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Impingement Sx
Impingement Syndrome
| Question | Answer |
|---|---|
| Encroachment of acromion, coracoacromial ligament, or AC joint on the RTC tendons & the sub-deltoid bursa lying beneath them | Impingement Syndrome |
| Causes of Impingement Syndrome | Abnormal acromion structure Humeral head depressor wkness/fatigue Unstable GH Tight post. capsule Sub-acromial crowding Scap stabilizer wkness/fatigue |
| Where are sites of impingement? | AC joint Inferior surface of acromion CA ligament Coracoid process |
| RTC Fxns | Stabilize humerus in glenoid fossa Weak RTC- superior shift or migration of humeral head Usually problems with flex/abd Fatigue leads to humeral head superior excursion at 45, 90, 135 deg elevation |
| GH Instability | Abnormal translation following fatigue of dynamic stabilizers Causes superior translation of humeral head during elevation |
| Posterior Capsule Tightness | Loss of IR & horizontal adduction Causes pain at end of flexion due to impingement of humeral head on ant-inf acromion (results in superior migration- impingement b/t soft tissues & acromion) |
| Pain in Impingement Syndrome | Acute or excruciating-chronic or low grade aching Pain in lateral arm- deltoid insertion (rarely referred below elbow) Difficulty sleeping |
| Decreased ROM in Impingement Syndrome | Active abd & ER Painful arc from 70-120 deg elevation as inflamed tendons pass under CA arch PROM generally full & painless |
| Muscle Dysfunction in Impingement Syndrome | MMT supra will be painful/weak Crepitus with humeral rotation- significant crepitus may indicate spur formation or full-thickness tear Tendon & bursal thickening |
| Impingement of supraspinatus against the CA arch during activities that require shoulder abduction & some fwd flexion | Primary Impingement |
| Causes of Primary Impingement | Decreased caudal glide of GH joint Tight posterior capsule Acromion morphology |
| GIRD | Loss of IR >20 deg resulting in loss of IR May have loss of IR but gain of ER- total motion intact, so not true GIRD |
| Treating Posterior Capsule Tightness | Cross arm stretch Sleeper stretch Stretching & Joint mobs |
| Decrease in subacromial space due to another pathology or condition- i.e. stability | Secondary Impingement |
| Neer's Classification- Stage 1 | Edema, inflammation, hemorrhage Age <25 yrs Reversible pathology Non-surgical, PT tx |
| Neer's Classification- Stage 2 | Bursal thickening with fibrosis & tendonitis Age 25-40 yrs Uncomplicated impingement Recurrent pn with activity Tx: PT but may be surgical |
| Neer's Classification- Stage 3 | Bone spurs with tendon rupture Age >40 yrs Complicated impingement Progressive disability Tx: usually need ant. acromioplasty with RTC repair, followed by PT |
| Inflammation of any of the 4 RTC tendons | RTC tendonitis |
| Which tendon is most commonly affected in RTC tendonitis? | Supraspinatus Distal 1 cm "critical zone" due to poor perfusion Worse blood flow on articular side compared to bursal side |
| Mechanical Causes of disruption to vascularity | Significant tension & compression during abduciton Significant tension during adduction |
| Scapular positions | Dominant shoulder scapula more downwardly rotated Dominant shoulder increased upward rotation more rapidly than non-dominant shoulder |
| Scapular Dyskinesia- Inferior Angle (Type 1) | at rest, inferior medial scapular border may be prominent dorsally During arm motion, inferior angle tilts dorsally Axis of rotation- horizontal plane |
| Scapular Dyskinesia- Medial Border (Type 2) | At rest, entire medial border may be prominent dorsally During arm motion, medial scapular border tilts dorsally off thorax Axis of rotation is vertical in frontal plane-sagittal axis |
| Scapular Dyskinesia- Superior Border (Type 3) | At rest, superior border of scapula may be elevated & scapula can also be anteriorly displaced During motion, shoulder shrug initiates mvmt without significant winging of scapula occurring Axis of motion occurs in sagittal plane- frontal axis |
| Scapular Dyskinesia- Symmetric Scapulohumeral (Type 4) | At rest, position of both scapulae are relatively symmetrical, taking into account that dominant arm may be slightly lower |
| Causes of Scapular Winging | Long thoracic n. palsy Serratus anterior weakness |
| Lateral Sapular Slide Test | determines stability of scapula during GH mvmts Base of scapula spine to SP T2-3; inf. angle to SP T7-9; Superior angle to T2 Resting, 45 deg abd, 90 deg abd with IR, 120 & 150 deg abd Position shouldn't vary >1-1.5 cm each side |
| Acromion Shapes | Type 1= flat Type 2= smooth curve Type 3= anterior hook type 2 & 3 have increased incidence RTC tears & impingement lesions |
| Acromial Spur | Incidence increases with age Spurs in RTC with bursal side tears is highest |
| What is the most widely used surgical procedure for pain due to primary impingement? | Anterior Acromioplasty |
| Symptoms After Acromioplasty | Post-op soreness- several days Week 1-2: s/sx decrease Week 2-4/6: s/sx return Week 6-8: s/sx decrease |
| Causes of secondary impingement (hypermobility) | Decreased dynamic caudal glide Posterior RTC wkness Osseous deformity (Type 2 or 3 acromion) Non-contractile post. capsule/ligament tightness |
| RTC lesions caused by secondary impingement usually occur where? | Inferior surface or articular side of RTC |
| Relationship b/t shoulder instability & RTC impingement | Static stabilizers stretched RTC fatigue while trying to limit sup. translation Overuse tendonitis Further dysfxn in mm control reduces scapular rotation Acromion limits fwd flexion Impingement syndrome occurs as a 2ndary process |
| Triad of Treatment for 2ndary Impingement | Neuromuscular stability Non-contractile stability Contractile stability Increase IR strength to decrease anterior translation |
| Internal Impingement Syndrome | MOI: shoulder in 90/90, compressive force created b/t RTC on posterior superior glenoid labrum Pt. c/o TTP under posterior acromion Pt. will have (+) Jobe's, but pn will be all posterior |
| Causes of Internal Impingement | Anterior laxity Posterior capsular hypomobility Hyperangulation during throwing Increased horizontal extension Repetitive microtrauma |
| S/sx Internal Impingement | Post. shoulder pain Pain with excessive ER at 90 deg abd (+) Jobe's Excessive ER, limited IR |
| Impingement Special Tests | Neer's- Supraspinatus (add IR to implicate supra the most) Hawkins-Kennedy- Subscap Coracoid Cross-Over Jobe's for Internal |
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