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Transcript of Shoulder Impingement
Osteophytes 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) Capsulo-ligamentous laxity Consequent minor sbluxation of glenohumeral joint, underlie impingement in the younger population. 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) Capsular Tightness A correlation has been shown between impingement and posterior capsular tightness (Tyler et al, 2000) 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) Soft Tissue Changes Itoi et al (1997) and Neer and Welsh (1997) Clinical Presentation Pain Acutely: e.g by trauma Insidiously over a period of weeks to months 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. ...caused either... Normal daily activities such as combing hair or reaching up into a cupboard become painful, and a general loss of strength may be noted. Objective Assessment Supraspinatus: patient abducts the arms
to 90°, forward flexes to 30°, and internally rotates each humerus so that the thumbs are pointed to the floor. A downward force is then applied to the forearms as the patient resists. The Neer impingement test involves injecting the subacromial space with 10 mL of local anesthetic and observing an amelioration of pain with these provocative tests. Thorough examination of neck and shoulder critical to properly diagnosing shoulder impingement syndrome. The muscles of the rotator cuff are best isolated with 3 separate maneuvers... Subscapularis: lift-off (patient places hand behind back and attempts to push away examiner's hand) Teres minor; infraspinatus: with arms at the sides and the elbows flexed. resist the patient in external rotation of the shoulder. 1 2 3 This may be painful or weak with tears of the anterior supraspinatus or subscapularis. This may be painful or weak with tears of the supraspinatus or infraspinatus. Pain or weakness may be seen in disorders of the rotator cuff. (Koester et al 2005) Dr Neer developed this test based on his observations during shoulder surgery. He reported that the critical area for degenerative tendonitis and tendon ruptures was focused on the supraspinatus tendon and at times involved the anterior infraspinatus and occasionally the long head of biceps. Elevation of the arm in external or internal rotation causes critical areas to pass under the coraco-acromialligament or anterior acromion. (Neer 1983) Neers sign elicits pain with maximum passive shoulder elevation and internal rotation while the scapula is stabilised. Hawkins sign is pain with passive forward elevation
to 90° and maximum internal rotation These 2 tests have a negative predictive value of greater than 90% when combined. Marked rotator cuff weakness with positive
impingement signs may indicate a complete cuff rupture. Common description of pain: sharp and catching or chronic following overuse. Other symptoms may include... Painful clicking A sense of instability Apprehension of dislocation on over head movements Heaviness of the arm Observations In chronic SIS, atrophy of the spinati may be marked. Miniaci and Salonen (1997) have illustrated this photographically. Atrophy also accompanies cuff rupture and neurogenic disorders. Muscle Bulk Cervical and upper thoracic posture Posture has been implicated in SIS which has been supported by verious forms of evidence. Crawford and Jull (1993) have shown an inverse relationship between thoracic kyphosis and the range of arm elevation. Static scapular posture Resting scapular postures involving abnormal depression of the acromion might contribute to SIS (Bohmer et al 1998) Scapulohumeral Rhythm Normal scapulohumeral rhythm is smoothly synchonus. SIS patients demonstrate reduced scapular rotation in mid range scapation, more so with loading and increased anterior tilt in the last third of range (Ludewig and Cook 2000) Aims and Objectives of Physiotherapy To minimise pain
To optimise function
To appropriately refer those patients who are unresponsive to physiotherapy To reduce subacromial inflammation and manage pain
To improve posture
To restore range, strength, stability and scapulohumeral rhythm.
To identify when patients should be referred for an orthopaedic opinion. Objectives Aims Physiotherapy Interventions in SIS Rest - there is consensus that the initial management of SIS shoud involve relative rest and avoidance of aggravating factors; particularly overhead activies. Avoidance of aggravating activies is usually combined with non-steroidal anti-inflammatory medication (NSAIDs) aiming to hasten resolution of pain and inflammation. Steroid Injections benefit SIS in the short term - typically considered as an adjunct to rehabilitation. An attempt to correct forward-head posture is appropriate, in view of its association with shoulder pain. Passive Mobilisation of the upper quadrant, as necessary and applied according to the standard princoples (Maitland, 1991) augments the beneficial effect of exercise and should be utilised. A programme of exercises to restore range, strength, stability and scapulohumeral rhythm benefits SIS. The sensitivity and specificity of most tests is low (Bhancdari and Diercks 2011) Unfortunately... Thank you Let's start with a definition... Why does this happen you might ask? There are numerous possibilities... So what should we look for in a patient with a possible shoulder impingement? Are the signs there? If yes, let's continue... Okay, now we know it could be shoulder impingement, what are we as physiotherapists going to do?