Impingement Syndrome Flashcards
What is another name for impingement syndrome?
Subacromial Pain Syndrome
When someone says “syndrome” what are they implying?
- A cluster of associated signs and symptoms
- Does not indicate definitive signs or cause
- Need to investigate more
What is the prevalence impingement syndrome?
44-65% of all shoulder complaints … dig deeper
What is the primary etiology of an impingement?
Limited motion
What can limited motion be caused by?
- Muscle/ Capsule Shortening
- Spurring or Hooking of Acromion
What are examples of muscle/capsule shortening?
- Disuse/ Immobilization
- Persistent FHP
What does persistent FHP lead to?
- Shortened IRs/ anterior capsule tightness and limits ER
- Shortened scapular protractors, elevators, and upward rotators
What is the secondary etiology of an impingement?
Excessive motion
What can cause excessive motion?
- Ligamentous laxity from trauma and/or activities with excessive motion (I.e. baseball)
- Muscle inhibition
What are the 4 causes of muscle inhibition?
- Disuse
- Laxity
- Pain
- Swelling
think regional interdependence from neck dysfunction as well
What is the third etiology of an impingement?
Combination of primary/ secondary (I.e. scapular hypomobility and GH hypermobility)
What is the most common structure involved in impingements?
Supraspinatus Tendon
Will the supraspinatus most likely have a tendinopathy or tendinosis?
Tendinopathy
Does the supraspinatus most often tear gradually or quickly?
Gradually
What can affect healing of the supraspinatus?
Limited vascularity in the distal supraspinatus
What head of the biceps is most likely to have a tendinopathy and tear gradually?
The long head
Does the labrum in an impingement usually tear gradually or quickly?
Gradually
During an impingement, what typically happens to the subacromial bursa?
They become a bursitis… not the source of the problem but a consequence
When the sub- and coracoacromial space is compromised what can happen?
Impingement or compression of tendon(s)
Greater than _____ degrees of abduction results in subacromial soft tissue impingement under the coracoacromial arch.
90
When you increase _____ on tendons when they are loaded and as they wrap around the bone it can result in compression.
Tension
What is an example of increased tension that causes compression?
Posterior- Superior Glenoid Impingement (PSGI)
Who are Posterior- Superior Glenoid Impingements (PSGI) more common in?
Overhead athletes
What motions are typically excessive in Posterior- Superior Glenoid Impingement (PSGI)?
ER ROM and anterior GH glide
Where is the impingement typically at with Posterior- Superior Glenoid Impingement (PSGI)
Posterior- Superior Glenoid on Labrum
What are common symptoms with impingement syndrome?
- Pain typically localized to the tip of the shoulder and referred into the lateral shoulder and arm
- Pain and/ or limitation with elevation, lifting, pushing, pressing, or reaching behind the back
When observing your patient, what are you looking for?
Possible scapular compensations for GH restrictions
What are examples of scapular compensations for GH restrictions?
- Increased elevation
- Inconsistent with upward rotation (increased/ decreased)
Is scapular dyskinesia equally or unequally prevalent in symptomatic and asymptomatic individuals?
Equally … dont try to fix something that doesnt need fixing
You may be thinking impingement syndrome when symptom alteration tests are _____ with the scapula.
Reliable
The Scapular Assistance Test (SAT) tests what kind of movement?
Passive upward rotation
The Scapular Repositioning Test tests what kind of movement?
Passive upwards rotation and posterior tilt
The Scapular Reaction Test tests what kind of movement?
Voluntary Retraction
What are common symptom alteration tests for the scapula?
- Scapular Assistance Test (SAT)
- Scapular Repositioning Test
- Scapular Retraction Test
- Taping for LT assistance
What are the symptom alteration tests helping you to learn?
The body needs help with muscle efficiency. Its not a strength problem its an activation problem
With impingement function looks like what?
Limited and painful reaching overhead and behind the back with lifting
With impingement ROM looks like what?
- Most often limited and painful into flexion, abduction, and external rotation… but internal rotation may be as well
- Posterior shoulder pain with external rotation indicates posterior impingement
What does resisted and MMT look like with impingement syndrome?
- Inhibited scapular and cuff muscles
- External rotators: ER/IR ratio < .66
- Most scapular muscle groups expect the elevators
Proprioceptive impairment is greatest where?
At higher elevations
Accessory motion throughout the shoulder complex joints with impingement syndrome represents hypo or hyper-mobility
Hypomobility with primary type, particularly post shoulder tightness with limited posterior glide
What are the special tests for impingement syndrome?
- Glenohumeral IR deficit (GIRD) ratio
- Infraspinatus or ER test in 0 degrees of abduction
- Internal rotation resisted strength test
- Speeds and Hawkins/ Kennedy
- Empty Can
What is the Glenohumeral IR deficit (GIRD) ratio?
- IR/ER at 90 degrees of abduction > 1
- ER typically increases as IR decreases in overhead athletes
- Influences humeral head position on the glenoid fossa
What does the Infraspinatus or ER test in 0 degrees of abduction tell us for impingement syndrome?
- Painful or giving away
- Highly specific
What does the internal rotation resisted strength test tell us for impingement syndrome?
- IR weaker than ER at 90 of abduction
- LR+ 22; LR- .12
Does the Speeds and Hawkins/ Kennedy test support impingement?
Minimal to no support for impingement
Does the empty can test support impingement?
Moderate specificity
There are other special tests for scapular muscle lengths and stability tests for hypermobility, what are the two things you can look at for hypermobility?
- Labrum and rotator cuff (labrum - fibrocartilage: stabilizer)
- Ligamentous tests
What are rotator cuff pathology prevalence related to age?
- Youngest age group: 32%
- Middle age group: 48%
- Oldest age group: 78%
Are rotator cuff pathologies associated with impingement symptoms?
No
In 14 asymptomatic professional pitchers ages 18 to 22 what percentage of them had rotator cuff and labral changes?
80% … meaning you can have changes without symptoms
In fifty-one, 40 to 70 year old asymptomatic men how many of them had DJD, tendinosis, partial thickness tears, and labral and bursal abnormalities?
96%
What kind of modalities can be used for impingement syndrome?
- Most are not beneficial
- Ultrasound, Laser, and Extra-corporeal shockwave therapy all have lack of evidence
What does scapular taping do for impingement syndrome?
- Improved short term pain
- May provide an earlier “window” for MET and limited ADL provocation
- No difference at 6 weeks; more needs to be done
Are joint mobs beneficial for impingement syndrome?
- Strong recommendation
- Glenohumeral joint mob
- Supporting for regional interdependence
What accelerated recovery and reduced pain and disability immediately versus usual care?
Thoracic spine joint mobilizations
T/F: Joint mobilizations added to exercises were more effective than exercises alone
True
What is the primary treatment option for impingement syndrome?
METs
Is the etiology of impingement syndrome limited or excess motion?
It could be Hyper or Hypomobility or a tendinosis
What are the first few initial purposes we should emphasize for the muscles when there is excess motion?
Endurance and Coordination
_____ dose MET is superior to conventional _____ dose exercise.
High; Low
T/F: Kinesthetic impairments are greater than proprioceptive
True
When does an impingement become a tendinosis?
When the patient has had symptoms for greater than 6 months … can be out to 3 years
What muscle exercises should you focus on for tendinosis?
- Cuff (SIT)
- Scapular exercises (Middle traps, lower traps, rhomboids, serratus anterior)
- These are local muscles
How often should a patient with a tendinosis do their exercises?
MET parameters 1-2x a day
At 3 months what kind of improvements were shown for tendinosis patients?
- 70% had improved pain and function following the MET plan versus traditional exercises
- Reduced need for subacromial decompression
He provides two cases series, this is case series #1 for tendinosis… state what you know:
- Average symptom duration was 12 months
- Partial, not full musculotendon tears included
- HEP with supporting PT visits
- Focused on cuff and scapular eccentric control and movement patterns
- MET parameters for teninosis 2x/day
- At 3 months, 8 out of 10 patients improved pain and 10 out of 10 improved function
He provides two cases series, this is case series #2 for tendinosis… state what you know:
- Average symptom duration was 41 months
- Partial and full muscultendon tears included
- HEP with supporting PT visits
- Targeted supraspinatus eccentric control with pulley … Start AAROM
- MET parameters for tendinosis 2x/day
- 5 out of the 9 patients avoided surgery except those with labral tears and full tendon tears
A patient will most likely have earlier improvements if they do not have what?
A tendinosis or tear
MET as described for tendinosis provides what kind of benefit?
Long-term
What kind of evidence does cortisone injections have for impingement syndrome?
Conflicting evidence
What is a subacromial decompression?
- A 3 step surgery
- A partial anterior acromioplasty due to hooking
- A distal clavicle resection and coracoclavicular ligament
- A Coracromial ligament resection
What are the two biggest issues with a subacromial decompression?
- It makes the AC joint hypermobile
- The ligaments that were cut help with rotation of the clavicle so now you have changed the biomehanics of the shoulder
What are the outcomes of a subacromial decompression?
- Equally or no more effective and more expensive than exercise alone
- 2019 Clinical Practice Guideline states that there is no important differences with pain, function, or quality of life vs placebo or other interventions and explains there may be adverse events without benefits
What should not be preformed if an impingement is atraumatic and presents for greater than 3 months?
Subacromial decompression
