Shoulder impingement syndrome

1. SHOULDER
IMPINGEMENT
SYNDROME
-Dr. AISHWARYA RAI
BPT, FELLOW IN REGENERATIVE
REHABILITATION, CKTP
18TH JULY,2018

2. ANATOMY OF THE
SHOULDER JOINT
•The shoulder joint is a synovial joint of the ball and
socket variety.
•Structurally, it is a weak joint because the glenoid cavity
is too small and shallow to hold the head of the humerus
in place
•The shoulder joints get excessive mobility at the cost of
its own stability, since both are not feasible to the same
degree.
•BONES FORMING THE SHOULDER COMPLEX
1. Clavicle 2. Humerus 3. Scapula 4. Sternum
• Due to the compromised mobility of the joint a few
structures that provide stability to the joint are:
1. The rotator cuff 2. Ligaments 3. Glenoid Labrum
4. Long head of Biceps brachii muscle

3. Fig: SHOULDER JOINT
COMPLEX

4. Fig: AC Joint
Fig: SC Joint

5. Fig: Scapulothoracic joint

6. Fig: GH Joint

7. BURSAE AROUND THE JOINT

8. LIGAMENTS OF SHOULDER JOINT

9. MUSCLES OF THE JOINT

10. MUSCLES OF SHOULDER
REGION
The Extensors of the
Shoulder
Muscle Nerve Spinal Nerve Root
Posterior fibres of Deltoid Axillary C5(C6)

13. MOVEMENTS AT THE
SHOULDER JOINT
The movements available at the
shoulder joint are:
•Flexion
•Extension
•Abduction
•Adduction
•External rotation &
•Internal rotation }
}
} In the Sagittal Plane
In the Frontal PLane
In the Horizontal Plane

16. THE ROTATOR CUFF

19. DEFINITION
Shoulder impingement syndrome can be defined
as the encroachment of the 1/3rd acromion,
coracoacromial ligament, coracoid process, and/or
acromioclavicular joint on the structures that pass
beneath them as the glenohumeral joint is moved,
particularly in flexion and rotation.
The term “Impingement Syndrome” was
popularized by Charles Neer in 1972.
This also affect the bursa – resulting in bursitis.
Shoulder complex is susceptible to impingement
injuries from overhead sports –
– Such as baseball, tennis, swimming, volleyball etc.

20. PATHOPHYSIOLOGY
The pathology of subacromial impingment generally
relates to a chronic repetitive mechanical process in
which the conjoint tendon of the rotator cuff muscles
undergoes repetitive compression and micro trauma
as it passes under the coraco-acromial arch.
As the arm is flexed, abducted or rotated the
subacromial space width changes and the cuff
becomes increasingly compressed.

21. AETIOLOGY
EXTERNA
L
INTERNAL
(GLENOID)
PRIMARY
SECONDAR
Y
REPETITIVE
TRAUMA
OUTLET
OBSTRUCTION
INSTABILITY INSTABILITY
ROTATOR
CUFF
DYSFUNCTION

22. TYPES OF IMPINGEMENT
SYNDROME
PRIMARY:
Impingement occurs beneath the coracoacromial arch and is
due to the subacromial overloading.
SECONDARY:
Occurs due to relative decrease in the subacromial arch and is
due to microinstability of the GH joint or ST joint.
POSTERIOR(INTERNAL):
In this the supraspinatus and infrapinatus tendons are pinched
between the posterior and superior aspects of the glenoid
when the arms are in an elevated and externally rotated
position. It is usually seen in athletes involved in more of
overhead activities like throwers, swimmers, etc.

23. NEER’S STAGES OF
IMPINGEMENT
 Stage 1 is characterized by edema and tendinitis and is more
typical in patients under 25 years old.
 Stage 2 is characterized by chronic inflammation, thickening and
fibrosis of the impinged tendon due to repeated insults. This
further decreases the size of the suprahumeral space. Stage 2 is
more typical in patients between 25 and 40 years old and patients
who have had a history of episodes of shoulder pain.
Stage 3 is characterized by tendon degeneration, rupture, and
arthritis. Patients with this stage of impingement are usually over
40 years old and have a prolonged history of shoulder problems.
Often, at this stage, there will be radiographic evidence and a high
likelihood of partial or full thickness rotator cuff tears.

24. CONTRIBUTING
FACTORS
FOR DEVELOPMENT OF EXTERNAL
IMPINGEMENT
FOR DEVELOPMENT OF INTERNAL
IMPINGEMENT
Anatomical abnormalities– shape of
acromion may be either flat, curved or
hooked
Overuse or RSI
Poor scapular control Loose joint
Anterior instablity Instability
Postural changes in upper quadrant
(Forwarded head & rounded shoulders)
Muscle imbalance
Superior Labrum Injury

25. SYMPTOMSKEY SYMPTOMS OF
IMPINGEMENT
•Toothache like Anterolateral shoulder region.
• Pain sleeping on the affected side
• Stiffness
• Catching of the shoulder during use
• Pain on active and passive range of motion
• Local tenderness
•Nocturnal pain

26. ASSESSMENT
DEMOGRAPHIC DATA:
NAME, AGE,GENDER, CONTACT DETAILS, OCCUPATION OF
pt. BMI.
---usually seen in pts aged 30-50 years, pts who have a
background of sports like swimming, basket ball etc, tend to
have IS.
CHIEF COMPLAINT:
Pain, restriction of ROM, Functional limitation
--- Pain and weakness after eccentric loading.
HISTORY OF:
Present of illness, past illness, medical, surgical, socio-
economic, environmental, family, drug, personal and pain.
--onset, diurinal pattern, systemic disorders, trauma, habits,
provocating and relieving factors, acute or chronic,
progressive or no.

27. OBSERVATION:
GAIT deviation, facial expression, body alignment, postural, soft tissue
contour, crepitus, swelling, redness.
--Arm swing less, face may reflect pt condition if severe,shoulder
rounded, hypertrophy if chronic due to less use and muscle weakness,
crepitus present if chronic case, swelling and redness in case bursitis
also involved or in acute cases.
EXAMINATION:
Vital signs, superficial, cortical and deep sensation in dermatomes and
myotomes affected, In Range of Motion Findings Impingement is
indicated when pain upon testing is located anterior and inferior to the
acromion and the AC joint, MMT, RIM, Functional assessment.
--- Weakness of abduction or rotation, or both in MMT, Crepitus may be
present, pain if impingement occurs, patient will have difficulty
performing overhead activities or others. A painful arc of GH motion may
be present at 60-100º of abduction, possibly accompanied by GH
catching, Pain and weakness on abduction and lateral rotation in RIM

28. SPECIAL TESTS:
Neer’s
Impingement
Test

29. Hawkins
Kennedy
Test

30. CROSSOVER
IMPINGEMENT
TEST

31. Scapulothoracic Rhythm
The scapula should not appreciably
move during first 30 and last 30
degrees of abduction. The middle of the
range should move at about a 1:1
relationship with the humerus.
Abnormal movement can suggest
scapular adhesions, capsular
adhesions, or poor muscular control
and coordination.

32. DIAGNOSTIC
IMAGING OPTIONS
**Indicators for imaging studies include localized swelling,
history of significant trauma, pain and limitation of motion
with shoulder movement in all directions, and significant
shoulder pain in those patients over 40 years of age.
Lab Tests:
If there is suspicion of a disease process, an ESR/CRP and CBC
can be ordered. In cases where an inflammatory process is
suspected, consider an arthritis screening panel that includes
uric acid level
Film Radiography:
X-ray views of the shoulder should include internal and external
rotation and axillary views to look for calcific bursitis, cystic
changes in the greater tuberosity, congenital abnor-malities in
the shape of the acromion, or superior migration of the humerus,
(indicates rotator cuff tear).

33. MRI:
Indicators include a strong suspicion of rotator cuff tear, large spurs on X-
rays, or failure to respond to six to eight weeks of conservative care. MRI of
the shoulder will detect or rule out bony or soft tissue pathologies of the
coracoacromial arch including rotator cuff tear, any impingement of the
tendon(s) by spurs, and avascular necrosis.
Computed Tomography:
When combined with arthrography, this is the most sensitive technique to
evaluate the glenoid labrum and joint capsule in suspected secondary
impingement.
.Ultrasound:
This is most useful in patients over 50 who are suspected of having complete
tears.

34. Fig: Calcific
tendinitis of the
supraspinatus
tendon is the
cause of
shoulder
impingement

35. Fig: MRI showing
a disruption of the
articular surface
of the
supraspinatus
near its insertion
(black arrow).
There is a bursal
surface tear of the
supraspinatus
near the
myotendinous
junction (white
arrow).

36. Fig: Ultrasound images of supraspinatus tendon in long axis (A) and short
axis (B) show well-defined anechoic disruption of the tendon fibers (curved
arrow), which surrounds the hyperechoic tendon stump distally and creates a
mixed hyperechoic-hypoechoic appearance

37. MANAGEMENT
CONSERVATIVE MANAGEMENT
SURGICAL MANAGEMENT
MEDICAL MANAGEMENT
NSAIDS
CORTICOSTEROID INJECTION
PT MANAGEMENT

38. PHARMACEUTICAL
THERAPEUTICS
Oral corticosteroids or NSAIDs: Occasionally, when
there is intractable pain then referral for prescription
strength NSAIDs or oral corticosteroids is considered
OTC medications can also be recommended
Corticosteroid Injection Therapy: Corticosteroids may be
injected into the subacromial space. It is a short-term
treatment for impingement syndrome.
Dosimetry: No more than 2 injections 3 months apart due to
mechanical disruption of the integrity of articular cartilage and
tendons. However, it isn’t very effective due to reversal of the
condition post 3-12 months of the therapy.

39. PHYSIOTHERAPEUTIC
MANAGEMENT
The management of the patients depend upon the
phase that the patients present with.
The treatment goals depend upon the phase the
patient is in.
Patients may enter care at any of the phases listed
below.
•Patients may enter care at any of the phases listed below. However, the
we should review the acute care recommendations to see if any would
still be applicable, while at the same time moving the patient into the
appropriate phase of management.
•The phases being:
Acute Inflammatory Phase Intervention:
Usually 1-3 days from time of onset or whenever the patient relapses into an
acute phase.
Phase 1 Rehabilitation: When the acute phase ends,
usually from day 3 to two weeks.
Phase 2 Rehabilitation: Approximately week 2 to week 4.
Phase 3 Rehabilitation: Approximately week 4 to week 6.
Phase 4 Rehabilitation: Approximately week 6 to week 8.

40. ACUTE INFLAMMATORY
PHASE
1. To reduce pain and inflammation.
2. Maintaining pain-free range of motion (ROM) and
proprioceptive awareness.
3. Preventing muscular atrophy.
4. Normalizing the biomechanics of the shoulder girdle
complex, the costovertebral articulations, and the
cervical and thoracic spinal joints.
5. Teaching postural awareness specific to the shoulder
girdle complex.
6. Protecting the injured tissue from further trauma
TREATMENTGOALS

41. REDUCE PAIN AND INFLAMMATION:
MAINTAIN PAIN-FREE RANGE OF MOTION AND
PROPRIOCEPTIVE AWARENESS:
Ice with compression
PUST: phonophoresis with hydrocortisone or lidocaine or salicylate
 Interferential therapy, 0.5-1.2 W/cm2, 3MHz, for 6 mins daily for 10 days
Iontophoresis (+) polarity (magnesium sulfate 2%, hydrocortisone
0.5%, xylocaine 5%);
DTFM is useful and yeilds better results when combined with other
modalities.
Myofacial Trigger point therapy– 2-3 times per week for 1-2 weeks.
Generalized passive-ROM therapy: Codmans exercises i.e pendular
exercises, wand exercises.
Active internal and external movts. With arm in dependant positions.
 Maitland mobilization to GH and ST joint, Grade I and II in initial stages
and progressed to III and IV. AP and inferior glides are applied, Usually 10
oscillations each in 3 sets is given.

42. Quad polar pad placement for
treating supraspinatus muscle.
Quad polar pad placement for
treatment of biceps tendon.
Graphic pad placement for treatment
of biceps or supraspinatus tendon.
Graphite pad placement for treatment of
supraspinatus tendon.
IFT
PLACEMENT

43. DTFM:
1. Supraspinatus muscle;
2. Tendon of the long head of the
biceps brachii muscle;
The above two are done by middle
finger superimposed by the index
finger;
3. Alternate method using thumb
whereas the 1st and 2nd fingers
anchor behind pts arm. Done for
15mins

44. Doctor-assisted isometrics:
To begin with submaximal isometrics (65% maximum) until pain limits. We
should focus on the rotator cuff muscles and the long head of the biceps.
Initially in the dependent position then in multi angle isometrics (MAI) as
pain allows while avoiding impingement positions.
--Can be done using physioball or patient’s free hand, done 6times a day
with reps and 6secs hold each.
Handball squeezes: These can also be done at multiple angles (20-
degree intervals in scaption or flexion), staying below the impingement
range.
PRE of unaffected large group muscles promotes healing and reduces
muscle atrophy.
PREVENT MUSCULAR ATROPHY
POSTURAL FIRST AID
The patient can be taught strategies to prevent inappropriately elevating or
“hiking” the shoulder when raising the arm. Rounded or anteriorly rolled
shoulders and forward head carriage can be corrected by “lifting” the
sternum.

45. REHABILITATION:
PHASE-1
1. Promoting collagen repair and preventing or reduce
adhesions
2. Improving pain-free range of motion and proprioceptive
awareness.
3. Preventing atrophy and strengthen GH stabilizers and
humeral head depressors.
4. Improving scapulothoracic stabilization.
5. Normalizing joint mechanics of spine and shoulder girdle.
6. Continuing postural education.
7. Continuing control of pain and inflammation
TREATMENTGOALS

46. PROMOTE COLLAGEN REPAIR &PREVENT OR REDUCE ADHESIONS
DTFM 3 times/week; to be done for 2-4 weeks.
Contrast bath- for a total of 20minutes, to be terminated using ice.
PUST with phonophoresis- It is used to manage inflammation with
hydrocortisone ointment (1%) or salicylate ointment (10%). Analgesic effects
can be achieved with lidocaine ointment (5%).
IFT- conventional type
IMPROVE PAIN-FREE ROM AND PROPRIOCEPTIVE AWARENESS
Elongate and relax muscles: Choosing any combination of post-isometric
relaxation (PIR), contract-relax, hold-relax, reciprocal inhibition, cool and
stretch, and myofascial release technique(MFR).
Stretch posterior capsule: Posterior capsule tightness is sometimes
implicated in impingement syndromes.
Increase range of motion: We can continue general passive ROM with
traction through the painful arc of abduction and external rotation.
ROM exercises can be followed by pulley exercises, or other home ROM
activities to improve all motions within pain-free limits. Emphasis should be
given on flexion, extension, and scaption. It includes wand exercises
(moving from passive to active assisted) wall walking, auto-mobilization
techniques and physioball ROM activities
PREVENT MUSCULAR ATROPHY
Russian muscle stimulation may be used in select cases to immediately
begin muscle conditioning.

47. Fig: Stretching procedure
in horizontal adduction,
targeting the posterior
capsule and the external
rotators of the shoulder
(infraspinatus and teres
minor). The posterior
capsule can often be tight
in impingement
syndromes.

48. Supine lying; Knees flexed;
Stretching affected arm up
overhead, assisted by other
arm. Aiming to get your arm
to the floor.
Holding a
doorframe with
both hands at
shoulder height.
Slowly lean away
from the door to
feel a stretch in
your chest or
arms.
External rotation – Abduct your
affected shoulder to 90 degrees
and bend your elbow. Use a
towel and hold the top with the
hand of the affected side. With
your other hand, gently pull on
the bottom of the towel and let
your top hand slowly move back
and down.
Internal Rotation - Place
the hand of the affected
side behind your back.
Hold a towel with your
other hand over your
affected shoulder. Grip the
bottom of towel and gently
pull the towel upwards
drawing your bottom hand
backwards and upwards
towards your mid back.Clasp both hands behind your
head. Keeping your shoulders
away from your ears slowly
take your elbows backwards to
feel a stretch.

49. These movements are done repetitively (10-15 times
or to patient tolerance). Once patients know the
cross patterns, these may be assigned as active
home exercises, either with resistance (e.g., bands
or tubing), or without. Two of the movements
(somewhat simplified here) are the “sword” and
“seat belt” patterns.
PROPRIOCEPTIVE AWARENESS

50. IMPROVE SCAPULOTHORACIC STABILIZATION
It is critical that patients have a properly functioning scapular
base from which the GH joint can operate. Our focus should be on the weak
scapular stabilizers: most commonly the serratus anterior and middle and
lower trapezius. If the scapular protractors are weak, the acromion may not
elevate high enough, which may cause impingement of the suprahumeral
structures. So begin with isometrics and work up to MAI.

51. NORMALIZE JOINT MECHANICS OF SPINE AND SHOULDER GIRDLE
Mobilizing GH joint.
Mobilizing the scapulothoracic articulation, the AC and SC joints.
ANTERIOR
SUPERIOR
INTERNALLY
ROTATED
HUMERUS

52. CONTINUING CONTROL OF PAIN AND INFLAMMATION.
POSTURAL EDUCATION

53. REHABILITATION:
PHASE-2
TREATMENT
GOALS
1. Continuing goals of Phase-1
2.Gradually increasing the muscle
strength to aid GH and
scapulothoracic stability.

54. Continuing soft tissue therapy: DTFM, Therapeutic stretching, MET,
Trigger point therapy, MFR.
Mobilisation of joints.
Continue doctor-assisted ROM or wand ROM activities or auto-
mobilization home exercises.
Continuing stretching activities for the GH muscles and posterior
capsule.
Continuing scapular stabilization track.
Electromodalities: IFT, PUST, Iontophoresis, Cryotherapy and
Contrast Bath.
Promoting local proprioceptive retraining- The ‘sword’ and ‘seat-
belt’ patterns.
CONTINUING GOALS OF
PHASE-1

55. GRADUALLY INCREASING THE MUSCLE STRENGTH TO AID GH AND
SCAPULOTHORACIC STABILIZATION
With the patient lying prone, use horizontal abduction with external rotation to
activate and train proximal scapular stabilizers.
Adding isometric and isotonic exercises in flexion and scaption plane, as well
as in IR
and ER. Begin biceps curls, palm up and palm down.
Add MAI abduction and adduction exercises.
Chair press-ups and, if available, lat pull downs can also be helpful.
INTERNAL
ROTATION
EXTERNAL ROTATION
ADDUCTION FLEXION (AT ELBOW)
ADDUCTOR STRENGHTHENING
DELTOID
STRENGHTHENING
EXTENSOR
STRENGHTHENING
MEDIAL ROTATOR
STRENGHTHENING
LATERAL ROTATOR
STRENTHENING

56. 1. Continue to build strength and endurance.
2. Begin functional-demand training and
return-to-work
strategy.
3. Continue proprioceptive coordination and
retraining.
REHABILITATION:
PHASE-3
TREATMENT
GOALS

57. TO CONTINUE TO BUILD STRENGTH AND
ENDURANCE.
By this phase, patients have achieved full pain-free ROM and have gained
muscle strength; so they are ready to perform the exercises introduced in
Phase 2 rehab through a full range of motion and up to the point of fatigue.
Strengthen GH and biceps muscles: To build strength, we can increase
resistance with bands or weights.
Building scapular muscle endurance: Serratus muscle can be
conditioned by doing push-ups on the floor or against a wall, or by
doing serratus punches with a hand weight or tubing.

58. “HIGH PAY OFF”
EXERCISES
Based on EMG studies, these exercises are “high pay off” in terms of
working many key muscles important in shoulder rehabilitation.
Example: Prone horizontal abduction with external rotation, exercises in
the scapular plane, chair press ups, prone (bent over) rowing and push
ups with a plus.*
Fig: Prone Horizontal Abduction with External Rotation
PRONE (BENT OVER) ROWING
This exercise is done with a weight in the hand. It can also be done
bilaterally. The motion should primarily be from the scapula.

59. The patient simply raises
his/her body weight off the
chair and can work up to six
repetitions of sixsecond
holds.
THE CHAIR PRESS UP

60. FUNCTIONAL-DEMAND TRAINING; RETURN-TO-WORK
STRATEGIES
Functional exercises and return-to-work advice: Prescribing exercises that
mimic the patient’s occupation, sports, or household chores. Light resistance
can be provided with bands or free weights. These exercises should be
introduced gradually and performed at slow speeds to preventing re-injury.
CONTINUE PROPRIOCEPTIVE COORDINATION AND
RETRAINING
Continuing exercises for proprioception: Exercises to continue to place a
proprioceptive demand on the shoulder should be performed. Examples: Use of
the BOING and PNF diagonals, which can be done with increased resistance.

61. BOING
It is an oscillating instrument that enhances proprioceptive feedback and
increases a patient’s kinesthetic awareness and motor control. When possible, the
oscillating motion should come from the GH joint. However, the wrist or elbow
may also instigate the rhythmic oscillations while the shoulder moves through
specific ranges of motion.
Fig: GH joint going through internal and external range of motion exercises
while the BOING is oscillating.
Fig: Flexion exercises while the BOING is oscillating

62. 1. Increasing strength and local
coordination.
2. Enhancing sensory-motor control.
3. Promoting plyometric power.
REHABILITATION:
PHASE-4
TREATMENT
GOALS

63. INCREASE STRENGTH AND LOCAL
COORDINATION
Continue strength and coordination program: Introducing challenges
that require coordination and balance. For example: Exercises on a
physioball (e.g., push ups); MAI activities with physioball (eyes closed);
BOING exercises; using free weights or throwing a medicine ball.
Continuing with advanced scapulothoracic and cervicothoracic
stabilization exercises.

64. Sensory Motor Testing
Advanced rehabilitation techniques incorporate activities that place a
proprioceptive demand on the joints of the shoulder girdle along with
sensory-motor coordination demands on the entire kinetic chain, from the
subtalar joints on up. We can use a rocker or wobble board to provide a
labile surface on which to train. Proper posture is to be maintained
throughout the exercises.

65. PROMOTING PLYOMETRIC POWER
Prescribing strengthening exercises such as bouncing wall push-ups,
mini-trampoline push-ups, medicine ball or small plyo-ball toss against a
wall or mini-trampoline. Throwing a medicine ball for power and
coordination can be introduced when the injured shoulder attains
90% of the strength and endurance of the uninjured shoulder
Fig: Wall Push-Ups

66. PREVENTIVE
MEASURES & HOME
ADVICE
1.Performing warming-up before & cooling-down after training
for no less than 15 minutes including stretching.
2. Performing a preventative strengthening exercise for the
shoulder twice a week.
3. Ensuring to take adequate rest & avoiding too much of
work in less time.
4. To avoid fatigue since it plays an important role in
occurrence of this kind of injury.

67. If the patient fails to respond after 3 to 4 months of
conservative therapy. Operative intervention may be
indicated and should be directed to the specific
lesion.
Treatmen of choice is Arthroscopic subacromial
decompression
SURGICAL
MANAGEMENT

68. REFERENCES
SHOULDER IMPINGEMENT SYNDROME
Primary Author: Laura L. Baffes, BS, DC, CCSP
Co-Author: Lisa Revell, BS, DC
Background and Evaluation Sections
Contributing Author: Ronald LeFebvre, DC
Rehabilitation of shoulder impingement syndrome
and rotator cuff injuries:
An evidence-based review
Article in British Journal of Sports Medicine · April
2010
DOI: 10.1136/bjsm.2009.058875 · Source: PubMed

69. Internet Links:
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https://www.slideshare.net/hardevsingh7731/shoulder-
impingement-syndrome-48363976
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Information for your shoulder impingement in conjunction with
the Nuffield Orthopaedic Hospital (Upper Limb Clinic).
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72. THANKS FOR YOUR KIND ATTENTION