Shoulder Impingement Syndrome Flashcards
What is shoulder impingement syndrome:
-involves compression of non-neural soft tissues between the head of the humerus and underside of the coracoacromial arch; may lead to tissue degeneration and is associated with tendinosis, rotator cuff tears, calcific tendinitis, bone spurs and/subacromial bursitis
Characteristics
Characteristics: tissues are compressed underneath the coracoacromial arch which is composed of the acromion process, coracoacromial ligament and coracoid process; upper margin of GH joint capsule, coracohumeral ligament, supraspinatus muscle-tendon unit, long head of biceps brachii tendon and subacromial bursa can be compressed
-impingement can result from:
• the structure of the acromial arch
• a combination of coracoacromial architecture and with repetitive motions (flexion and internal rotation of humerus)
• bone spurs or osteophytes can develop on the underside of the acromion process and decrease the subacromial space
• trigger points or hypertonic muscles can cause dysfunctional biomechanics
supraspinatus outlet:
space where supraspinatus emerges from under the acromion process
Neers progressive stages:
Neers progressive stages: used to describe shoulder impingement syndrome
Stage 1: common in patients younger than 25 years; acute inflammation, edema, hemorrhage in affected tissues; repeated overuse of the upper extremity
Stage 2: common in patients between 25-40 years; progressive degeneration in rotator cuff structures that involves fibrosis and tendon degeneration
Stage 3: common in patients over 40 years; tears of supraspinatus and long head of biceps tendon, bone spurs and osteophytes may develop
-also divided into primary or secondary categories; involve patients who perform repetitive overhead motion or constant overhead positions
Primary impingement
-caused by the architecture of the subacromial region
Type 1: flat undersurface
Type 2: curved undersurface
Type 3: hooked acromion: associated with a greater incidence of impingement and rotator cuff
pathology
Secondary impingement
-caused by the underlying instability in the GH joint and faulty biomechanics but not necessarily the decrease in subacromial space
-rotator cuff muscle weakness, posterior capsule tightness and dysfunctional coordination of scapulothoracic muscles are the biomechanical factors
-pain in the lateral or anterior region of GH joint; associated with motions that increase soft-tissue compress (flexion, abduction or medial rotation when the shoulder is flexed); night pain due to tissue compression; pain is deep in the joint and difficult to locate
History
History: activities involving repetitive abduction or flexion with medial rotation; gradual onset but traumatic injuries can alter GH mechanics and cause acute symptoms; weakness is typical; inability to lift arm into certain positions with additional resistance; ask about age at onset
Observation
Observation: no clear signs; may be inflammation; some alteration in smoothness of movement during ROM evaluation; apprehension with abduction or flexion; disturbances to scapulothoracic rhythm; compensating patterns to avoid pain; postural distortions such as upper thoracic kyphosis and medially rotated glenohumeral joint
Palpation
Palpation: difficult to produce pain of the primary complaint because impingement is under the acromion process; with distal supraspinatus tendon or subacromial bursa impingement, tenderness inferior to acromion process on the lateral shoulder; excess edema or heat not identifiable; if impinged under coracoacromial ligament, biceps brachii long head tendon is affected and may reproduce pain with shoulder flexion
Range of Motion and Resistance Testing
AROM: pain with abduction and flexion, movements recruiting supraspinatus elicit pain and limitation;
pain avoidance may accompany lack of coordination
PROM: as with AROM; pain increased with medial rotation when shoulder in flexion; other motions not
painful if performed from a neutral position
MRT: resisted abduction and flexion may cause pain; resisted elbow flexion may cause pain with affected biceps tendon; weakness with abduction and flexion due to reflex muscular inhibition; other motions not painful if performed from a neutral position
Special Tests:
- Hawkins-Kennedy Impingement: standing; therapist brings patient’s shoulder and elbow into 90° flexion; therapist medially rotates humerus to end range; if pain is reproduced, tissue impingement under coracoacromial arch; does not determine exact tissue (biceps brachii long head, anterior-superior margin of GH joint capsule, supraspinatus tendon, coracohumeral ligament)
- Empty Can: performed bilaterally; if pain reproduced, discontinue; standing; patient brings both arms into 45° horizontal adduction; ask about pain/discomfort as holds position; then patient medially rotates arms (empty cans); ask about pain/discomfort; patient holds position as therapist attempts to push both arms down with moderate effort; positive if pain reproduces complaint
-final step engages supraspinatus in resisted isometric contraction
- Neer Impingement: standing; therapist slowly brings patient’s arm into full forward flexion; therapist watches for signs of apprehension; ask about pain/discomfort during movement; positive if pain reproduces complaint; impingement under coracoacromial arch
-anterior and superior soft tissues under coracoacromial arch are compressed, pain due to impingement of long head of biceps brachii, anterior-superior portion of GH joint capsule and/or coracohumeral ligament; not specific to muscles involved
Differential Evaluation:
subacromial bursitis, rotator cuff tears, rotator cuff tendinosis, calcific tendinitis, suprascapular neuropathy, frozen shoulder/adhesive capsulitis, acromioclavicular joint injury, bicipital tendinosis, brachial plexus pathology, cervical dis radiculopathy, myofascial trigger point pain, thoracic outlet syndrome, labral damage
Suggestions for Treatment:
reduce compression of tissues; surgery may be necessary to reshape the acromion process; correct dysfunctional biomechanics (reduce/eliminate offending activities); trigger points and hypertonic muscle addressed with massage and stretching
