Shoulder Impingment Flashcards
What is impingement?
- A progressive condition of shoulder pain and loss of motion function
What can cause impingement?
- A genetic structure of the shoulder
- Injury
- Repetition
What are the main joints of the shoulder?
- Glenohumeral joint: multiaxial, ball-and-socket synovial joint
- Acromioclavicular joint: plane synovial joint
- Sternoclavicular joint: saddle-shaped synovial joint
- Scapulothroacic joint: not a true joint
What are the 4 muscles of the rotator cuff?
- Subscapularis
- Supraspinatus
- Infraspinatus
- Teres minor
What is the origin, insertion and innervation of the subscapularis?
O: scapula
I: lesser tuberosity of the humerus
Nerve: Subscapular
What is the origin, insertion, and nerve supply of the Supraspinatus and infraspinatus?
O: Scapula
I: greater tuberosity
Nerve: Suprascapular nerve
What is the origin, innervation, and insertion of the teres minor?
O: scapula
I: greater tuberosity
Nerve: axillary
What is the subacromial space?
- The area beneath the acromion, the coracoid process, the Acromioclavicular joint, and the coracoacrmial ligament
What are the dynamic stabilizers of the glenohumeral joint?
- Rotator cuff
- Biceps tendon
- Other shoulder girdle muscles
What are the static stabilizers of the glenohumeral joint?
- Capsule
- Labrum
- Glenohumeral ligaments
What do the rotator cuff muscles do to the humeral head?
- Generate torque
- Depress the humeral head
*90% ER strength
*45% abduction strength
What are some possible causes or contributing factors to shoulder impingement?
- Outlet syndrome
- Subacromial spurs
- AC joint osteophytes
What are the 3 different variations of an acromion?
Type I: normal or flat
Type II: increased curve and dips downward
Type III: further increased curve (hooks) and dips downward, obstructs the Supraspinatus outlet
Where is there increased risk of rotator cuff tears?
Type II and Type III
If the coracoacromial ligament is calcified what can that lead to?
- Impingement
Why is impingement classified as a vicious cycle?
- Bc pain from injury can lead to disuse of the shoulder
- The disuse can lead to weakness/atrophy of the rotator cuff and upward migration of the humeral head
- The superior migration then increases the impingement
What is stage one of impingement?
- Edema and or hemorrhage
- Occurs most in patients less than 25 years old
- Due to overuse
- Typically reversible
What is stage 2 of impingement?
- More advanced of stage I
- Tends to occur in patients aged 25-40 years
- Irreversible tendon changes/fibrosis typically present
What is stage III of impingement?
- Occurs in patients over 50
- Involves tendon tearing/rupture
- Typically associated with joint degeneration overuse, fibrosis, and tendinosis
What are the common symptoms of shoulder impingement?
- Pain
- Weakness
- Loss of motion
- Sleep disrupted
*sleeps in a recliner can’t lie down flat bc of painful shoulder
What is the age group of shoulder impingement?
- Usually older patients
*but can be see in overhead athletes at a younger age
What will be shown on the PE if a patient has shoulder impingement?
- AROM is painful
- A/C joint tenderness
- Supraspinatus/greater tuberosity tenderness
- Biceps tendon tenderness
- Atrophy
What are the specials test to complete is you’re suspecting a patient has shoulder impingement?
- Neer’s sign
*Passively raise the arm and put it into flexion (+ if grimace) - Hawkins sign
*Abducted and externally rotate arm - Speed testing
*Want to isolate biceps tendon, the arm will be in supination and push down on the arm - Supraspinatus isolation
*Arms out, thumbs down, push down (+will not be able to resist your movement)
If a patient has a RCT or impingement how will corticosteroids help it?
Impingement: condition will improve
RCT: pain improves, but may still have strength and motion deficits
What degrees will the arm be able to move if there is shoulder impingement syndrome?
0 to 70 degrees
120 to 180
*will be painful around 70-120 degrees
What diagnostic testing is recommended for shoulder impingement?
- Plain radiograph
*AP view with arm at 30 degrees external rotation
*Outlet Y view
*Axillary view
*wont show the tendon but will show a calcified tendon
What is the best test for evaluating a rotator cuff?
- MRI
*can evaluate RCT, tendinitis, bursitis, tumors/masses
*the fluid will look black or white (black is where the tear is)
What is the treatment for Type I shoulder impingement?
1: rest and stop aggravating activities
2: prolonged PT/ strengthening for the rotator cuff
*IR, ER, abduction
3: NSAIDS (naproxen 600-800mg)
4: ice
*NEVER USE A SLING
What is the treatment for a type II shoulder impingement
1: Involves more formal PT
2: modalities (E-stim and ultrasound)
*can use corticosteroids
What is the treatment for Type III impingement?
1: Most likely will need surgery due to associated tearing of the rotator cuff as well as the bicep
What type of injections are used for shoulder impingement?
- Lidocaine + Corticosteroid
*can be therapeutic and diagnostic
What are the indications to use lidocaine + corticosteroid if a patient has shoulder impingement?
- Non responsive to therapy NSAIDS
- Poor surgical candidates with surgical conditions
What is the injection technique?
- Posterior subacromial approach
- Feel for the acromion and inject inferior to the acromion, but angle up to the underside of the acromion
What are the adverse affects if a patient has a RCT but does not want surgery?
- Will not heal
- Retraction
*the rotator cuff is pulling away from the tendon. The muscle of the rotator cuff starts pulling on the tendon - Atrophy
*The patient will lose the muscle, the tendon will atrophy. There will be fatty atrophy the tendon and the muscle turns to fat
What are the different types of surgical options for shoulder impingement?
- Open procedure
- Arthroscopic procedure
- Rotator cuff repair
- Subacromial decompression
