Painful arch syndrome

Dr. Pushpendra Yaduvanshi

1. PAINFUL ARCH SYNDROME PRESENTED By:- Dr. Pushpendra Yaduvanshi Asst. prof, Physiotherapy Career point University, Kota

2. INTRODUCTION

3. Supraspinatus tendinitis or painful arc syndrome occurs in the shoulder. The shoulder joint owes its stability to the 'rotator cuff' muscles - which are four small muscles located around the shoulder joint which help with movement, but importantly their tendons stabilise the head of the humerus within the joint capsule.

4. The tendon of one of these muscles - the supraspinatus commonly impinges on the acromion (the bone forming the tip of the shoulder) as it passes between the acromion and the humeral head. The supraspinatus muscles helps abduct (lift up sideways) the arm.

5. Any friction between the tendon and the acromion is normally reduced by the subacromial bursa - a fluid filled sac between the supraspinatus tendon and the acromion. Sometimes, with wear and tear supraspinatus tendinitis results, which is commonly associated with inflammation of the bursa - subacromial bursitis.

6. There may even be little tears in the tendon fibres - partial tears or sometimes even complete tears. Tendinitis and partial tears in the supraspinatus tendon causes a 'painful arc' since as the person elevates his arm sideways. The tendon begins to impinge under the acromion throught the middle part of the arc, and this is usually relieved as the arm reaches 180 degrees (vertical).

7. There may be other causes of a painful arc. Arthritis of the acromio-clavicular joint (at the tip of the shoulder) may also cause pain but that is typically at the end of the arc - when the arm is almost vertical. Supraspinatus tendinitis is very common, it the most common inflammatory problem encountered around the shoulder joint. It is typically seen in people aged 25-60.

8. DEFINITION Impingement syndrome also called painful arc syndrome , supraspinatus syndrome , swimmer's shoulder , and thrower's shoulder , is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder.

9. SIGN & SYMTOMS The most common symptoms in impingement syndrome are pain, weakness and a loss of movement at the affected shoulder. The pain is often worsened by shoulder overhead movement and may occur at night, especially if the patient is lying on the affected shoulder. The onset of the pain may be acute if it is due to an injury or may be insidious if it is due to a gradual process such as an osteoarthritic spur.

10. Other symptoms can include a grinding or popping sensation during movement of the shoulder. The range of motion at the shoulder may be limited by pain. A painful arc of movement may be present during forward elevation of the arm from 60° to 120° Passive movement at the shoulder will appear painful when a downwards force is applied at the acromion but the pain will ease once the downwards force is removed.

11. CAUSES The rotator cuff muscle tendons pass through a narrow space between the acromion process of the scapula and the head of the humerus. Anything which causes further narrowing of this space can result in impingement syndrome.

12. This can be caused by bony structures such as subacromial spurs (bony projections from the acromion), osteoarthritic spurs on the acromioclavicular joint, and variations in the shape of the acromion.

13. Thickening or calcification of the coracoacromial ligament can also cause impingement. Loss of function of the rotator cuff muscles, due to injury or loss of strength, may cause the humerus to move superiorly, resulting in impingement. Inflammation and subsequent thickening of the subacromial bursa may also cause impingement.

14. DIAGNOSIS Impingement syndrome can usually be diagnosed by history and physical exam. Plain x-rays of the shoulder can be used to detect some joint pathology and variations in the bones, including acromioclavicular arthritis, variations in the acromion, and calcifcation.

15. Ultrasonography , arthrography and MRI can be used to detect rotator cuff muscle pathology. Due to lack of understanding of the pathoaetiology, and lack of diagnostic accuracy in the assessment process by many doctors,several opinions are recommended before intervention.

16. MRI findings of impingement A = acromion, Cl = clavicle, B = subacromial bursa, Su = supraspinatus muscle, H = proximal portion of humerus. Diagram shows inferiorly oriented osteophyte producing impingement ( arrow ).

17. Neer test: Forcefully elevate an internally rotated arm in the scapular plane, causing the supraspinatus tendon to impinge against the anterior inferior acromion.

18. Hawkins-Kennedy test: Forcefully internally rotate a 90° forwardly flexed arm, causing the supraspinatus tendon to impinge against the coracoacromial ligamentous arch. Note: Pain and a grimacing facial expression indicate impingement of the supraspinatus tendon, indicating a positive Neer/Hawkins impingement sign.

19. Cross-Arm Test Patients with acromioclavicular joint dysfunction often have shoulder pain that is mistaken for impingement syndrome. The cross-arm test isolates the acromioclavicular joint. The patient raises the affected arm to 90 degrees. Active adduction of the arm forces the acromion into the distal end of the clavicle.Pain in the area of the acromioclavicular joint suggests a disorder in this region .

20. Supraspinatus isolation test/empty can test: The supraspinatus may be isolated by having the patient rotate the upper extremity so that the thumbs are pointing to the floor and apply resistance with the arms in 30° of forward flexion and 90° of abduction (assimilates emptying of a can). This test is positive when weakness is present (compared to the unaffected side), suggesting disruption of the supraspinatus tendon.

21. Supraspinatus examination ("empty can" test). The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward

22. Drop-Arm Test A possible rotator cuff tear can be evaluated with the drop-arm test. This test is performed by passively abducting the patient's shoulder, then observing as the patient slowly lowers the arm to the waist. Often, the arm will drop to the side if the patient has a rotator cuff tear or supraspinatus dysfunction. The patient may be able to lower the arm slowly to 90 degrees (because this is a function mostly of the deltoid muscle) but will be unable to continue the maneuver as far as the waist.

23. Impingement test: Inject 10 mL of 1% lidocaine solution into the subacromial space. Repeat testing for an impingement sign. Elimination or significant reduction of pain constitutes a positive impingement test.

24. INSTABILITY TESTS Apprehension Test The anterior apprehension test is performed with the patient supine or seated and the shoulder in a neutral position at 90 degrees of abduction. The examiner applies slight anterior pressure to the humerus (too much force can dislocate the humerus) and externally rotates the arm. Pain or apprehension about the feeling of impending subluxation or dislocation indicates anterior glenohumeral instability.

25. Relocation Test The relocation test is performed immediately after a positive result on the anterior apprehension test. With the patient supine, the examiner applies posterior force on the proximal humerus while externally rotating the patient's arm. A decrease in pain or apprehension suggests anterior glenohumeral instability.

26. Sulcus Sign With the patient's arm in a neutral position, the examiner pulls downward on the elbow or wrist while observing the shoulder area for a sulcus or depression lateral or inferior to the acromion. The presence of a depression indicates inferior translation of the humerus and suggests inferior glenohumeral instability. The examiner should remember that many asymptomatic patients, especially adolescents, normally have some degree of instability.

27. treatment Impingement syndrome is usually treated conservatively, but sometimes is treated with arthroscopic surgery or open surgery . Conservative treatment includes rest, cessation of painful activity, and physiotherapy focused at maintaining range of movement and avoid shoulder stiffness. NSAID 's and ice packs may be used for pain relief.

28. Therapeutic injections of corticosteroid and local anaesthetic may be used for persistent impingement syndrome. The total number of injections is generally limited to 3 due to possible side effects from the corticosteroid.

29. Corticosteroids actually cause musculoskeletal disorders,which explains the low success rate of cortisone injections. Research has shown that over 90% of tendinopathies have no inflammation, thus the term tendinosis is more appropriate than tendinitis for most diagnoses. For tendinosis, prolotherapy injections or cross-fiber (transverse) friction massage can be very effective.

30. Surgical treatment When nonsurgical treatment does not relieve pain, the doctor may recommend surgery. The goal of surgery is to remove the impingement and create more space for the rotator cuff. This allows the humeral head to move freely in the subacromial space and to lift the arm without pain.

31. The most common surgical treatment is subacromial decompression or anterior acromioplasty. This may be performed by either arthroscopic or open techniques:

32. Arthroscopic technique: In an arthroscopic procedure, two or three small puncture wounds are made. The joint is examined through a fiberoptic scope connected to a television camera. Small instruments are used to remove bone and soft tissue.

33. Open technique: Open surgery requires placement of a small incision in the front of the shoulder. This allows for direct visualization of the acromion and rotator cuff. In most cases, the front (anterior) edge of the acromion is removed along with some of the bursal tissue.

34. Techniques to treat anterior acromioplasty. Left, arthroscopic repair. Right, Open surgical procedure

35. The surgeon may also treat other conditions present in the shoulder at the time of impingement surgery. These can include acromioclavicular arthritis, biceps tendonitis, or a partial rotator cuff tear.

36. Left, Arthroscopic view of the anterior edge of the acromion. An instrument is positioned beneath to begin the acromioplasty. Right, Impingement may result in a partial rotator cuff tear (RC), shown by the three arrows. The surface of the humeral head (HH) lies below the rotator cuff.

37. prognosis Around 70% of patients with tendinitis will improve over 5-20 days and mobilize the joint themselves, though treatment with physiotherapy and steroid injections will help. Further tendinitis and even partial or complete tears may occur in the future.

38. Complete tears are treated surgically in young people, though this may be harder in older people or patients with other causes such as rheumatoid arthritis. Chronic trauma and impingement may lead to osteoarthritis of the shoulder in the long term.

39. REFERENCES Clinical References. orthopaedic rehablitation S. brent brotzman. Orthopeadic physical Assessment David j. magee. Essentials of orthopeadics & applied physiotherapy. Jayant joshi. www.google.com

40. THANK YOU