Week 1: Subacromial Impingement Syndrome

Question 1

What is the most common condition of the shoulder that patients seek medical management?

Answer 1

Rotator cuff disease

Question 2

At what age and activity level does rotator cuff disease occur?

Answer 2

Any age and activity level

Question 3

According to the medical community, is rotator cuff disease from a single cause?

Answer 3

No, it is multifactorial

Question 4

RCD classifications

Answer 4

• Tendon degeneration
• Tear to avascular region
• Impingement
• Trauma/instability

Question 5

How does the process of tendon degeneration occur?

Answer 5

• Fibroblasts undergo senescence and apoptosis
• The fibers lose their parallel organization and fray
• Tendon swells, making it susceptible to further damage

Question 6

Senescence

Answer 6

The condition or process of deterioration with age

Question 7

Apoptosis

Answer 7

The death of cells which occurs as a normal and controlled part of an organism’s growth or development

Question 8

What is the critical zone of the tendon?

Answer 8

Region with low blood flow on the tendon

Question 9

Where is the critical zone of the supraspinatus?

Answer 9

~10 mm from the distal attachment on the humerus

Question 10

Impingement classifications

Answer 10

• Primary
• Secondary
• Internal

Question 11

What is primary impingement?

Answer 11

• Impingement is the primary problem
• Mechanical impingement b/t the GH joint and subacromial space
• Associated AC joint problems

Question 12

What role does strength imbalance play in primary impingement of the shoulder?

Answer 12

If the supraspinatus and deltoid are imbalanced, the humerus might flight superiorly

Question 13

Structures involved in primary impingement?

Answer 13

• RC tendons
• Long head of biceps
• GH joint capsule
• Subacromial bursa
• Subacromial arch

Question 14

What causes primary impingement?

Answer 14

• RC tendinopathy
• Posterior capsule tightness
• Morphology of the acromion
• Postural dysfunction
• Hooked acromion

Question 15

Acromial types

Answer 15

• Type 1
• Type 2
• Type 3

Question 16

Type 1 acromion

Answer 16

Large area available for tendons and bursa

Question 17

Type 2 acromion

Answer 17

Small area available for tendons and bursa

Question 18

Type 3 acromion

Answer 18

• Small area available for tendons and bursa

- Hooked acromion

Question 19

Neer classification for SIS

Answer 19

• Stage 1
• Stage 2
• Stage 3

Question 20

Stage 1 SIS Neer Classification

Answer 20

• Edema and hemorrhage
• <25
• Reversible
• Conservative treatment

Question 21

Stage 2 SIS Neer Classification

Answer 21

• Fibrosis and tendinopathy
• 25-40
• Recurrent pain
• Consider subacromial decompression (SAD)

Question 22

Stage 3 SIS Neer Classification

Answer 22

• Bone spurs and tendon rupture
• > 40
• Progressive disability
• Surgical management

Question 23

Secondary impingment

Answer 23

Impingement is due to underlying instability

Question 24

Internal impingement

Answer 24

• AKA undersurface impingement
• Occurs at 90+ degrees ER and 90 degrees ABD
• Inferior surface of supra/infraspinatus contacts glenoid rim

Question 25

Structures involved in internal impingement

Answer 25

- Supra/infraspinatus - GH joint capsule - Subacromial bursa

Question 26

Causes of internal impingement

Answer 26

- Capsular laxity - RC weakness - Scapular dyskinesia - Poor throwing mechanics

Question 27

Test item cluster for SIS (Park et al.)

Answer 27

- Hawkins-Kennedy Test - Painful arc sign - Infraspinatus muscle test

Question 28

Patient presentation for SIS

Answer 28

- Pain at night - Pain w/ OH activities - Complaints of stiffness

Question 29

Hawkins-Kennedy Test

Answer 29

- Elbow flexed - IR - Horizontal ADD

Question 30

Painful arc sign

Answer 30

- Patient actively elevates the arm in the scapular plane | - Sign of RC tendon pathology when patient hikes shoulder during ABD

Question 31

Infraspinatus muscle test

Answer 31

Pain on resisted ER

Question 32

Neer's Test

Answer 32

- Pt sitting - One hand depresses scapula - IR pt arm - Forced forward flexion - Positive test is pain

Question 33

Empty Can (Jobe)

Answer 33

- Standing or sitting - Arms elevated to 90 degrees in scapular plane - Full IR - Downward force applied - Positive test is weakness or pain

Question 34

Patient presentation for secondary SIS

Answer 34

- Young - History of instability - Pain w/ OH - Generalized laxity - OH reaching increases symptoms

Question 35

Objective findings for secondary SIS

Answer 35

- Scapular dyskiinesis - Weakness or scapular stabilizers - Hypermobility of anterioir capsule - + instability tests

Question 36

Patient presentation for internal SIS

Answer 36

- Athlete - Pain OH reaching, throwing - Aching posterior shoulder

Question 37

Objective findings for internal SIS

Answer 37

- +posterior impingement test - +instability tests - Scapular dyskinesis - Weakness of scapular stabilizers - Hypermobility anterior capsule

Question 38

Best exercises to manage scapular dyskinesis

Answer 38

- Forward in side-lying - Horizontal ABD w/ ER - Side-lying ER - Prone extension

Question 39

Clinical prediction rule via logistic regression analysis

Answer 39

- Pain-free shoulder flexion <127 - Shoulder IR <53 at 90 degree ADB - Negative Neer test - Not taking meds for pain - Symptoms < 90 days