Shoulder Impairments Flashcards
What is impingement syndrome?
A general term describing shoulder pain, typically diagnosed following a positive midrange/end-range painful arc and various special tests.
What are the two types of impingement?
- External (Subacromial) Impingement: Pinching of soft tissue structures in the subacromial space (e.g., supraspinatus tendon, subacromial bursa, biceps LH tendon) during humeral elevation.
- Internal Impingement: Impingement of rotator cuff tendons and/or the labrum between the humeral head and glenoid rim.
What structures are affected in external impingement?
• Supraspinatus tendon
• Subacromial bursa
• Biceps long head tendon
Where does internal impingement typically occur?
• Anterosuperior glenoid impingement: Involves subscapularis and labrum.
• Posterosuperior glenoid impingement: Involves supraspinatus, infraspinatus, and labrum.
What is GIRD, and how is it associated with internal impingement?
Glenohumeral Internal Rotation Deficit, often due to posterior capsule contracture.
Who is at risk for internal impingement?
Overhead athletes or those performing loaded tasks at end-range external rotation
What are the two classifications of impingement causes?
- Primary (Structural) Impingement: Mechanical narrowing of the subacromial space.
- Secondary (Functional) Impingement: Functional disturbances affecting humeral head positioning in the GH joint.
What factors cause primary impingement?
• Bony narrowing or malpositioning (e.g., after trauma, scarring).
• Structural variation in acromion (Type I: flat; Type III: hooked).
• Fibrosis/thickening of the coracoacromial ligament.
• Trophic changes to the humeral head, AC joint, or coracoacromial arch.
• Vascular changes in rotator cuff tendons (e.g., due to age or secondary disease).
What are functional causes of secondary impingement?
• Posterior capsule tightness: Causes anterosuperior translation of the humeral head.
• Weak external rotators/short internal rotators: Limits external rotation during abduction, preventing the greater tubercle from clearing the acromion.
• Deltoid overpowering rotator cuff: Results in superior translation of the humeral head.
• Poor scapular stability/muscular imbalances: Disrupts the length-tension relationship of the rotator cuff.
• Hyperkyphosis: Positions the scapula in downward rotation, protraction, and posterior tipping, causing internal rotation of the humerus.
• Rotator cuff/biceps LH overuse and fatigue: Reduces dynamic stabilizing forces.
• Lax connective tissue: Allows excessive humeral head translation.
• Labral or rotator cuff tears: Create instability.
Repeated dislocation: Causes ligament damage or scarring, leading to excessive movement.
What are the potential impairments caused by impingement syndromes?
Tendinopathy:
• Tendonitis (inflammation/edema decreases subacromial space).
Tendinosis (thickening/fibrosis of tendons with chronic inflammation reduces subacromial space).
Bursitis:
• Often presents with tendinopathy.
• Can cause acute burning/sharp pain and painful “catch” when lowering the arm from abduction.
Rotator Cuff Tears:
• Partial or full-thickness tears from trauma or overuse.
• Poor posture and mechanics predispose to these injuries.
How does supraspinatus tendinopathy present?
• Pain on palpation inferior to the anterior acromion.
• Painful GH arc.
• Positive impingement tests.
How does infraspinatus tendinopathy present?
• Pain on palpation inferior to the posterior acromion when the patient externally rotates and horizontally adducts.
• Painful GH arc with abduction and flexion.
How does biceps long head tendinopathy present?
• Pain on palpation of the bicipital groove.
• Positive Speed’s test.
What causes partial-thickness rotator cuff tears, and how are they treated?
Causes: Chronic inflammation, spurs under the acromion, arthritis, overcontraction, or overstretch.
Treatment:
• Modified activity (limit overhead movements/lifting).
• Progressive rehabilitation through healing stages (acute to chronic).
What causes full-thickness rotator cuff tears, and how are they treated?
Causes: Trauma, heavy lifting, or unresolved partial tears.
Treatment:
• Modified activity.
• Progressive rehabilitation.
• Arthroscopic surgery may be needed to repair tears and shave bone spurs.
What are the treatment goals and techniques for the acute phase of impingement?
Goals: Control inflammation, promote healing.
Techniques:
• Superficial fluid techniques.
• Lymphatic drainage.
• Spasm techniques.
• Low-grade joint mobilization.
What are the treatment goals and techniques for the subacute phase of impingement?
Goals: Eliminate residual inflammation, maintain tissue extensibility, and prevent adhesions.
Techniques:
• Myofascial release (MFR).
• Trigger point (TrP) techniques.
• Decrease UMRT (upper muscle resting tension).
• Isometric exercises.
• Passive stretching.
• Low-to-high grade joint mobilization.
What are the treatment goals and techniques for the chronic phase of impingement?
Goals: Increase tissue extensibility, ROM, and mobilize scar tissue.
Techniques:
• Myofascial release (MFR).
• Frictions (if applicable).
• Decrease UMRT.
• TrP techniques.
• Passive stretching.
• High-grade joint mobilization.
• Isotonic and functional exercises.
What should treatment for secondary impingement focus on?
Identifying and treating the root cause, as secondary impingement often results from poor mechanics.
How can chronic inflammation and tendon overload further complicate impingement syndromes?
They can stimulate osteophyte formation, leading to further damage to surrounding musculature.
What is primary frozen shoulder (adhesive capsulitis)?
A condition characterized by dense adhesions, capsular thickening, and restrictions of the GH joint, leading to pain and limited motion.
What are the four stages of frozen shoulder?
- Stage 1:
• Gradual onset of pain, especially at night.
• Loss of external rotation.
• Duration: <3 months. - Stage 2 (“Freezing”):
• Persistent pain at rest and with movement.
• GH motion limited in all directions.
• Duration: 3–9 months. - Stage 3 (“Frozen”):
• Pain only with movement.
• Significant adhesions, limited GH motion, scapular compensations.
• Duration: 9–15 months. - Stage 4 (“Thawing”):
• Minimal pain, no inflammation.
• Gradual improvement in motion (may not regain full ROM).
• Duration: 15–24 months.
