Shoulder impingement syndrome

Shoulder Impingment Syndrome: Clinical understanding, management, physiotherapy management

1. Physiotherapy in “ Shoulder Impingement Syndrome” Dr. P. Ratan khuman (PT) M.P.T., (Ortho & Sports)

2. Anatomy of shoulder Left Anterior Shoulder 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 2

3. Scapula Anterior View Posterior View 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 3

4. rotator cuff Muscles 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 4

5. Muscle Force Couple Two forces of equal magnitude , but in opposite direction, that produce rotation an axis. 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 5

6. Muscles of Shoulder Girdle 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 6

7. introduction The term “Impingement Syndrome” was popularized by Charles Neer in 1972 Neer defined impingement as pathologically compression of rotator cuff against the anterior structure of coracoacromial arch, anterior 1/3 of the acromion, coraco -acromial ligament & AC joint. Progression of syndrome is define by a narrowing of the sub-acromial outlet by spur formation in coracoacromial ligament & undersurface. 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 7

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9. Definition : Shoulder impingement: It is compression & mechanical abrasion of supraspinatus as they pass beneath the coracoacromial arch during elevation of the arm. Rotator Cuff Tendinitis : It encompasses impingement & result from acute rotator cuff overload, intrinsic rotator cuff degeneration, or chronic overuse. Rotator cuff syndrome : It is the term used to describe the process whereby tendinitis & impingement are ongoing simultaneously. Painful arc syndrome: Pain in the shoulder and upper arm during the midrange of glenohumeral abduction, with freedom from pain at extremes of the range due to supraspinatus damage 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 9

10. Impingement causes Mechanical irritation of cuff tendons - resulting in haemorrhage and swelling (commonly known as tendonitis of rotator cuff ) The supraspinatus muscle is usually involved . This also affect the bursa – resulting in bursitis . S houlder complex is susceptible to impingement injuries from overhead sports – Such as baseball, tennis, swimming, volleyball etc. Impingement with rotator-cuff tendonitis is one of most common shoulder injuries seen in athletes . 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 10

11. Signs and Symptoms Pain & tenderness in the gleno -humeral area Pain or weakness with active abd in midrange Limited internal rotation compared to normal side Confirmation with special tests (Hawkins impingement test) Tenderness to palpation in the sub-acromial area 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 11

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13. Factor development of External impingement Anatomical abnormalities e.g. beaked/ # acronion , osteophyte Poor scapular control Anterior instability Postural changes in upper quadrant Forward head & rounded shoulder posture 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 13

14. Types of acromions 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 14

15. Factor development of internal impingement Overuse – repetitive trauma Loose joint Instability Muscle imbalance Superior labrum injury 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 15

16. stage of shoulder impingement syndrome (Sis) 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 16

17. Stage-I: edema & inflammation Age – younger than 25 years (but may occur at any age) Reversible lesion Tenderness over greater tuberosity of humerus Tenderness over anterior ridge of acromion Painful arch 60 – 120 (+) ve Neer impingement test ROM may restricted with sub-acromial inflammation 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 17

18. Stage-II: fibrosis & tendinitis Age – 25 – 40 years Not reversible by modification of activities Stage-I signs + the following – Soft tissue crepitus Catching sensation at lowering arm (approx 100 ) Limitation of active & passive ROM 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 18

19. Stage-III: bone spur & tendon rupture Age > 40 years Not reversible Stage I + II signs + following – Limited ROM more prominently Atrophy of infra- spinatus Weakness of abductor & external rotator Bicep tendon involvement AC joint tenderness 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 19

20. Common test For impingement – Neer impingement test Hawkins impingement test Crossover impingement test Rotator cuff test – Intraspinatus – external rotation Supraspinatus – empty can position & resistance Subscapularis – hand behind back (Lift off) Drop arm – for full thickness rotator cuff 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 20

21. Common test for impingement 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 21

22. Treatment goal To relieve pain & swelling To decrease inflammation To retard muscle atrophy & strengthen cuff muscle To maintain & improve ROM To increase neuromuscular control To increase strength, endurance & power Unrestricted symptom free activities To modified activity & prevent 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 22

23. Treatment approaches 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 23

24. Functional modification Complete restriction of painful movt Analysis of aggravating exercises & motion will help in modification of training programs A logical approach to restriction of activity & gradually return Activity from painful column should not reintroduce until pain free 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 24

25. Pharmacological approach Oral anti-inflammatory medication Subacromial steroid in early inflammation stage Medication combine with therapeutic modalities like – LASER, TENS, US etc 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 25

26. Cryotherapy Over the tenderness in early inflammation stage Duration – 10 – 15 min Greater effect along with medication 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 26

27. Electrotherapy TENS is useful in controlling muscular pain US therapy with 0.8 w/cm 2 , 3MHz, 6 min – to restore inflammation Other modalities like LASER, IFT & heat therapy are also effective in pain control 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 27

28. Bio feed back It may be appropriate if there is excessive laxity of humeral head Helpful in athlete unable to gain control of the rotator cuff musculature 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 28

29. Manual therapy approach Maitland’s concept – Mobilization for GH & ST joint Grade – I & II in early stage As symptoms response, can shift to even grade III & IV Glide – AP & inferior in scapular plane Combine glide as per requirement Oscillation – Usually 10 oscillation, 3 set is used. 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 29

30. Manual therapy approach Cyriax’s concept Transvers friction massage is useful Better effect when combine with other modalities & medications Mulligan’s concept Movement with mobilization (MWM) is effective 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 30

31. Therapeutic exercise ROM exercise – Penduler exercises with light weight (1kg or Less) Active assisted ROM exercises in pain free range E.g. Rope & Pulley – flexion Anterior & posterior capsular stretching Stretching of upper trapezius, pectorals, biceps etc. Towel exercise Codman's exercises 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 31

32. Stretching exercises Posterior Complex Pectoralis Internal Rotator 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 32

33. Therapeutic exercise Strengthening exercise – Isometric exercises – External & internal rotators Biceps Deltoid (all 3 fibers ) Scapulo -thoracic stability exercise – Important for primary & secondary impingement OKC & CKC scapular stabilizing exercises Arm aerometry for endurance exercise 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 33

34. Strengthening exercise – Plyometric shoulder strengthening using therabend Isokinetic exercise for Supraspinatus, prone extension & horizontal abduction 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 34

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36. Strengthening exercises Adductor Strengthening 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 36

37. Deltoid Strengthening 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 37

38. Extensor Strengthening 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 38

39. Medial Rotator Strengthening 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 39

40. Lateral Rotator Strengthening 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 40

41. taping Taping for scapular abnormal movt or dyskinesia Taping + strengthening 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 41

42. Mechanical correction taping 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 42

43. Kinesio -taping for impingement 1 2 3 4 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 43

44. Surgery Arthroscopic subacromial decompression Capsulorrhaphy 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 44

45. Preventive measures Perform warm-up exercises & flexibility training Exercise the whole kinetic chain, including strength training. Avoid abuse (pain-causing situations). 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 45

46. Preventing Re-injury Perform warming-up before & cooling-down after training, for no less than 15 minutes. Include stretching ex for the posterior shoulder. Perform preventative strengthening exercises for the shoulder twice a week. Ensure you take adequate rest & avoid playing too many games in too short period . Fatigue plays an important role in occurrence of this kind of injury. 5/6/2013 Ratan Khuman (MPT Ortho & Sports) 46