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Impingement Sx

Impingement Syndrome

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
Created by: 1190550002