Subacromial Pain syndrome/Shoulder impingement Flashcards
1
Q
Subacromial pain syndrome/anterior shoulder pain frequency and prevalence in what areas?
A
- most common shoulder disorder
- prevalence is high in repetitive over head sports (swimming, volleyball, throwing)
- prevalent in manual jobs requiring overhead work
2
Q
what are the types of shoulder impingement
A
- anterior impingement/subacromial space
- posterior internal impingement
3
Q
Anterior impingement/subacromial space
A
- compression of structures between anterior humerus and corocoacromial arch
4
Q
Posterior internal impingement
A
- overhead athletes/thrower RC infraspinatus is compressed against posterior glenoid and labrum
5
Q
Types of Anterior impingement/subacromial space
A
- primary vs secondary
6
Q
Primary Anterior impingement
A
Anatomical reasons:
- osteophytes on acromion
- abnormally shaped acromion
7
Q
Secondary Anterior impingement
A
- muscle imbalances: rotator cuff, scapular muscle weakness, decreased endurance, muscle tightness (pec minor)
- hyper mobility/hypomobility GH, ST joints leads to abnormal kinematics
- poor posture: anterior tilt of scapula with rounded shoulders –> muscle tightness/weakness
8
Q
What structures are involved in shoulder impingement
A
- SA bursa
- supraspinatus tendon
- superior capsule
- LH of biceps tendon
9
Q
For full abduction how much does each joint int he shoulder move for the motion to occur
A
- GH: 120º
- ST: 60º
- AC: 30º upward rotation
- SC: 30º elevation
- 40º of clavicle with posterior rotation
10
Q
What are the force couples at the shoulder
A
- supraspinatus, deltoid = abductor couple
- Subscap, infraspinatus, teres minor = downward pull of HH in glenoid
- Upward rotation of scapula thoracic: upper trap, lower trap and Serratus anterior
11
Q
How does posture/rounded shoulders cause impingement
A
- scapular depression, anterior tilt due to tight pec minor
- decreases subacromial space
12
Q
True abduction and Scaption in regards to shoulder impingement
A
- true abduction: gives less space due to hitting the back of the acromion
- scapular plane: humeral head is more situation in the higher part of the acromial arch = less likely to impingement
13
Q
How does an anterior impingement naturally progress
A
- cumulative: many reps over head and overtime in a decreases subacromial space
1. initial tendonitis/tendonosis
2. enlargement of bursae
3. osteophytes off acromion
4. partial tears in RC
5. full thickness RC tears
*due to poor vascularity and degeneration of RC
14
Q
Mulitfactoral - acromial shapes due to osteophytes
A
- Smooth (stage 1)
- Curved (stage 2)
- hooked (stage 3)
15
Q
How does hypomobility in GH joint cause impingement?
A
- joint capsule tightness
- esp. if it is limited inferiorly or posteriorly
- HH cant glide inferior or posterior on glenoid
16
Q
How does hypermobility and RC weakness cause impingement
A
- weak infraspinatus, Teres minor, subscapularis casues an inefficient downward pull of the humeral head
- combined with excessive movement can cause impingement and less stability
17
Q
How can posture cause impingement
A
- forward head and rounded shoulders can decrease subacromial space
- tightness in pec minor
- weakness of serratus anterior, upper adn lower trap
18
Q
Describe how a posterior internal impingement occurs
A
- in late cocking phase
- throwers: excessive ER with posterior roll and anterior glide of humeral head
- infraspinatus internal surface impinges against glenoid due to excessive ER
19
Q
Posterior internal impingement signs and symptoms
A
- pain in posterior shoulder during late cocking phase
- posterior internal impingement test: place shoulder in 90 of abduction with 15-20 extension and max ER
- positive if pain occurs in the posterior shoulder
- pain with palpation of infraspinatus to confirm as well as RI of ER
20
Q
Examination for impingement: Review of systems and history
A
- anterior impinge = frequent elevation activites; pain with elevation or adduction/IR
- Internal impingement: throwers; pain posterior, excessive ER and anterior glide, many reps, overuse, inadequate rest
21
Q
Examination for impingment: diagnostic test/PMH
A
DX:
- X-Rays: acromion shape (hooked) osteophytes
- MRI: rotator cuff tear
PMH:
- episodes of bursitis, tendinitis/tendinosis
- cortisone injections (2-3 over weeks or months)
- previous physical therapy bouts
22
Q
Examination for impingement: observations
A
- posture: fwd head, rounded shoulders, anterior scapular tilt, scapula elevation/winging
- functional screen: dysfunctional movement
- Atrophy RC
23
Q
Examination for impingement: examination/signs of impingement
A
- GH A/PROM = limited or excessive
- Painful arc = 60-120 (anterior impingement)
- posterior impingement (throwers) = pain in late cocking phase, increase ER than IR
24
Q
Examination for impingement: GH, AC, SC, ST mobility testing
A
- hypomobile, abnormal capsular end feel (stiff), posterior/inferior capsule
hypermobilty/instability: - abnormal capsular end feel = laxity
- poor dynamic stabilization of RC
25
Examination for impingement: musculature
- resisted isometrics = weakness/painful (rotator cuff and biceps)
- ST muscles weak, poor endurance of serratus anterior upper and lower trap
- length testing: pec minor and major
26
impingement special tests
- Neer
- hawkins-kennedy
- coracoid impingement sign
- supine impingement test
- painful arc test
- scapular relocation tests/empty can
27
Predictors for anterior impingement syndrome:
| Clinical Findings
- (+) hawkins-kennedy
- (+) painful arc test
- supraspinatus, infraspinatus pain and weakness
28
Examination for impingement: palpation
- pain with palpation on
- suprapsinatus tendon: put arm in Ext+IR and palpate near greater tubercle
- infraspinatus tendon
- long head of biceps tendon
29
Impingement due to ...?
- posture:
- decreased RC strenght/endurance
- decrease scapula strength and endurance
- scapula dyskinesia
- shoulder hypomobility
- shoulder hypermobility
- hooked acromion
- combination
30
Neer Subacromial impingement classification: stage 1
- young age <25
- inflammation of RC, edema, hemorrhage
- RI = strong and painful
- mild
31
Neer Subacromial impingement classification: stage 2
- age 25-40 (history of episodes)
- hx: tendinitis/bursitis; fibrosis of RC tendon
- RI = strong and painful
- capsular pattern developing
- could have injections
32
Neer Subacromial impingement classification: stage 3
- age >40
- bone spurs, osteophytes, hooked acromion
- tendon disruption
- RI weak and painful (could have a tear now)
- capsular pattern present
- may require surgery
33
Neer Subacromial impingement classification: stage 4
- age>60
- chronic RC tear progressed to full tear
- surgery -- depends on quality of tissue
- decompression/acromioplasty (create more space) :
- RC repair
- removal of the acromion
- resect the distal calvicle
- release the coracoacromial ligament
34
Acute stage impingement treatment
- modalities: pulsed US (LIPUS), iontophoresis, cryotherapy
- rocking rhythmic exercise (pendulums)
- grade 1-2 mobs
- educate the patient: posture, impinge zone, activity modification
35
MD interventions for shoulder impingement
- medications (NSAIDs, pain meds, steriods)
- steriod injections
- surgery decompression acromioplasty
- RC repair if needed
36
standardized treament program
- 3 phase = 12 weeks
- manual therapy: shoulder stretches, mobilization/manipulations
- strengthening RC/scapular muscules
- patient HEP, educaiton, activity modificaiton
- 8/10 patients increase DASH by 50%
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