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IMPINGEMENT SYNDROME

(Rotator Cuff Tendinitis, Bursitis)
■ ■ ■
Description
Impinement s!ndrome is "#ara"teri$ed %! pain in t#e
s#ou&der due to inf&ammation of t#e tendons of t#e rotator
"uff or t#e %ursa (su%a"romia& %ursa) t#at sits %et'een t#e
rotator "uff and t#e roof of t#e s#ou&der (a"romion)( T#e
rotator "uff is a series of four mus"&es t#at surround t#e %a&& of
t#e s#ou&der (#umera& #ead)( T#e su%a"romia& %ursa sits o)er
t#e top of t#e "uff, a&&o'in for t#e "uff tendons to s&ide near
t#e roof of t#e s#ou&der 'it#out undue fri"tion( Norma&&! t#e
#umera& #ead ets "&oser to t#e a"romion '#en t#e s#ou&der
is mo)ed, parti"u&ar&! as !ou rea"# o)er#ead( *#en t#e
rotator "uff %e"omes inf&amed %e"ause of in+ur! or o)eruse,
or '#en t#e %ursa %e"omes inf&amed, t#en %ot# t#e s'o&&en
tendon and s'o&&en %ursa ma! %e"ome pin"#ed %et'een
t#e #umera& #ead and t#e a"romion( Impinement s!ndrome
ma! represent a rade , or - strain of t#e tendon( . grade 1
strain is a mi&d strain( T#ere is a s&i#t pu&& 'it#out o%)ious
tearin (it is mi"ros"opi" tendon tearin)( T#ere is no &oss of
strent#, and t#e tendon is t#e "orre"t &ent#( . grade 2
strain is a moderate strain( T#ere is tearin of fi%ers 'it#in
t#e su%stan"e of t#e tendon or '#ere t#e tendon meets t#e
%one or mus"&e( T#e &ent# of t#e '#o&e mus"&e/tendon/%one
unit is in"reased, a&t#ou# t#ere usua&&! is de"reased strent#(
. grade 3 strain is a "omp&ete rupture of t#e tendon(
■ ■ ■ Common Signs and
Symptoms
0 Pain around t#e s#ou&der, often at t#e outer portion of t#e
upper arm
0 Pain t#at is 'orse 'it# s#ou&der fun"tion, espe"ia&&! '#en
rea"#in o)er#ead or &iftin
0 O""asiona&&!, a"#in '#en not usin t#e arm
0 Often, pain t#at a'a1ens !ou at ni#t
0 O""asiona&&!, tenderness, s'e&&in, 'armt#, or redness
o)er t#e ot#er aspe"t of t#e s#ou&der
0 2oss of strent#
0 2imited motion of t#e s#ou&der, espe"ia&&! rea"#in
%e#ind
(su"# as to %a"1 po"1et or to un#oo1 %ra) or a"ross !our
%od!
0 Crepitation (a "ra"1&in sound) '#en mo)in t#e arm
0 Bi"eps tendon pain and inf&ammation (in t#e front of t#e
s#ou&der)3 'orse '#en %endin t#e e&%o' or &iftin
■ ■ ■
Causes
0 Strain from sudden in"rease in amount or intensit! of
a"ti)it!
0 Dire"t %&o' or in+ur! to t#e s#ou&der
0 .in, deeneration of t#e tendon 'it# norma& use
0 ."romia& spur
■ ■ ■ Risk Increases
With
0 Conta"t sports su"# as foot%a&&, 'rest&in, and %o4in
0 T#ro'in sports, su"# as %ase%a&&, tennis, or )o&&e!%a&&
0 *ei#t&iftin and %od!%ui&din
0 5ea)! &a%or
0 Pre)ious in+ur! to rotator "uff, in"&udin impinement
0 Poor p#!si"a& "onditionin (strent# and f&e4i%i&it!)
0 Inade6uate 'arm/up %efore pra"ti"e or p&a!
0 Inade6uate prote"ti)e e6uipment
0 In"reasin ae
0 Spurrin of t#e a"romion
■ ■ ■ Preventive
Measures
0 .ppropriate&! 'arm up and stret"# %efore pra"ti"e or
"ompetition(
0 .&&o' time for ade6uate rest and re"o)er! %et'een
pra"ti"es and "ompetition(
0 Maintain appropriate "onditionin7
0 Cardio)as"u&ar fitness
0 S#ou&der f&e4i%i&it!
0 Mus"&e strent# and enduran"e
0 8se proper te"#ni6ue(
■ ■ ■ Expected
Outcome
T#is "ondition is usua&&! "ura%&e 'it#in 9 'ee1s if treated
appropriate&! 'it# "onser)ati)e treatment and restin of t#e
affe"ted area( 5ea&in is usua&&! 6ui"1er if in+ur! is "aused %!
a dire"t %&o' ()ersus o)eruse)(
■ ■ ■ Possibe
Compications
0 Pro&oned #ea&in time if not appropriate&! treated or if
not i)en ade6uate time to #ea&
0 C#roni"a&&! inf&amed tendon, "ausin persistent pain 'it#
a"ti)it! t#at ma! proress to "onstant pain ('it# or 'it#out
a"ti)it!)
0 S#ou&der stiffness, fro$en s#ou&der, or &oss of motion
0 Rotator "uff tendon tear
0 Re"urren"e of s!mptoms, espe"ia&&! if a"ti)it! is resumed
too soon, 'it# o)eruse, 'it# a dire"t %&o', or '#en usin
poor te"#ni6ue
■ ■ ■ !enera "reatment
Considerations
Initia& treatment "onsists of medi"ation and i"e to re&ie)e t#e
pain, stret"#in and strent#enin e4er"ises, and modifi"ation
of t#e a"ti)it! t#at initia&&! "aused t#e pro%&em( T#ese a&& "an
%e "arried out at #ome, a&t#ou# referra& to a p#!si"a&
t#erapist or at#&eti" trainer ma! %e re"ommended( .n
in+e"tion of "orti/ sone to t#e area around t#e tendon ('it#in
t#e %ursa) ma! %e re"ommended( Surer! to remo)e t#e
"#roni"a&&! s"arred %ursa and spur from t#e a"romion ma! %e
ne"essar!, %ut t#is is usua&&! on&! "onsidered after at &east :
mont#s of "onser)ati)e treatment( Surer! ma! %e performed
art#ros"opi"a&&! or 'it# an open in"ision( Return to fu&&
a"ti)it! is usua&&! possi%&e in : mont#s(
:;,
IMPINGEMENT SYNDROME 3
■ ■ ■ Medication
0 Nonsteroida& anti/inf&ammator! medi"ations, su"# as
aspirin and i%uprofen (do not ta1e 'it#in ; da!s %efore
surer!), or ot#er minor pain re&ie)ers, su"# as a"etamino/
p#en, are often re"ommended( Ta1e t#ese as dire"ted %!
!our p#!si"ian( Conta"t !our p#!si"ian immediate&! if an!
%&eedin, stoma"# upset, or sins of an a&&eri" rea"tion
o""ur(
0 Pain re&ie)ers are usua&&! not pres"ri%ed for t#is "ondition(
If pres"ri%ed, use on&! as dire"ted and on&! as mu"# as
!ou need(
0 Cortisone in+e"tions redu"e inf&ammation, and anest#eti"s
temporari&! re&ie)e pain( T#ere is a &imit to t#e num%er of
times "ortisone ma! %e i)en, %e"ause it ma! 'ea1en
mus"&e and tendon tissue(
■ ■ ■ #eat and Cod
0 Co&d is used to re&ie)e pain and redu"e inf&ammation for
a"ute and "#roni" "ases( Co&d s#ou&d %e app&ied for ,< to
,= minutes e)er! - to : #ours for inf&ammation and pain
and immediate&! after an! a"ti)it! t#at ara)ates !our
s!mptoms( 8se i"e pa"1s or an i"e massae(
0 5eat ma! %e used %efore performin stret"#in and
strent#enin a"ti)ities pres"ri%ed %! !our p#!si"ian,
p#!si"a& t#erapist, or at#&eti" trainer( 8se a #eat pa"1 or a
'arm soa1(
■ ■ ■ $oti%y Our O%%ice I%
0 S!mptoms et 'orse or do not impro)e in > to 9 'ee1s
despite treatment
0 Ne', une4p&ained s!mptoms de)e&op (drus used in
treatment ma! produ"e side effe"ts)
Acromion/clavicle
Impingement
Bursa
Tendon
Supraspinatus
muscle
Arm socket
&igure '
From Shankman GA: Fundamental Orthopaedic Management for
the h!sical Therap! Assistant" St" #ouis$ Mos%! &ear Book$ '(()$
p" *++" , Ma!o Foundation"
-eltoid
muscle
.umerus
/upper arm %one0
&igure (
From 1conomou SG$ 1conomou TS: Instructions for Surger! atients"
hiladelphia$ 2B Saunders$ '((3$ p" 4+("0
➢ R)$!E O& MO"IO$ )$D S"RE"C#I$!
E*ERCISES
+
Impingement S!ndrome
/5otator 6uff Tendinitis$ Bursitis0
T#ese are some of t#e initial e4er"ises !ou ma! start
!our re#a%i&itation proram 'it# unti& !ou see !our
p#!si"ian, p#!si"a& t#erapist, or at#&eti" trainer aain
or unti& !our s!mptoms are reso&)ed( P&ease remem%er7
0 ?&e4i%&e tissue is more to&erant of t#e stresses
p&a"ed on it durin a"ti)ities(
0 Ea"# stret"# s#ou&d %e #e&d for -< to :< se"onds(
0 . gentle stret"#in sensation s#ou&d %e fe&t(
S#O,-DER
7
Fle8ion
,( 2ie on !our %a"1( Grasp t#e %ottom of a sti"1, #and&e of
an um%re&&a, or %&ade of a o&f "&u% in !our #and
as s#o'n(
-( 8sin t#e sti"1, raise !our arm o)er#ead as s#o'n unti&
!ou fee& a ent&e stret"#( 2ead 'it# t#e t#um% in a
@t#um%s upA position(
:( Repeat e4er"ise times, times per da!( 5o&d
ea"# repetition = to ,< se"onds(
S#O,-DER
7
Fle8ion
,( 2ie on !our %a"1 #o&din a sti"1 in %ot# #ands, 1eepin
!our #ands s#ou&der/'idt# apart(
-( Raise %ot# #ands o)er !our #ead unti& !ou fee& a ent&e
stret"#(
:( Repeat e4er"ise times, times per da!( 5o&d
ea"# repetition = to ,< se"onds(
S#O,-DER
7
A%duction
,( 2ie on !our %a"1 #o&din a sti"1, um%re&&a #and&e, or o&f
"&u% in !our #and as s#o'n( T#e #and s#ou&d %e in t#e
@t#um%s upA position(
-( 8sin t#e sti"1, s&o'&! pus# !our arm a'a! from !our
side and as far o)er#ead as !ou "an 'it#out pain( Pus#
unti& !ou fee& a ent&e stret"#(
:( Repeat e4er"ise times, times per da!( 5o&d
ea"# repetition = to ,< se"onds(
S#O,-DER
7
Internal 5otation
,( Grasp a sti"1 %e#ind !our %a"1 'it# %ot# #ands as s#o'n(
-( S&ide t#e sti"1 up !our %a"1 unti& !ou fee& a ent&e stret"#(
:( Repeat e4er"ise times, times per da!( 5o&d
ea"# repetition = to ,< se"onds(
S#O,-DER
7
Internal 5otation
,( P&a"e !our #and %e#ind !our %a"1(
-( Drape a to'e& o)er !our opposite s#ou&der and rasp it
'it# t#e #and t#at is %e#ind !our %a"1(
:( 8se t#e to'e& to ent&! pu&& !our #and fart#er up !our
%a"1 unti& !ou fee& a ent&e stret"#(
>( Repeat e4er"ise times, times per da!( 5o&d
ea"# repetition = to ,< se"onds(
S#O,-DER
7
Internal 5otation
,( 2ie on !our %a"1 'it# !our arm out a'a! from
!our %od! a%out 9< derees and a ro&&ed/up to'e& p&a"ed
under !our e&%o' as s#o'n(
-( TurnBrotate !our arm in'ard to'ard !our %od! from t#e
s#ou&der(
:( To assist in t#is stret"# !ou ma! use a rope or t o'e& to
ent&! pu&& t#e arm fart#er in'ard as s#o'n(
>( Ma1e sure to 1eep !our s#ou&ders f&at on t#e f&oorB%ed on
'#i"# !ou are &!in(
S#O,-DER
7
.ori9ontal Adduction
,( Stand or &ie on !our %a"1, raspin !our e&%o' as s#o'n
in t#e diaram(
-( Ceepin !our arm at s#ou&der #ei#t, pu&& !our arm a"ross
!our "#est unti& !ou fee& a ent&e stret"# in t#e %a"1 of
!our s#ou&der(
:( Repeat e4er"ise times, times per da!( 5o&d
ea"# repetition = to ,< se"onds(
➢ S"RE$!"#E$I$! E*ERCISES
+
Impingement
S!ndrome /5otator 6uff Tendinitis$ Bursitis0
T#ese are some of t#e initial e4er"ises !ou ma! start
!our re#a%i&itation proram 'it# unti& !ou see !our
p#!si"ian, p#!si"a& t#erapist, or at#&eti" trainer aain
or unti& !our s!mptoms are reso&)ed( P&ease remem%er7
0 Stron mus"&es 'it# ood enduran"e to&erate stress
%etter(
0 Do t#e e4er"ises as initially pres"ri%ed %! !our
p#!si/ "ian, p#!si"a& t#erapist, or at#&eti" trainer(
Proress s&o'&! 'it# ea"# e4er"ise, radua&&!
in"reasin t#e num%er of repetitions and 'ei#t used
under t#eir uidan"e(
0 If 'ei#t e6uipment is used durin t#e proression
of !our strent# proram, !ou s#ou&d a)oid
a"ti)ities t#at in)o&)e !our #ands or e&%o's
oin %e#ind !our #eadB%od!( T#ese t!pes of
e4er"ises p&a"e undue stress on !our s#ou&ders(
S"RE$!"#
7
Shoulder A%duction$ Isometric
,( *#i&e standin, raise t#e arm s&i#t&! a'a! from
t#e %od! as s#o'n(
-( P&a"e t#e ot#er #and on top of !our arm and pus# do'n(
Do not a&&o' !our arm to mo)e( Pus# as #ard as !ou "an
'it#out #a)in an! pain or mo)in t#e arm(
:( 5o&d t#is position for se"onds and t#en slowly return
to t#e startin position(
>( Repeat e4er"ise times, times per da!(
S#O,-DER
7
Scapular 1levation$ Shrugs
,( Stand 'it# !our arms at !our side in a good erect posture.
-( Su%t&! @s#ruA !our s#ou&ders up and %a"1 to'ard !our
ears(
:( 5o&d t#is position for se"onds and t#en slowly return
to t#e startin position(
>( Repeat e4er"ise times, times per da!(
=( You ma! perform t#is e4er"ise 'it# a pound 'ei#t
in ea"# #and(
9( .)oid standin in a s&ou"#ed position 'it# poor posture
%! usin t#is te"#ni6ue intermittent&! t#rou#out t#e da!(
S"RE$!"#
7
Shoulder$ 18ternal 5otation$ Isometric
,( Bend !our e&%o' to D< derees as s#o'n, #o&din
!our arm s&i#t&! in front of !our %od!(
-( P&a"e !our opposite #and o)er !our 'rist as s#o'n(
:( Tr! to turnBrotate !our arm out'ard, a'a! from !our
%od!, as if it 'ere a ate s'inin open( Resist t#is
motion 'it# t#e opposite #and t#at is on !our 'rist( Do
not &et an! motion o""ur(
>( 5o&d t#is position for se"onds(
=( Repeat e4er"ise times, times per da!(
:;°<;°
S"RE$!"#
7
Scaption$ Thum% =p
,( 5o&d a 'ei#t in !our #and 'it# !our arm
at !our side %ut s&i#t&! for'ard (appro4imate&! :<
derees3 see sma&& diaram)( T#is e4er"ise ma! a&so %e
done 'it# ru%%er %andBtu%in as s#o'n(
-( Your #and s#ou&d %e in a @t#um%s/upA position(
:( S&o'&! raise !our arm in t#e @t#um%s/upA position
t#rou# !our pain free rane( If t#is is painfu&, stop and
dis"uss t#is 'it# !our p#!si"ian, p#!si"a& t#erapist, or
at#&eti" trainer( Do not a&&o' !our s#ou&der to @s#ru upA
'#i&e doin t#is e4er"ise(
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
S#O,-DER
7
Scapular rotraction
,( Stand 'it# !our #and aainst a 'a&& as s#o'n(
-( Ceep !our e&%o's strai#t and pus# do'n 'it# !our
#ands, raisin t#e %a"1 of !our s#ou&ders a'a! from t#e
'a&& as s#o'n in t#e dra'in(
:( T#e fart#er a'a! from t#e 'a&& !ou stand, t#e #arder t#e
e4er"ise(
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
S"RE$!"#
7
Shoulder 18ternal 5otation
,( 2ie on !our side 'it# !our arm up and t#e e&%o'
%ent to D< derees, or stand 'it# !our arms at !our side
and t#e e&%o's %ent to D< derees as s#o'n( P&a"e a sma&&
ru%%er %a&& (> to 9 in"#es in diameter) or ro&&ed/up to'e&
%et'een !our e&%o' and !our side as s#o'n(
-( 5o&d a pound 'ei#t in !our #and and turn t#e arm
up to'ard t#e "ei&in, 1eepin t#e e&%o' %ent as s#o'n( If
usin ru%%er %andBtu%in, turn t#e arm(s) out from !our
side '#i&e 1eepin t#e e&%o's %ent(
:( Do t#is s&o'&! and in "ontro& t#rou# !our pain free rane
of motion on&!( If t#is is painfu&, stop and dis"uss t#is 'it#
!our p#!si"ian, p#!si"a& t#erapist, or at#&eti" trainer(
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
S#O,-DER
7
Scapular rotraction
,( 2ie on !our %a"1 'it# !our arm strai#t up in t#e
air as s#o'n( 5o&d a pound 'ei#t in !our #and(
-( Pus# !our #and up to'ard t#e "ei&in, 1eepin !our e&%o'
strai#t and raisin !our s#ou&der off t#e f&oor(
:( 5o&d t#is position for se"onds and t#en slowly return
to t#e startin position(
>( Repeat e4er"ise times, times per da!(
S#O,-DER
7
Scapular rotraction
,( Position !ourse&f on !our #ands and 1nees as s#o'n(
-( Ceep !our e&%o's strai#t and pus# do'n 'it# !our
#ands, raisin t#e %a"1 of !our s#ou&ders up as s#o'n in
t#e dra'in(
:( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
>( Repeat e4er"ise times, times per da!(
This exercise may be made harder by assuming a
push-up position. Before trying this check with your
physician, physical therapist, or athletic trainer.
S#O,-DER
7
Scapular 5etraction
,( .n"#or ru%%er %andBtu%in to a sta%&e, fi4ed o%+e"t(
-( 5o&d one end of t#e %andBtu%in in ea"# #and 'it# !our
arms strai#t out in front of !ou(
:( S6uee$eB@pin"#A !our s#ou&der %&ades toet#er(
>( Ceepin !our s#ou&der %&ades pin"#ed toet#er, pu&& !our
arms %a"1 as s#o'n( Your #ands s#ou&d %e &e)e& 'it#
!our s#ou&ders '#en !ou finis#( Do not &et !our e&%o's o
%e#ind !our %od!(
=( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
9( Repeat e4er"ise times, times per da!(
S#O,-DER
7
Internal 5otation
,( .n"#or t#e ru%%er %andBtu%in to a #ea)!Bso&id o%+e"t as
s#o'n(
-( P&a"e a sma&& %a&& or to'e& %et'een !our e&%o' and %od!
as s#o'n in t#e dra'in and %end !our e&%o' to D<
derees( S6uee$e t#e %a&& ent&! to t#e side of !our "#est
'it# !our e&%o'(
:( TurnBrotate !our arm in to'ard !our %od! (a"ross !our
"#estBstoma"#)( Do not &et t#e %a&& mo)eBfa&& a'a! from
t#e side of !our "#est(
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
S"RE$!"#
7
Shoulder 18tension
,( .n"#orBse"ure ru%%er %andBtu%in around a sta%&e o%+e"t
su"# as a stair post or around t#e 1no% of a "&osed door(
-( Stand #o&din t#e ru%%er %andBtu%in in front of !ou 'it#
!our arms e4tended as s#o'n(
:( S6uee$eBpin"# !our s#ou&der %&ades toet#er and pu&& !our
arms do'n and %a"1'ard as s#o'n( Do not pull arms
past the midline of your body.
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
S#O,-DER
7
Scapular 5etraction and 18ternal 5otation
,( If using a weight—2ie on !our stoma"# 'it# !our
arm out to t#e side and o)er t#e ede of t#e %ed as s#o'n(
T#e e&%o' s#ou&d %e %ent to D< derees and t#e upper arm
s#ou&d %e supported %! t#e %ed( 5o&d a pound
'ei#t in !our #and(
-( TurnBrotate !our arm up to'ard t#e "ei&in '#i&e 1eepin
t#e e&%o' %ent(
:( S6uee$eB@pin"#A !our s#ou&der %&ades toet#er(
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
,( If using rubber band/tubing—5o&d one end of t#e
%andBtu%in in ea"# #and( Your e&%o's s#ou&d %e %ent D<
derees and at s#ou&der #ei#t(
-( S6uee$eB@pin"#A !our s#ou&der %&ades toet#er(
:( Ceepin !our s#ou&der %&ades pin"#ed toet#er, turn !our
arms up as if someone #ad said @Sti"1 Eem upFA Your
#ands s#ou&d %e in t#e position s#o'n '#en !ou finis#(
Do not bring your elbows or your hands past the middle
of your body.
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
S"RE$!"#
7
Shoulder$ 18ternal 5otation/5o>ing
,( .n"#orBse"ure ru%%er %andBtu%in around a sta%&e o%+e"t
su"# as a stair post or around t#e 1no% of a "&osed door(
-( Stand #o&din t#e ru%%er %andBtu%in in front of !ou 'it#
!our arms e4tended as s#o'n(
:( S6uee$eBpin"# !our s#ou&der %&ades toet#er and pu&& !our
arms %a"1 as s#o'n, %endin !our e&%o's( Your fists
s#ou&d end at s#ou&der #ei#t and "&ose to !our %od!(
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
S#O,-DER
7
-epression
,( Support !ourse&f as s#o'n in an arm"#air( Your e&%o's
s#ou&d %e strai#t and !our fee& f&at on t#e f&oor(
-( Pus# !our s#ou&ders do'n'ard( Do not bend your elbows.
:( Support !our 'ei#t as needed %! usin !our &es(
>( 5o&d t#is position for se"onds and t#en slowly
return to t#e startin position(
=( Repeat e4er"ise times, times per da!(
?otes: /=p to ++;; characters onl!0
?otes and suggestions