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SHOULDER IMPINGEMENT SYNDROMEIli Diyana Binti Nor Azni
ANATOMY OF THE SHOULDER
SHOULDER IMPINGEMENT SYNDROME
Definition : Occurs when the rotator cuff tendons, long head of the biceps tendon, glenohumeral joint capsule, and/or subacromial bursa become impinged between the humeral head and anterior acromion.
MECHANISM OF INJURY
Shoulder instability- rotator cuff weakness A radiographic study of normal subjects has
shown that the humeral head migrates proximally when the cuff is fatigued (Chop et al 2010)
Bony anatomical pathological factors
Type 3 hooked shaped acromion
Capsular Tightness A correlation has been shown between
impingement and posterior capsular tightness (Tyler et al, 2000)
Impaired scapulohumeral rhythm and scapular instability Scapula motion is impaired with people with
shoulder impingement. This is linked to decreased serratus anterior activity and scapular instability (Ludewig and Cook, 2000)
Capsulo-ligamentous laxity Consequent minor subluxation of glenohumeral
joint, underlie impingement in the younger population.
Postural Factors The potential link between posture and
impingement may be illustrated by elevation of the arm in a coronal plane while slouching. It causes a painful arc, presumably by depressing the point of the acromion and lowering the acromial arch.( Lin et al., 2010)
CLINICAL PRESENTATION Pain
Pain is typically localised to the anterolateral acromion and frequently radiates to the lateral mid-humerus
Patients usually complain of pain at night, exacerbated by lying on the involved shoulder, or sleeping with the arm overhead.
Normal daily activities such as combing hair or reaching up into a cupboard become painful, and a general loss of strength may be noted.
Painful arch syndromeQuality of pain (eg, sharp, dull, radiation, throbbing,
burning, constant)
Painful clicking sound Apprehension of dislocation on overhead
movement Feeling of heaviness of hand.
DR MX.1.Conservative Rest and avoid overhead
activities Anti-inflammatory drugs
http://www.shouldersurgeon.com/shoulder_impingement/
2. Surgical
- A small incision is made- Shave off a tiny portion of the acromion process- Allowing a pain free movement in the shoulder joint
PT MANAGEMENT
Modalities Manual therapy Stretching Mobilizing exercise Strethening exercise
STRETCHES
Codman’s Pendulum Swings
Triceps Stretch
Horizontal Adduction Stretch
Internal Rotation Stretch
http://www.athleticadvisor.com/images/Acrobat/Impingement.pdf
STRETCHES CONT..
External Rotation
Standing Adduction Stretch
http://www.athleticadvisor.com/images/Acrobat/Impingement.pdf
Chest and Biceps Stretch
EXERCISES TO STRENGTHEN SITS MUSCLES
Bent over rows
http://www.athleticadvisor.com/images/Acrobat/Impingement.pdf
Seated Dips
Active Flexion
CASE STUDY-
Demographic Data Name : Mr. H. Age : 67 Gender : Male Race : Malay Doctor’s Diagnosis : Sh. Pain secondary to old
injury Date of PT assessment : 25/3/2014
Pt.’s Problems c/o inability to fully lift up his Lt sh. and on
overhead movement Claim had difficulty removing shirt and inability
lift heavy (>5kg objects)
Pain Assessment
Area : ant. aspect of Lt. sh.
Nature : throbbing, catching pain
Agg. : Lift hand >90deg, remove off shirt, carry heavy
objects >5kg, do exercise (VAS : 5/10)
Ease : Rest, hand in normal position (VAS : 0/10)
24 hrs: Depend on activity, more pain at night if
sleep on Lt. sd. but not disturbing sleep
Irritability : non-irritable (pain will subside
immediately after agg. factor removed )
Severity : not severe
AREA OF PAIN
Special QuestionGeneral health : GoodOther health condition : HPT and DM since past 2 yrsMedication : HPT and DM medicationX-ray : NilDominant hand : Lt. hand
Current Hx.Pt referred to physio HKK after receiving physio
treatment at KK Cheras for 3/52 Past Hx. : Pt had Lt sh. pain since past 6/12 after
knitting fruit. The pain gradually increase and
pt referred dr. on Jan 2014 as the pain
became unbearable. Pt then referred to do
physio at KK Cheras
Past Hx. : Pt had h/o Lt ant sh. dislocation 10 yrs ago
Social Hx. : Occ: Retired estate manager
Dominant hand : Lt hand
OBJECTIVE ASSESSMENT
ObservationGeneral :
Pt medium sized Malay man came into dept. with normal gait.
Posture : - Slightly kyphotic - ears slightly anterior than shoulder
- Lt. Sh. and scapula lower than Rt.
- No winging of scapula - Pelvic same level - Kn. same level
Local :No swelling at shoulder regionNo redness at shoulder region
Palpation Muscle spasm noted on Lt upper trapezius Pain on palpation over biceps long head,
supraspinatus and subscapularis tendon.
ROM
Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-100° 0-110°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM
UL Muscle strength 30 secs biceps curl
Reading Lt Rt
1st 23 25
2nd 22 24
3rd 21 24
Average 22 24
CLEARING TEST
Scapula physiological movement –
Neck - AFROM
movement
Lt. Rt
Active Passive Active Passive
Elevation normal normal normal normal
Depression
normal normal normal normal
Protraction
normal normal normal normal
Retraction
normal normal normal normal
SPECIAL TEST
Neer’s test: +ve indicate impingement Hawkin Kennedy : +ve indicate impingement Speed test : +ve indicate bicipital tendinitis Empty can test: +ve indicate supraspinatus
tendinitis Anterior drawer test : -ve Posterior drawer test : -ve
FUNCTIONAL ACTIVITY
DASH Diasability Symptom scoreScore: 42.5% - moderate disability
ANALYSIS
Impairment Pain at Lt anterior and lateral sd. of Lt. sh d/t
subacromial inflammation Reduced ROM of Lt. glenohumeral jt. d/t pain Recduced Lt Sh. Muscle power d/t reduced mobility Muscle spasm of upper trapezius d/t protective
mechanism of muscle
Functional limitation Difficulty to remove off shirt Difficulty on reaching high objects (overhead
movement) Unable to carry heavy objects (>5kg)
Participation rx Restricted sports and recreational activity with
friends and family members
SHORT TERM GOAL
To reduce pain in 1/7 To improve ROM in 1/52 To increase muscle power in 2/52 To reduce upper trap muscle spasm in 1/7
LONG TERM GOAL
To maximize functional activity of daily living To prevent secondary complication
PLAN OF TX
Pain mx. Mobilizing exe Strengthening exe Stretching MFR HEP Pt. edu
INTERVENTION U/S at biceps long head, supraspinatus , and subscapularis tendon; 1MHz, 0.8 W/cm X 5min
MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;
rep 10 X every movt. Std.; put hands on hips, lean back, hold 15 sec.;
rep 5X Std.; pull sh. Up and back; hold 15s; rep 5X Sitt.;horizontal add. Lt sh.;hold and push Lt
elbow backward using Rt. Arm; hold 5s; rep 5X Sitt.; ext rot sh. With 1kg dumbell ;rep 10X Sitt.; int rot sh. With 1kg dumbell ;rep 10X Hot pack at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day
Evaluation : Pt able to do exercise with minimal pain.
Review : To reasess ROM and painscale on next visit
2ND VISIT ON 26TH MAR 2014 Subjective Ax: Pt. claim VAS still same Objective Ax:
ObservationGeneral :
Pt medium sized Malay man came into dept. with normal gait.
Local :No swelling at shoulder regionNo redness at shoulder region
Palpation Muscle spasm noted on Lt upper trapezius Pain on palpation over biceps long head,
supraspinatus and subscapularis tendon.
Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-100° 0-110°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM
Analysis : no significant improvement Plan :
Pain mx. Mobilizing exe Stretching Strengthening exe MFR HEP Pt. edu
INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ;
10X; 6 cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.;
abd.;add.; rep 10 X every movt. Sitt.;horizontal add. Lt sh.;hold and push Lt elbow
backward using Rt. Arm; hold 5s; rep 5X Std.;place hand at sh. Level on room corner; lean fwd;
hold 15 s; rep 5X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X Hot pack at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day
Evaluation : Pt able to do exercise with minimal pain.
Review : To reasess ROM and painscale on next visit
3RD VISIT ON 31ST MAR 2014
Subjective Ax: Pt. claim VAS still same Objective Ax:
Observation General :
Pt medium sized Malay man came into dept. with normal gait.
Local :No swelling at shoulder regionNo redness at shoulder region
Palpation Muscle spasm noted on Lt upper trapezius Pain on palpation over biceps long head,
supraspinatus and subscapularis tendon.
Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-120° 0-125°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM
Analysis :Sh. flex ROM improved by 10 ° Plan :
Pain mx. Mobilizing exe Stretching Strengthening exe MFR HEP Pt. edu
INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ; 10X; 6
cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;
rep 10 X every movt. Sitt.;neck stretching; hold 5s; rep 5X Std.;place hand at sh. Level on wall; wall push up; hold 10 s;
rep 10X Std.; bend elbows at sh. Level using elastic cord; hold 10s; rep
10 X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X SWD at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day
Evaluation : Pt able to do exercise with minimal pain.
Review : To reasess ROM and painscale on next visit
4TH VISIT ON 3 APR 2014 Subjective Ax: Pt. claim VAS still same Objective Ax:
ObservationGeneral :
Pt medium sized Malay man came into dept. with normal gait.
Local :No swelling at shoulder regionNo redness at shoulder region
PalpationMuscle spasm noted on Lt upper trapeziusPain on palpation over biceps long head,
supraspinatus and subscapularis tendon.
Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-140° 0-145°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM
Analysis : no significant improvement Plan :
Pain mx.Mobilizing exeStretchingStrengthening exeMFRHEPPt. edu
INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ;
10X; 6 cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.;
abd.;add.; rep 10 X every movt. Sitt.;horizontal add. Lt sh.;hold and push Lt elbow
backward using Rt. Arm; hold 5s; rep 5X Std.;place hand at sh. Level on room corner; lean fwd;
hold 15 s; rep 5X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X Hot pack at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day
Evaluation : Pt able to do exercise with minimal pain.
Review : To reasess ROM and painscale on next visit
5TH VISIT ON 7TH APR 2014
Subjective Ax: Pt. claim VAS still same Objective Ax:
Observation General :
Pt medium sized Malay man came into dept. with normal gait.
Local :No swelling at shoulder regionNo redness at shoulder region
Palpation No spasm noted on Lt upper trapezius Pain on palpation over biceps long head tendon.
Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-150° 0-155°
FROM
Ext FROM FROM
Abd 0-100° 0-105°
Int. Rot. 0-20° 0-20°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM
Analysis : Increased Sh. ROM and reduced VAS to 4/10 on agg condition.
Plan : Pain mx. Mobilizing exe Stretching Strengthening exe HEP Pt. edu
INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ; 10X; 6
cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;
rep 10 X every movt. Sitt.;neck stretching; hold 5s; rep 5X Std.;place hand at sh. Level on wall; wall push up; hold 10 s;
rep 10X Std.; keep elb. Straight and pull elastic band posteriorly; hold
10s; rep 10X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X SWD at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day
Evaluation : Pt able to do exercise with minimal pain.
Review : To reasess ROM and painscale on next visit
CONCLUSION
Manual technique and exercise is beneficial in order to reducing pain and improving function on patient with shoulder impingement syndrome
Review on articles found that ultrasound is either not give a significant benefit or giving no benefit at all for impingement cases.
Grade 1 oscillatory joint mobilization technique can be used in order to relieve pain in impingement syndrome only but not necessary to improve mobility and function when combined with modalities, stretching strengthening exercise and patient education.
REFERENCES Atalar, Hakan, Yilmaz, Cengiz, Polat, Onur, Selek, Hakan, Uras, Ismail, & Yanik, Burcu. (2009).
Restricted scapular mobility during arm abduction: implications for impingement syndrome. Acta Orthopaedica Belgica, 75(1), 19.
Boileau, Pascal, Moineau, Grégory, Roussanne, Yannick, & O’Shea, Kieran. (2011). Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clinical Orthopaedics and Related Research®, 469(9), 2558-2567.
Faber, Elske, Kuiper, Judith I, Burdorf, Alex, Miedema, Harald S, & Verhaar, Jan AN. (2006). Treatment of impingement syndrome: a systematic review of the effects on functional limitations and return to work. Journal of occupational rehabilitation, 16(1), 6-24.
Hughes, PC, Green, Rodney A, & Taylor, Nicholas F. (2012). Measurement of subacromial impingement of the rotator cuff. Journal of Science and Medicine in Sport, 15(1), 2-7.
Jia, Xiaofeng, Ji, Jong Hun, Pannirselvam, Vinodhkumar, Petersen, Steve A, & McFarland, Edward G. (2011). Does a positive neer impingement sign reflect rotator cuff contact with the acromion? Clinical Orthopaedics and Related Research®, 469(3), 813-818.
Kelly, Susan M, Wrightson, Patricia A, & Meads, Catherine A. (2010). Clinical outcomes of exercise in the management of subacromial impingement syndrome: a systematic review. Clinical rehabilitation, 24(2), 99-109.
Michener, Lori A, Walsworth, Matthew K, & Burnet, Evie N. (2004). Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. Journal of Hand Therapy, 17(2), 152-164.
Patel, Bhavesh, Bamrotia, Praful, Kharod, Vishal, & Trambadia, Jagruti. (2013). Effects of Scapular Stabilization Exercises and Taping in Improving Shoulder Pain & Disability Index in Patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis. Indian Journal of Physiotherapy & Occupational Therapy-An International Journal, 7(1), 191-195.
Senbursa, Gamze, Baltacı, Gul, & Atay, Ahmet. (2007). Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee surgery, sports traumatology, arthroscopy, 15(7), 915-921.