Shoulder Bursitis & Impingement: Evaluation and Treatment

Question 1

Shoulder Bursitis & Impingement

Throughout the progression of muscular shoulder pathology;

• what responds to rehab?
• what may require surgery?

Answer 1

Responds to rehab:

• shoulder impingement syndrome
• micro tears of RTC

May require surgery:

• full thickness RTC tear
• end stage OA with cuff tears

Question 2

Shoulder Bursitis & Impingement

Typical presentation of bursitis = ?

Answer 2

Typical Presentation of Bursitis:

• Acute sudden onset of severe shoulder pain most commonly after a strenuous bout of unusual activity or an excessive amount of activity with the arm.
• Markedly restricted ROM and strength is only due to severe pain.
• Often mimics RTC tear or fracture due to severity but, NO history of trauma.
• Occasionally bursitis is insidious in nature.

Question 3

Shoulder Bursitis & Impingement

Subacromial push button sign for bursitis = ?

Answer 3

Subacromial push button sign for bursitis;

• Point palpation over the coracoid process and along the anterior aspect of the shoulder just inferior to the acromion.
• Distinct concordant pain
• NOTE: Validity is very questionable as several pathologies could be produce pain (adhesive capsulitis)

Question 4

Shoulder Bursitis & Impingement

Lift-off Sign / Gerber Test

Answer 4

• The patient is seated with affected arm behind his or her back.
• The patient is asked to lift the arm off the back.
• Positive Test for subscapularis tear is indicated by inability of the patient to lift the arm off the back.
• If pain is the greater limitation, then suspect bursitis.

video
references

Question 5

Shoulder Bursitis & Impingement

Bursitis treatment = ?

Answer 5

• Bursitis is typically short lived
• Codmens, Isometrics, Scapular exercises
• Ice packs, cold Laser, even ultrasound is sometimes used to decrease acute symptoms
• Gentle distractive mobilizations
• Mobility activities outside of their impingement ranges of motion

Question 6

Shoulder Bursitis & Impingement

What does impingement sound like in subjective patient interview = ?

Answer 6

What does impingement sound like in subjective patient interview;

• Shoulder pain but little to no weakness
• Sudden increase in UE activity (painting, remodeling…)
• Pain came on recently or is linked to activities
• Younger patient
• Repetitive overhead activity
• Weightlifting (Military press, incline press, overhead shoulder raises…)
• Pitching, Volleyball, Softball
• Painful arc

Question 7

Shoulder Bursitis & Impingement

Causes for:

• Primary Impingement = ?
• Secondary Impingement = ?

Answer 7

Causes for Primary Impingement:

• Mechanical narrowing of the subacromial space
• Osteophytes of AC joint
• Hooked acromion (3 acomial types)
• Subacromial bursitis (taking up space)
• Lack of mobility in the shoulder
• Tendonopathy of RTC or bicep

Causes of Secondary Impingement:

• Functional disturbances
• Weakness of shoulder/muscular imbalance
• Laxity / instability of shoulder
• Scapular dysfunction (Altered GH/Scap-Thor Arthrokinematics)
• Postural dysfunctions

Question 8

Shoulder Bursitis & Impingement

What should you be able to explain about impingement and biomechanics = ?

Answer 8

• When the shoulder movement becomes dysfunctional impingement can happen.
• When the biomechanical relationship break down then the supraspinatus starts to impinge not just the acromial undersurface, but also the coracoacromial ligament, and the undersurface of the acromioclavicular (AC) joint.
• Boney impingement is debated.
• Regardless, the more the cuff muscles are subjected to impingement the less likely it is to function normally and the problem worsens.
• (I.E. biomechanics poor, leads to impingement, leads to decrease RTC function and cycle continues).

Question 9

Shoulder Bursitis & Impingement

Explain the painful arc

Answer 9

• As the patient elevates upper extremity by abducting the shoulder, note whether a painful arc is present.
• May be caused by subacromial bursitis, a peritendonitis or tendinosis of the rotator cuff muscles, or most commonly by scapular dysfunction (stiffness or instability).

Question 10

Shoulder Bursitis & Impingement

Tests for Impingement/Subacromial Impingement Syndrome (SAIS) = ?

Answer 10

Tests for Impingement / Subacromial Impingement Syndrome (SAIS):

1. Neer impingement test
2. Hawkins-Kennedy impingement test
3. Internal (medial) rotation resistance strength test / (Zaslav test)
4. AC Joint Impingement test

• Physio U Neer Video
• Physio U Hawkins Video
• Zaslav IR resistance strength test Video
• Neer impingement Video
• Internal (medial) rotation resistance strength (Zaslav test) Video

Question 11

Shoulder Bursitis & Impingement

Neer Impingement Sign = ?

Answer 11

Neer impingement test:

• Client Position: Sitting or standing.
• Clinician Position: Standing alongside the client, stabilizing the scapula in an attempt to block scapulothoracic movement.
• Movement: The clinician brings the client’s involved arm into passive forward flexion with glenohumeral internal rotation. This is also described as having the client actively forward flex the involved arm until the point of pain or until end range of motion is achieved.
• Assessment: A test is (+) if pain is reproduced, particularly along the anterior or lateral aspect of the shoulder.

• SN = 81%
• SP = 35%
• Negative (-) LR = .35
• Same test can be performed in Supine and is called a supine impingement test.

Question 12

Shoulder Bursitis & Impingement

Hawkins-Kennedy Impingement Test = ?

Answer 12

Hawkins-Kennedy impingement test:

• The patient is standing or seated while the examiner stands anteriorly to the involved shoulder.
• The examiner first raises the patient’s arm into approximately 90 degrees of shoulder flexion or abduction with one hand while the other hand stabilizes the scapula (typically superiorly).
• The examiner applies forced humeral internal rotation in an attempt to reproduce the concordant shoulder pain.
• Positive Test: If concordant shoulder pain is present.

• SN = 80%
• SP = 56%
• Positive (+) LR = 1.84
• Negative (-) LR = .35
• “Impingement between the greater tuberosity of the humerus against the coraco-humeral ligament” Link

Question 13

Shoulder Bursitis & Impingement

Zaslav test / Internal Rotation Resisted Strength Test = ?

Answer 13

Internal Rotation Resisted Strength Test (Zaslav test):

• The patient is seated while the examiner stands anteriorly to the involved shoulder.
• The examiner first raises the patient’s arm into approximately 90 degrees of shoulder flexion or abduction with one hand while the other hand stabilizes the scapula (typically superiorly).
• The examiner applies forced humeral internal rotation in an attempt to reproduce the concordant shoulder pain.
• Postive Test: If concordant shoulder pain is present, if there is weakness in IR relative to ER.

Question 14

Shoulder Bursitis & Impingement

Acromioclavicular Horizontal Adduction Test for AC joint and for impingement

(Also called Crossover or Cross-body Test)

Answer 14

Acromioclavicular Horizontal Adduction Test for AC joint and for impingement / Crossover or Cross-body Test:

• Patient standing or sitting
• Flex the shoulder to 90 degrees and horizontally adduct the arm across the body.
• Positive Test: Reproduction of pain at the AC joint.

Question 15

Shoulder Bursitis & Impingement

Diagnostic Cluster for Impingement = ?

Answer 15

Sensitivity / True Positive Rate or Recall:

• It measures the ability of a test to correctly identify positive cases.

Specificity / True Negative Rate:

• It measures the ability of a test to correctly identify negative cases.

Question 16

Shoulder Bursitis & Impingement

Diagnosis of Subacromial Impingement Syndrome = ?

Answer 16

Predictor variables for impingement syndrome:

• Positive Hawkins-Kennedy impingement sign
• Postive painful arc sign
• Postive infraspinatus muscle strength test

Question 17

Shoulder Bursitis & Impingement

Rotator cuff tear test clusters = ?

Answer 17

Rotator cuff tear (Litaker et al., 2000):

• age > 65, and
• weakness in external rotation, and
• night pain

Rotator cuff tear [full thickness] (Park et al., 2005):

• age > 60, and
• (+) painful arc test, and
• (+) drop arm test, and
• (+) infraspinatus test

Article: combining orthopedic special tests

Question 18

Shoulder Bursitis & Impingement

• Impingement test cluster = ?
• (HIP)

Answer 18

Impingement test (Park et al., 2005):

• (+) Hawkins-Kennedy, and
• (+) painful arc test, and
• (+) infraspinatus test

Question 19

Shoulder Bursitis & Impingement

Anterior instability (traumatic) test cluster = ?

Answer 19

Anterior instability (traumatic) test cluster (Farber et al., 2006):

• (+) apprehension test, and
• (+) relocation test

Article: combining orthopedic special tests

Question 20

Shoulder Bursitis & Impingement

Labral tear test clusters = ?

Answer 20

Labral tear (Guanche & Jones, 2003):
* (+) relocation test, and
* (+) active compression test

Labral tear (Guanche & Jones, 2003):
* (+) relocation test
* (+) apprehension test

Physio U - Anterior Apprehension with Relocation Test Video

Question 21

Shoulder Bursitis & Impingement

Keys to rehab for impingement = ?

Answer 21

Rehab for impingement:

• Address the impairments!
• What is wrong with the scapula?
• • Stiff…
• • Not enough upward rotation…
• • Not enough elevation…
• • Reversal of rhythms?
• Is the Humeral head translating too much?
• • Anteriorly or superiorly?
• Is the activity / load on the joint too excessive?
• Is the cuff getting beat up from over time and thus not functioning as well?
• Is T-spine stiff
• What exercises retrain the software and what can we do to influence the hardware?

Question 22

Shoulder Bursitis & Impingement

Scapular thoracic joint mobilizations

Answer 22

Scapular Thoracic Joint Mobilizations:

• Scapulothoracic mobilization or stretching is beneficial for improving mobility of the upper quadrant.
• The procedure may lead to postural improvements and is generally very relaxing to a patient who has high levels of pain.
• The patient assumes a sidelying position, facing the clinician. The non-plinth-sided arm of the patient is secured to the clinician by placing the thumb of the patient in a belt loop or by having the patient relax his or hand on the clinician’s hip.
• The clinician secures the inferior border of the scapula with his or her caudal-most hand and does the same for the spine of the scapula with the cephalad-most hand .
• The clinician can apply a downward, medial, lateral, or upward force of the scapula and may combine the movements if desired

• Protraction & Retraction Video
• Elevation & Depression Video
• Upward & Downward Rotation Video

Question 23

Shoulder Bursitis & Impingement

Examples of shoulder rehab isometrics in early-stage rehab = ?

Answer 23

Shoulder isometrics for early stage rehab:

• Internal rotation iso
• Flexion iso
• Extension iso
• Abduction iso
• External rotation iso

Goal:

• Decrease pain
• Initiates increased blood flow to the area.
• Exercises the muscles in low stress situations/positions.

video

Question 24

Shoulder Bursitis & Impingement

How to address impairments of excessive superior/anterior migration of the humeral head = ?

Answer 24

Humeral head pull downs (Armpit depression):

• “Pull the humeral head down into the armpit”
• The patient should feel a hard structure pushing into their fingers.
• Don’t let the shoulder / elbow torque (ER) in towards their side (pec substitution) or the trunk side-bend (erectors or latissimus).

Very good supraspinatus activation exercise for beginner who needs to find cuff muscles and limit humeral head superior migration.

Question 25

Shoulder Bursitis & Impingement

Shoulder Joint Mobilization Grades (1-5) = ?

Answer 25

Shoulder Joint Mobilization Grades:

Grade I:

• Small amplitude rhythmic oscillating mobilization
• Early range of movement

Grade II

• Large amplitude rhythmic oscillating mobilization
• Mid-range of movement

Grade III

• Large amplitude rhythmic oscillating mobilization
• To point of limitation in range of movement

Grade IV

• Small amplitude rhythmic oscillating mobilization
• At end of the available range of movement

Grade V (Thrust Manipulation)

• Small amplitude
• Quick thrust at end of the available range of movement

Example:

• Shoulder Oscillatory External Rotation Mobilization (Grades I-IV) Video

Question 26

Shoulder Bursitis & Impingement

Shoulder joint mobilizations to increase flexion and internal rotation = ?

Answer 26

Shoulder Joint Mobilizations to Increase Flexion and IR:

• Lateral Glide
• Posterior / lateral force to increase shoulder flexion

• Mike Reinold -Shoulder Posterior Joint Mobilization Example Video
• Mike Reinold -Shoulder Lateral Distraction Joint Mobilization Example Video

Question 27

Shoulder Bursitis & Impingement

Glenohumeral Joint Superior-anterior Capsule Mobilization:

• Goal = ?
• Indication = ?
• Technique = ?

Answer 27

Glenohumeral Joint
Superior-anterior Capsule Mobilization:

Indication:

• This technique is used for patients experiencing glenohumeral restriction in flexion.

Goal:

• Improve capsular mobility
• Improve ROM

Technique:

• The patient is positioned in supine with their arm off the table.
• Their arm is positioned in external rotation, adduction, and flexion.
• Stabilization is applied through the elbow.
• Mobilization force is applied in an posterior and slightly lateral direction past the posterior acromion.

Rx:

• Perform this distraction for 30-45 seconds 4x, or until capsular change
• Finish the technique with neuro-muscular re-education; Agonist -> Antagonist -> Agonist

• The more you adduct, the more you address the Coracohumeral Ligament.
• (You can also impact this tissue with an Inferior Glide)

Question 28

Shoulder Bursitis & Impingement

Glenohumeral Joint Superior-Posterior capsule mobilization:

• Goal = ?
• Indication = ?
• Technique = ?

Answer 28

Glenohumeral Joint
Superior-Posterior Capsule Mobilization:

Indication:

• This technique is used for patients experiencing glenohumeral restriction in flexion.

Goal:

• Improve capsular mobility
• Improve ROM

Technique:

• The patient is positioned in supine with their arm off the table.
• Their arm is positioned in internal rotation, adduction, and flexion.
• Stabilization is applied through the elbow.
• Mobilization force is applied in an posterior and slightly lateral direction past the posterior acromion.

Rx:

• Perform this distraction for 30-45 seconds 4x, or until capsular change.
• Finish the technique with neuro-muscular re-education; Agonist -> Antagonist -> Agonist

Question 29

Shoulder Bursitis & Impingement

Shoulder joint posterior capsule mobilization = ?

Answer 29

Shoulder Joint Posterior Capsule Mobilization:

• Stabilize shoulder blade
• IR to end rage
• Adduct past midline
• Flex to 90
• Inferior force along the shaft of the humerus.
• Pain / stretch should be felt posterior shoulder not medial.
• If medial then reposition to see if you can eliminate impingement.

Question 30

Shoulder Bursitis & Impingement

Shoulder joint mobilizations to increase abduction = ?

Answer 30

Shoulder Joint Mobilizations to increase abduction:

• Inferior glide, and
• GH traction helps with pain control and loss of mobility in all planes

Question 31

Shoulder Bursitis & Impingement

Glenohumeral Joint Inferior-Anterior Capsule Mobilization:

• Goal = ?
• Indication = ?
• Technique = ?

Answer 31

Glenohumeral Joint Inferior-anterior Capsule Mobilization:

Indication:

• This technique is used for patients experiencing glenohumeral restriction in abduction.

Goal:

• Improve capsular mobility
• Improve ROM

Technique:

• The patient is positioned in supine with their arm off the table.
• Their arm is positioned in internal rotation, abduction, and slight extension.
• Stabilization is applied through the elbow.
• Mobilization force is applied in an inferior and lateral direction toward the axilla.

Rx:

• Perform this distraction for 30-45 seconds 4x, or until capsular change.
• Finish the technique with neuro-muscular re-education.

Question 32

Shoulder Bursitis & Impingement

Glenohumeral Joint Inferior-Posterior Capsule Mobilization:

• Goal = ?
• Indication = ?
• Technique = ?

Answer 32

Glenohumeral Joint Inferior-Posterior Capsule Mobilization:

Indication:

• This technique is used for patients experiencing glenohumeral restriction in abduction.

Goal:

• Improve capsular mobility
• Improve ROM

Technique:

• The patient is positioned in supine with their arm off the table.
• Their arm is positioned in external rotation, abduction, and slight flexion.
• Stabilization is applied through the elbow.
• Mobilization force is applied in an inferior and lateral direction toward the axilla.

Rx:

• Perform this distraction for 30-45 seconds 4x, or until capsular change.
• Finish the technique with neuro-muscular re-education.

Question 33

Shoulder Bursitis & Impingement

AC and SC Joint impingement mobilizations = ?

Answer 33

AC and SC Joint impingement mobilizations:

• Posterior glide
• Inferior glide

Question 34

Shoulder Bursitis & Impingement

How to mobilize the thoracic spine = ?

Answer 34

How to mobilize the thoracic spine:

• Prone P-A mobilization
• Supine A-P mobilization

Question 35

Shoulder Bursitis & Impingement

Shoulder Bursitis:

• Classifications = ?

Answer 35

Shoulder Bursitis:

Classifications:

• Subacromial Bursitis
• Shoulder Tendonitis

Question 36

Shoulder Bursitis - Characteristics:

• Pain Pattern = ?
• Risk Factors = ?
• Observation = ?
• Examination = ?

Answer 36

Shoulder Bursitis - Characteristics:

(a) Pain Pattern:

• Sudden, severe pain shoulder pain
• Anterior/Superior Shoulder Pain
• Pain is often results in patient appearing extremely weakness

(b) Risk Factors:

• Often younger/middle age individuals
• Overhead activities
• Increase in UE activities

(c) Observation:

• Frequently NO significant observations
• Possible limited scapular upward mobility
• Superior/Anterior translation of humeral head
• Kyphotic Posture or limited thoracic mobility may be present

(d) Examination:

• (+) Push button sign
• Lift off sign

Question 37

Shoulder Bursitis - Manual Therapy:

• Joint Mobilization = ?
• STM/MRF = ?
• PNF = ?

Answer 37

Shoulder Bursitis - Manual Therapy:

(a) Joint Mobilization:

• Inferior/Posterior, Tractional GH Mobilizations
• AC and SC mobs
• Cervical & Thoracic mobilization
• Hyper or Painful = I/II
• Hypo = III/IV/V

(b) STM/MFR:

• Cross Frictional Pin and Stretch to RTC, Pecs/Traps

(c) PNF:

• PNF diagonal ROM/stretching
• Multiple angle isometrics with humeral head control/centering
• Contract relax stretching for improved mobility utilizing PNF
• Increase speed with PNF for quick reversals from muscle groups and multiplanar activities
• LASER, Non-thermal Ultrasound, Ice packs also possible interventions

Question 38

Shoulder Bursitis - Therapeutic Exercise:

• Motor = ?
• Sensory = ?

Answer 38

Shoulder Bursitis - Therapeutic Exercise

(a) Motor:

• Pain control and Inflammation reduction (Codmens, Isometrics, table slides).
• Scapular mobility Squeezes, protraction/retraction.
• RTC Strengthening endurance/reactivation.
• All Trapezius muscles, serratus, and rhomboids for improved scapular mobility and control.
• Improved mobility of T-spine in all planes especially extension and rotation.

(b) Sensory:

• Rhythmical stabilization
• Humeral head control to prevent anterior and superior migration
• Body Blade
• Undermining/challenging postural stability as progression

Question 39

Shoulder Bursitis & Impingement

Shoulder Impingement:

• Classifications = ?

Answer 39

Shoulder Impingement

Classifications:

• Subacromial Impingement
• Subacromial Pain Syndrome
• Posterior/Anterior Internal Impingement
• Primary vs Secondary Impingement
• Internal vs External Impingement
• AC joint Impingement
• Shoulder Tendonitis

Question 40

Shoulder Bursitis & Impingement

Shoulder Impingement - Characteristics:

• Pain pattern = ?
• Risk Factors = ?
• Observation = ?
• Examination = ?

Answer 40

Shoulder Impingement - Characteristics:

(a) Pain Pattern:

• Anterior/Superior Shoulder Pain
• Possible Painful Arc of motion 60-120d abduction
• Pain but minimal weakness
• Pain worse with activity

(b) Risk Factors:

• Under 20 up to 40 Years Old
• After 40 typically RTC involvement is co-occurring with impingement
• Overhead activities
• Increase in UE activities

(c) Observation:

• Possible limited scapular upward mobility
• Superior/Anterior translation of humeral head
• Kyphotic Posture or limited thoracic mobility

(d) Examination:

• (+) Neer
• Hawkin’s Kennedy
• Cross Body
• Int Rot Resistance tests

Question 41

Shoulder Bursitis & Impingement

Shoulder Impingement - Manual Therapy:

• Joint Mobilization = ?
• STM/MFR = ?
• PNF = ?

Answer 41

Shoulder Impingement - Manual Therapy:

(a) Joint Mobilization:

• Inferior/Posterior, Tractional GH Mobilizations
• AC and SC mobs
• Cervical & Thoracic mobilization
• Hyper or Painful = I/II
• Hypo = III/IV/V

(b) STM/MFR:

• Cross Frictional Pin and Stretch to RTC, Pecs/Traps, Biceps

(c) PNF:

• PNF diagonal ROM/stretching
• Multiple angle isometrics with humeral head control/centering
• Contract relax stretching for improved mobility utilizing PNF
• Increase speed with PNF for quick reversals from muscle groups and multiplanar activities

Question 42

Shoulder Bursitis & Impingement

Shoulder Impingement - Therapeutic Exercise:

• Motor = ?
• Sensory = ?

Answer 42

Shoulder Impingement - Therapeutic Exercise:

Motor:

• Scapular mobility for improved upward rotation.
• RTC Strengthening endurance/reactivation.
• Isometrics, Theraband isotonics, weights, single plane progressing to multiple plane endurance.
• Scapular muscular strengthening
• All Trapezius muscles, serratus, and rhomboids for improved scapular mobility and control.
• Improved mobility of T-spine in all planes especially extension and rotation.

Sensory:

• Body blade
• Rhythmical stabilization
• Humeral head control to prevent anterior and superior migration.
• Undermining/challenging postural stability as progression.