techniques to address muscle spasm and compensatory problems
- Friction therapy
- Joint mobilizations to address capsular pattern restrictions
Stage 3
- if surgery is needed deal with post-surgical healing and complications

Question 7

Precautions and contraindications:

Answer 7

• As per bursitis and tendonitis
• If there is boney change, avoid joint mobilizations
• Possible corticosteroid injections to the shoulder

Question 8

REMEX & homecare:

Answer 8

Stage 1 & Stage 2
- Ice to decrease inflammation
- When inflammation ceases, apply heat and stretch
- Strengthening exercises (improve force coupling)
Stage 3
- Similar as stage 1 and 2 but more conservative and gradual as the guest may be post surgical