IMPINGEMENT SYNDROME

BY, NEHA GAGGAR (MPT)

CONTENTS
IMPINGEMENT SYNDROME
 DEFINITION

Shoulder impingement occurs when the rotator cuff tendons are

impinged as they pass through the sub-acromial space
(b/w acromian coraco-acromial arch & AC joint above & GH joint below)
Impingement

Mechanical irritation

Inflammation

Swelling

Damage to the tendons

Functional anatomy:
The rotator cuff comprises four muscles The
subscapularis, the supraspinatus, the infraspinatus
and the teres minor and their musculotendinous
attachments.
The subscapularis muscle is innervated by the
subscapular nerve and originates on the scapula. It
inserts on the lesser tuberosity of the humerus.
The supraspinatus and infraspinatus are both
innervated by the suprascapular nerve, originate in
the scapula and insert on the greater tuberosity.
The teres minor is innervated by the axillary nerve,
originates on the scapula and inserts on the greater
tuberosity.
A bursa in the subacromial space provides lubrication
for the rotator cuff.
The rotator cuff is the dynamic stabilizer of the glenohumeral joint.

The static stabilizers are the capsule and the labrum complex, including
the glenohumeral ligaments.

Although the rotator cuff muscles generate torque, they also depress
the humeral head. The deltoid abducts the shoulder. Without an
intact rotator cuff, particularly during the first 60 degrees of humeral
elevation, the unopposed deltoid would cause cephalic migration of
the humeral head, with resulting subacromial impingement of the
rotator cuff.

In patients with large rotator cuff tears, the humeral head is poorly
depressed and can migrate cephalad during active elevation of the
arm.
 Etiology:
1. Extrinsic causes:
A- Bony factors:
 The type I acromion, which is flat, is the "normal"
acromion.
 The type II acromion is more curved and downward
dipping,
 The type III acromion is hooked and downward
dipping, obstructing the outlet for the supraspinatus
tendon and therefore may impinge on the rotator cuff
on elevation of the arm.
• Osteophytes under the acromioclavicular joint reduces
the subacromial space and can also lead to cuff
impingement and therefore failure" '
Type I Type II Type III

Figure 22 : Types of anatomical acromion variation: Flat

acromion, curved and hoocked
B- Soft tissue factors Examples include
• Thickened coracoacromial ligament.
2. Intrinsic causes
a. Degenerative cuff failure :
This constitutes the commonest cause of cuff failure and
usually occurs in the older individual. Degeneration of the
cuff may later result in partial tears which may progress to
complete tears. The precise cause of degenerative cuff tear is
unknown. One possible theory relates to the 'critical vascular
zone' of the cuff tendon where the blood supply is
precarious, and relative ischemia leads to degenerative
changes.
b. Traumatic cuff failure:
This may occur when the upper limb is subject to a
violent force and the rotator cuff sustains a traumatic tear. In
the younger individual where the tendinous part of the cuff-
bone complex is stronger than the bony part, the tendons
may avulse with a piece of bone.
c. Reactive cuff failure:
Calcific rotator cuff tendinitis is an example of
reactive cuff failure. The calcifying mass inside the
tendon may give rise to a swelling which leads to
impingement under the subacromial arch, hence
resulting in cuff failure.
 NEER’S CLASSIFICATION OF ROTATOR CUFF
DISEASE
STAGE 1 STAGE 2 STAGE 3
Oedema & Fibrosis & tendinitis Bone spurs & tendon
inflammation ruptures
Reversible lession Not reversible by Not reversible
activty modification
< 25 yrs 25-40 yrs > 40 yrs
Tenderness : GT, ant Stage 1 + soft tissue Stage 1 & 2
ridge of acromion crepitus AROM > restriced
Painfull arc : 60-120 Catching sensation : Atrophy of muscle
lowering of arm to 100
Impingement sign : + AROM,PROM : limited Weakness of abductors
& int rotators
ROM : decreased MMT : decreased Biceps tendon involved
MMT : normal AC jt tenderness
MMT : decreased
TYPES OF IMPINGEMENT

EXTERNAL INTERNAL
•Primary
•Secondary
 PRIMARY EXTERNAL IMPINGEMENT
Narrowing of the sub-acromial outlet : d/t
Abnormal bony relationship between rotator cuff & C-A arch
 Other primary factors like

1.AC joint :
congenital anomaly
degenerative spur formation
2. Acromion :
unfused acromion
degenerative spur
malunion/nonunion of #
 Contd...

3. Corocoid :
congenital anomaly
abnormal shape after surgery or trauma
4.Rotator cuff :
thickening of tendon from calcific deposits
thickening of tendon after surgery or trauma
5.Humerus :
increased prominence of GT from congenital anomaly,
malunion
 CLINICAL FEATURES

 Age > 40 yrs

Pain : anterior shoulder , lateral arm
Inability to sleep on affected arm
Difficulty performing overhead activities
Loss of ROM
Weakness of rotator cuff muscle strength
Hawkins sign : +ve
Neers sign : + ve
May also complaint of AC joint discomfort
 SECONDARY EXTERNAL
IMPINGEMENT
Relative narrowing of subacromial space
Secondary factors like :
glenohumeral instability
scapulothoracic instability
Loss of stability of rotator cuff muscles

Abnormal superior translation of humeral head

Decreased depression of the humeral head during

throwing & less clearance

Mechanical impingement of rotator cuff on the C-A

arch
 Scapular instability

Improper positioning of the scapula with relation to humerus

Insufficient retraction of scapula

 Posterior capsule tightness

Oblique translation of the humeral head on rotator cuff

in anterior & superior direction

impingement
 INTERNAL IMPINGEMENT

Also called as glenoid impingement

Mainly in overhead athletes during the late cocking stage

of throwing (ext+abd+ext rot )

Impingement of undersurface of rotator cuff against the

post-sup surface of glenoid
 TENDINITIS / BURSITIS

Neer identified tendinitis/bursitis as a stage 2 of

impingement syndrome.
 SUPRASPINATIS TENDINITIS
 Inflammation of supraspinatis tendon
Painful arc : 60-120 abd
I HISTORY :

• Site of pain : lateral brachial region

referred below e elbow in c5, c6
• nature of pain : sharp twings felt during movement
abduction, putting on jacket, reaching above shoulder level
• Onset of pain : gradual with no known trauma
occupation or recreational overuse

II EXAMINATION :

1.OBSERVATION
• Postural assessment
• Forward head
• Rounded shoulders
• Flattening of thoracic spine
• Shoulder girdle asymmetry

• biomechanical screening
• antalgic movement pattern
• functional assessment
•Scapulo humeral rhythm
2. INSPECTION :
atrophy may be noticed in chronic cases
swelling

3, cervical screening

4. Upper limb ROM :

•Active movements : painful arc 60-120 degrees
•Passive movements
•RIC

5. PALPATION
tenderness
crepitus

6. Special’s test : Neer’s sign

hawkins sign
empty can
 INFRASPINATIS TENDINITIS
Inflammation of infraspinatis tendon

MECHANISM OF INJURY :
Decellaration (eccentric) injury d/t overload during
repetative or forceful throwing activity

CLINICAL FEATURES :
pain : end range ext rot
upper arm ,slightly over back of the arm
RIC : weak & painful ext rotators
 SUBSCAPULARIS TENDINITIS

Inflammation of subscapularis tendon

Rarely occurs
Pain during internal rotation
Weakness of internal rotators
 BICIPITAL TENDINITIS
Inflammation of biceps tendon

Persistence friction of the inflammed tendon leads

to tearing of the tendon

Pain over anterior shoulder region, arm &

sometimes passing through the upper limb

Pressure on the groove is painful

 SUBACROMIAL BURSITIS
Bursitis occurs secondary to calcific tendinitis in which the deposit migrates
superficially into the floor of the subacromial bursae.

SIGNS AND SYMPTOMS :

 PAIN : lateral brachial region

 Active movements : marked restriction in all planes with severe pain
while elevating arm
 Passive movements : restriction by pain in a noncapsullar pattern,
empty end feel, rotation with arm at side : free, but abduction beyond
60 and flexion past 90 extremely painful.
 RIC : pain during abduction caused by squeezing of the bursae.
 Palpation : warmth , swelling , tenderness.
 Rehabilitation Protocol
Conservative (Non operative)
Treatment of Shoulder
Impingement
Phase 1:
Maximal Protection-Acute Phase

Goals
• Relieve pain and swelling.
• Decrease inflammation.
• Retard muscle atrophy.
• Maintain/increase flexibility.
 Phase 1 contd...
1.Active Rest

• Eliminate any activity that causes an increase in symptoms

(e.g., throwing).

2.Range of Motion

• Pendulum exercises.
• Active-assisted ROM -limited symptom-free available range
• Rope and pulley
• Flexion.
• L-bar
• Flexion.
• Neutral external rotation.

3.Joint Mobilizations
• Grades 1 and 2.
• Inferior and posterior glides in scapular plane.
 Phase 1 contd ....
4.Modalities
• Cryotherapy.
• Transcutaneous electrical stimulation (TENS),

5.Strengthening Exercises
• Isometrics-submaximal
• External rotation.
• Internal rotation.
• Biceps.
• Deltoid (anterior, middle, posterior).

6.Patient Education and Activity Modification

• Regarding activity, pathology, and avoidance of overhead activity, reaching, and
lifting activity.
Phase 2: Motion Phase-Subacute Phase
Criteria for Progression to Phase 2

• Decreased pain and/or symptoms.

• Increased ROM.
• Painful arc in abduction only.
• Improved muscular function.

Goals

• Reestablish nonpainful ROM.

• Normalize athrokinematics of shoulder complex.
• Retard muscular atrophy without exacerbation of pain.
 Phase 2 contd...
1.Range of Motion
• Rope and pulley
• Flexion.
• Abduction (symptom-free motion only).
• L-bar
• Flexion.
• Abduction (symptom-free motion).
• External rotation in 45 degrees of abduction, progress to 90 degrees of abd.
• Internal rotation in 45 degrees of abduction, progress to 90 degrees of abduction.
• Initiate anterior and posterior capsular stretching.

2.Joint Mobilizations
• Grades 2, 3, and 4.
• Inferior, anterior, and posterior glides.
• Combined glides as required.
• stretching of the posterior capsule.
 Phase 2 contd...

3. Modalities

• Cryotherapy.
• Ultrasound/phonophoresis.
• Strengthening Exercises
• Continue isometrics exercises.
• Initiate scapulothoracic strengthening exercises
• Initiate neuromuscular control exercises.
Phase 3: Intermediate Strengthening
Phase
Criteria for Progression to Phase 3

• Decrease in pain and symptoms.

• Normal active-assisted ROM.
• Improved muscular strength.

Goals

• Normalize ROM.
• Symptom-free normal activities.
• Improve muscular performance.
 Phase 3 contd...
1.Range of Motion

• Aggressive L-bar active-assisted ROM in all planes.

• Continue self-capsular stretching (anterior-posterior).
 Phase 3 contd...
4.Strengthening Exercises
• Initiate isotonic dumbbell program
Side-lying neutral
• Internal rotation
• External rotation
Prone
• Extension.
• Horizontal abduction.
Standing
• Flexion to 90 degrees.
• Supraspinatus.
• Initiate serratus exercises
• Wall push-ups.
• Initiate tubing progression in slight abduction for internal
and external rotation strengthening.
• Initiate arm ergometer for endurance.
 Phase 4: Dynamic Advanced
Strengthening
Criteria for Progression to Phase 4
• Full, nonpainful ROM.
• No pain or tenderness.
• 70% of contralateral strength.

Goals
• Increase strength and endurance.
• Increase power.
• Increase neuromuscular control.

Isokinetic Testing

• Internal and external rotation modified neutral.

• Abduction-adduction.
 Phase 5: Return to Activity Phase
Criteria for Progression to Phase 5

• Full, nonpainful ROM.

• No pain or tenderness.
• Isokinetic test that fulfills criteria.
• Satisfactory clinical examination.

Goal

• Unrestricted symptom-free activity.

 Phase 5 contd...

Isokinetic Test
• 90/90 internal and external rotation, 180 degrees/sec,
300 degrees/sec.
• Abduction-adduction, 180 degrees/sec, 300 degrees/sec.

Initiate Interval Throwing Program

• Throwing.
• Tennis.
• Golf.
 Phase 5 contd...
Maintenance Exercise Program
Flexibility Exercises
• L-bar
• Flexion.
• External rotation.
• Self-capsular stretches.

Isotonic Exercises
• Supraspinatus.
• Prone extension.
• Prone horizontal abduction.

Theratubing Exercises
• Internal and external rotation.
• Neutral or 90/90 position.
• Serratus Push-ups
• Interval Throwing Phase II for Pitchers
 Rehabilitation Protocol
After Arthroscopic Subacromial
Decompression-Intact Rotator
Cuff
(Distal Clavicle Resection)
 Phase 1
Restrictions
 ROM
• 140 degrees of forward flexion.
• 40 degrees of external rotation.
• 60 degrees of abduction.
• ROM exercises begin with the arm comfortably at the patient's side, progress
to 45 degrees of abduction and eventually 90 degrees. Abduction is advanced
slowly depending on patient comfort level.
• No abduction or rotation until 6 wk after surgery-this combination re-creates
the impingement maneuver.
• No resisted motions until 4 wk postoperative.
• (No cross-body adduction until 8 wk postoperatively if distal clavicle
resection.)
 Phase 1 contd...
Immobilization
• Early motion is important.
• Sling immobilization for comfort only during the first 2 wk.
• Sling should be discontinued by 2 wk after surgery.
• Patients can use sling at night for comfort.
Pain Control
• Reduction of pain and discomfort is essential for recovery
• Medications
• Narcotics-lO day-2 wk following surgery.
• Nonsteroidal anti-inflammatory drugs (NSAIDs)-for patients with
persistent discomfort following surgery.
• Therapeutic modalities
• Ice, ultrasound.
• Moist heat before therapy, ice at end of session.
 Phase 1 contd..
Motion: Shoulder
 Goals
• 140 degrees of forward flexion.
• 40 degrees of external rotation.
• 60 degrees of abduction.
 Exercises
• Begin with Codman pendulum exercises to promote early motion.
• Passive ROM exercises.
• Capsular stretching for anterior, posterior, and inferior capsule, using the
opposite arm.
• Active-assisted ROM exercises.
• Shoulder flexion.
• Shoulder extension.
• Internal and external rotation.
• Progress to active ROM exercises as comfort improves.
 Phase 2: Weeks 4-8
Criteria for Progression to Phase 2
• Minimal pain and tenderness.
• Nearly complete motion.
• Good "shoulder strength" 4/5 motor.

Restrictions
• Progress ROM goals to
• 160 degrees of forward flexion.
• 45 degrees of internal rotation (vertebral level Ll).

Immobilization
• None.
 Phase 2 contd...
Pain Control
• NSAIDs-for patients with persistent discomfort.
• Therapeutic modalities
• Ice, ultrasound.
• Moist heat before therapy, ice at end of session.
• Subacromial injection: lidocaine/steroid - for patients with acute
inflammatory symptoms that do not respond to NSAIDs.
Motion
Goals
• 160 degrees of forward flexion.
• 60 degrees of external rotation.
• 80 degrees of abduction.
• 45 degrees of internal rotation (vertebral level Ll).
Exercises
• Increasing active ROM in all directions.
• Focus on prolonged, gentle passive stretching at end ranges to
increase shoulder flexibility.
• Utilize joint mobilization for capsular restrictions, especially the
posterior capsule
 Phase 2 contd...
Muscle Strengthening
• Rotator cuff strengthening (only three times per week to avoid rotator
cuff tendinitis)
• Begin with closed-chain isometric strengthening
• Internal rotation.
• External rotation.
• Abduction.
• Progress to open-chain strengthening with Therabands
• Exercises performed with the elbow flexed to 90 degrees.
• Starting position is with the shoulder in the neutral position of forward
flexion, abduction, and external rotation (arm comfortably at the
patient's side).
• Exercises are performed through an arc of 45 degrees in each of the
five planes of motion.
 Phase 2 contd ...
Six color-coded Theraband bands are available; each provides increasing
resistance from 1 to 6 pounds, at increments of one pound.

 Progression to the next band occurs usually in 2to 3-wk intervals.

 Patients are instructed not to progress to the next band if there is any
discomfort at the present level.

 Theraband exercises permit both concentric and eccentric strengthening of

the shoulder muscles and are a form of isotonic exercises
• Internal rotation.
• External rotation.
• Abduction.
• Forward flexion.
• Extension.
 Phase 2 contd...
Progress to light isotonic dumbbell exercises
• Internal rotation.
• External rotation.
• Abduction.
• Forward flexion.
• Extension.

Scapular stabilizer strengthening

• Closed-chain strengthening exercises
• Scapular retraction (rhomboideus, middle trapezius).
• Scapular protraction (serratus anterior).
• Scapular depression (latissimus dorsi, trapezius, serratus anterior).

 Progress to open-chain scapular stabilizer strengthening

 Phase 3: Weeks 8-12

Criteria for Progression to Phase 3

• Full painless ROM.
• Minimal or no pain.
• Strength at least 50% of contralateral shoulder.
• "Stable" shoulder on clinical examination-no impingement signs.

Goals
• Improve shoulder strength, power, and endurance.
• Improve neuromuscular control and shoulder proprioception.
• Prepare for gradual return to functional activities.
 Phase 3 contd...

Motion
• Achieve motion equal to contralateral side.
• Utilize both active and passive ROM exercises to maintain
motion.

Muscle Strengthening
• Advance strengthening of rotator cuff and scapular stabilizers as tolerated.
• Eight to 15 repetitions for each exercise, for three sets.
• Continue strengthening only three times per week to avoid rotator cuff tendinitis
from overtraining.
 Phase 3 contd...

Motion
• Achieve motion equal to contralateral side.
• Utilize both active and passive ROM exercises to maintain motion.

Muscle Strengthening
• Advance strengthening of rotator cuff and scapular stabilizers as tolerated.
• Eight to 15 repetitions for each exercise, for three sets.
• Continue strengthening only three times per week to avoid rotator cuff tendinitis
from overtraining.
 Phase 3 contd...
Functional Strengthening

• Plyometric exercises

For Patients with Concomitant Distal Clavicle Resections

• Now begin cross-body adduction exercises
• First passive, advance to active motion when AC joint pain is minimal.
 Phase 4: Weeks 12-16
Criteria for Progression to Phase 4

• Full, painless ROM.

• No pain or tenderness.
• Shoulder strength that fulfills established criteria.
• Satisfactory clinical examination.

Goals

• Progressive return to unrestricted activities.

• Advancement of shoulder strength and motion with a home exercise
program that is taught throughout rehabilitation.
 Phase 4 contd...
Progressive, Systematic Interval Program for Returning to Sports

• Throwing athletes (see p. 190).

• Tennis players (see p. 192).
• Golfers (see p. 195).
• Institute "Thrower's Ten" program (p. 165) for overhead athlete.
Maximum improvement is expected by 4 - 6 mo following an
acromiopIasty, and 6 - 12 mo following an acromiopIasty combined with
a distal clavicle resection.
 Phase 4 contd...
Warning Signals
• Loss of motion-especially internal rotation.
• Lack of strength progression-especially abduction.
• Continued pain-especially at night.

Treatment of above "Problems"

• These patients may need to move back to earlier routines.
• May requite increased utilization of pain control modalities
as outlined above.
• If no improvement, patients may require repeat surgical as outlined
• It is important to determine that the appropriate surgical procedure
was done initially.
• Issues of possible secondary gain must be evaluated.