P Rafful

SHOULDER IMPINGEMENT SYNDROME
Project
Submitted to the
DEPARTMENT OF PHYSIOTHERAPY
GD GOENKA UNIVERSITY
SOHNA, GURUGRAM (HARYANA)
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF
Bachelor of Physiotherapy
2018-2022
Supervisor CO-Supervisor
Dr. Divya Goyal Dr. Dheerja Babbar
Assistant Professor, SOMAS, Head of Department
GD, Goenka University, Sohna, Sarvodaya Hospital
Gurugram, Haryana
Submitted By:
Prafful Singh
180100201046
SCHOOL OF MEDICAL AND ALLIED SCIENCES
GD GOENKA UNIVERSITY, GURGAON
January, 2023
SHOULDER IMPINGEMENT SYNDROME
Project
Submitted to the
GD GOENKA UNIVERSITY
SOHNA, GURUGRAM (HARYANA)
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF
Bachelor of Physiotherapy
2018-2022
Supervisor CO-Supervisor
Dr. Divya Goyal Dr. Dheerja Babbar
Assistant Professor, SOMAS, Head of Department
GD, Goenka University, Sohna, Sarvodaya Hospital
Gurugram, Haryana Faridabad
Submitted By:
Prafful Singh
180100201046
SCHOOL OF MEDICAL AND ALLIED SCIENCES
GD GOENKA UNIVERSITY, GURGAON
January, year
CERTIFICATE OF DECLARATION
I do hereby declare that this project work entitled “Shoulder Impingement Syndrome” done at
"Sarvodaya Hospital, Faridabad” during the period of my compulsory rotatory internship for 6 months
(dates 22 July 2022 to 24 January 2023), and it is the result of my original and independent project work
which is submitted by me in partial fulfillment for the requirement of Bachelor of Physiotherapy from
Department of Physiotherapy, School of Medical & Allied Sciences, G D Goenka University,
Gurugram.
Jan,2023 Prafful Singh

GD Goenka University 180100201046
DECLARATION BY SUPERVISOR
This is to certify that the work contained in the project entitled “Shoulder Impingement Syndrome”,
submitted by Prafful Singh (180100201046) for the award of the degree of Bachelor of Physiotherapy to
the G D Goenka University, Gurgaon, is a record of bonafide work carried out by him under my
supervision guidance. I considered that the project has reached the standards and fulfilling the
requirements of the rules and regulations relating to the nature of the degree. The contents embodied in the
project have not been submitted for the award of any other degree or diploma in this or any other
university.
Date: Signature of Supervisor
Place: Faridabad Dr. Divya Goyal

Ass. Professor, SOMAS
G.D Goenka University
Signature of co-supervisor
Dr. Dheerja Babbar,

Head of Department,
Sarvodaya Hospital
ACKNOWLEDGMENT
Every successful work is backed by sincerity and hard work. During this six-month tenure of my
internship, I was able to gain a lot of knowledge both application and theory wise. My training period
would not have been possible without the wonderful support and guide of respected trainers/ teachers and
hospital staffs. I am very grateful to those people who have helped me in every way of training. I would
like to express my warm and heart full gratitude towards Dr. Dheerja Babbar, HOD Physiotherapy for
selecting and accepting me as a trainee in Sarvodaya Hospital, Faridabad. I am also thankful to Dr.
Divya Goyal (PT) for the continues guidance throughout the training period and for giving me the
opportunity to complete my internship project in well stipulated time.
Dedicated to
I would like to dedicate this project to my Parents because without their support and courage I am not able
to complete this project.
To my guide Dr. Divya Goyal and Dr. Dheerja Babbar who have constantly supported and encouraged me
to complete this project effectively.
SUMMARY
Subacromial impingement syndrome (SAIS) is a commonly diagnosed disorder of the shoulder. Though
this disorder has been known for a long time, it remains a poorly understood entity. Over the years several
hypotheses have been put forward to describe the pathogenesis of SAIS but no clear explanation has been
found. Two mechanisms, the extrinsic and intrinsic mechanism, have been described for the impingement
syndrome. The intrinsic mechanism theories which deny the existence of impingement are gaining
popularity in recent years. The various shoulder tests used to diagnose SAIS have low specificity with an
average of about 50%. Meta-analysis shows that neither the Neer sign nor the Hawkins sign has diagnostic
utility for impingement syndrome. Several randomized controlled trials have shown that the outcome of
treatment of SAIS by surgery is no better than conservative treatment. Physiotherapy alone can provide
good outcome which is comparable to that achieved with surgery without the costs and complications
associated with surgery. Since decompression with surgery does not provide any additional benefits as
compared to conservative treatment for patients with SAIS, the impingement theory has become
antiquated and surgical treatment should have no role in the treatment of such patients. There are calls by
some practitioners to abandon the term impingement syndrome and rename it as anterolateral shoulder
pain syndrome. It appears that SAIS is a medical myth. There are others who called SAIS as a clinical
illusion.
The subacromial space lies between the coracoacromial arch above and the humeral head and greater
tuberosity of the humerus below. It contains the rotator cuff tendons, the long head of biceps tendon, the
shoulder joint capsule, the glenohumeral ligament, coraco-humeral ligament and the subacromial bursa.
Subacromial pathology has attracted the attention of orthopaedic surgeons for a long time. In 1934,
Codman1 described rotator cuff pathology and he was of the opinion that humeral head and acromion
impingement during shoulder abduction was the cause of rotator cuff lesions and he suggested that lateral
acromioplasty would resolve the patient's symptoms. In 1972, Neer coined the term impingement
syndrome and he was of the opinion that impingement occurred anterolaterally at the anterior acromion
and the coracoacromial ligament. He proposed anterior acromioplasty as a mode of treatment for
impingement syndrome. Subacromial impingement syndrome (SAIS) of the shoulder is probably the most
common disorder of the shoulder and accounts for about 48% of all shoulder complaints.
List of Abbreviations:
 SAIS: Subacromial Impingement Syndrome

 SIS: Shoulder Impingement Syndrome
 GH Joint: Glenohumeral Joint
 RC: Rotator Cuff
 SIS: Shoulder Impingement Syndrome
 AC Joint: Acromioclavicular Joint
 GH Joint: Glenohumeral Joint
 AROM: Active Range of Motion
 PROM: Passive Range of Motion
 NSAIDs: Non-Steroidal Anti-Inflammatory Drugs
 MRI: Magnetic Resonance Imaging
 CT: Computed Tomography
 X-ray: Radiography
 EMG: Electromyography
 ROM: Range of Motion
 ORIF: Open Reduction Internal Fixation
 TENS: Transcutaneous Electrical Nerve Stimulation
 US Therapy: Ultrasound Therapy
TABLE OF CONTENTS
CERTIFICATE OF DECLARATION…………………………………………………………i
DECLARATION BY SUPERVISOR…………………………………………………………ii
ACKNOWLEDGEMENT…………………………………………………………………….iii
LIST OF ABBREVIATIONS…………………………………………………………………iv
CHAPTER 1: INTRODUCTION
1.1 Shoulder Anatomy
CHAPTER 2: PATHOPHYSIOLOGY
2.1 Mechanism
CHAPTER 3: ETIOLOGY
3.1 Causes
CHAPTER 4: SIGN AND SYMPTOMS
CHAPTER 5: INVESTIGATION
5.1 Diagnostic Procedure
CHAPTER 6: MEDICAL TREATMENT
CHAPTER 7: PHYSIOTHERAPY MANAGEMENT
CHAPTER 8: PRECAUTIONS
CHAPTER 9: ERGONOMIC ADVICE
CHAPTER 10: REFERENCES

Chapter 1
Introduction
Shoulder Impingement Syndrome
Shoulder impingement occurs when the top outer edge of shoulder blade, called the acromion,
rubs against or pinches the rotator cuff beneath it, causing pain and irritation.
The concept of shoulder impingement syndrome is attributed to Charles Neer following his paper
published in 1972. The term shoulder impingement itself however now belongs to a group of
terms that essentially describes pain in the shoulder region as a result of mechanical
‘impingement’ of the rotator cuff as it passes under the coraco-acromial ligament. If left untreated
rotator cuff impingement may proceed to partial or complete rotator cuff tendon rupture. (David,
2009).
Neer’s Classification of Impingement identified four types of shoulder impingement

identified below:
 Type I: <25 years old, Reversible, Swelling, Tendonitis, No Tears, Conservative

Treatment. Moderate pain during exercise, no loss of strength and no limitation in
movement. Edema and/or hemorrhage may be present. This stage generally occurs in
patients less than 25 years of age and is frequently associated with an overuse injury.
At this stage, the syndrome could be possibly reversible.
 Type II: 25-40 years old, Permanent Scarring, Tendonitis, No Tears, Subacromial
Decompression. Pain is usually reported during ADL and especially during the night.
loss of mobility is associated with this stage. Type II is more advanced and tends to
occur in patients between 25 to 40 years of age. The pathological changes show
fibrosis as well as irreversible tendon changes.
 Type III: >40 years old, Small Rotator Cuff Tear, Subacromial Decompression with
Debridement/Repair
 Type IV: >40 years old, Large Rotator Cuff Tear, Sub Acromial Decompression with
Repair.
While Neers Classification of SIS was key to understanding shoulder pathology at the time,
SIS was further broken down into four subtypes associated with either External
Impingement (Primary or Secondary) and Internal Impingement. (David, 2009)
Shoulder impingement syndrome also may be called "subacromial" impingement syndrome.
The rotator cuff tendon and the bursa sit beneath the acromion (a bony, bump-like
prominence at the tip of the shoulder). Over time, these tissues can become compressed or
pinched under the acromion:
 Rotator cuff tendons. These tendons are often the most affected by this condition.
 Long head of the biceps tendon.
 Ligaments.
 Bursa (a fluid-filled sac that provides a cushion between the bony acromion and the
rotator cuff tendon.
Subacromial impingement syndrome (SIS) is the most common cause of shoulder pain and it
affects shoulder sensory-motor control and maximal shoulder muscle strength. After shoulder
injuries or pathologies, disruption of mechanoreceptors results in partial deafferentation of the
joint. This has been shown to inhibit normal neuromuscular reflex stabilization and it contributes
to repetitive injuries and the progressive decline of the joint. In histologic studies, the periarticular
mechanoreceptors, which play an important role in proprioception, were shown to exist in the
capsule, bursae, and coracoacromial ligament. Numerous studies demonstrated that damage in the
capsule, ligaments, glenoid labrum, or the pericapsular muscles was associated with a
proprioceptive deficit in the shoulder joint. The proprioceptive impairment was demonstrated in
patients with rotator cuff pathology and also with shoulder instability. It is suggested that
proprioception should be improved to ensure the synergic contractions and normal functioning of
the muscles in the shoulder, thereby providing protection from future injuries. Subacromial
impingement syndrome (SAIS) is the most common disorder of shoulder, accounting for 44-65%
of all complaints of shoulder pain during a physician’s office visit. SAIS encompasses a spectrum
of subacromial space pathologies including partial thickness rotator cuff tears, rotator cuff
tendinosis, calcific tendinitis, and subacromial bursitis. The main consequences of SAIS are
functional loss and disability. Subacromial space is defined by the humeral head inferiorly, the
anterior edge and under surface of the anterior third of the acromion, coracoacromial ligament and
the acromioclavicular joint superiorly. The height of space between acromion and humeral head
ranges from 1.0 to 1.5 centimeters as seen on radiographs. Interposed between these two osseous
structures are the rotator cuff tendons, the long head of the biceps tendon, the bursa, and the
coracoacromial ligament. Any abnormality that disturbs the relationship of these subacromial
structures may lead to impingement. Neer described three stages of impingement.
 Stage-I impingement is characterized by edema and hemorrhage of the subacromial bursa
and cuff. It is typically found in patients. who are less than twenty-five years old.
 Stage-II impingement represents irreversible changes, such as fibrosis and tendinitis of the
rotator cuff, and is typically found in patients who are twenty-five to forty years old.
 Stage-III impingement is marked by more chronic changes, such as partial or complete
tears of the rotator cuff, and usually is seen in patients who are more than forty years old.
Given the high prevalence of this condition, the aim of this review is to evaluate the
different etiological theories that may explain SAIS. The different anatomical structures
involved in this type of impingement are described; the clinical findings are presented and
treatment guidelines are suggested. (William et al.,2018)
1.1 Shoulder Anatomy

The shoulder girdle is made up of three bones, the humerus (upper arm bone), scapula (shoulder
blade) and the clavicle (collar bone). Due to its makeup, the shoulder joint has a great range of
movement, but not much stability. It is therefore very reliant on the muscles around the joint to
provide stability with movement, and as long as all the parts are in good working order, the
shoulder can move freely and painlessly. The rotator cuff is a group of muscles that connects the
humerus to the scapula namely; supraspinatus, infraspinatus, teres minor and subscapularis. The
main function of the rotator cuff is to keep the humerus tightly in its socket on the scapula (the
glenoid fossa) throughout movement allowing it to move effectively, as well as provide rotational
movements for the shoulder. The upper part of the scapula, known as the acromion, forms a roof
over the top of the shoulder joint. The space between the under surface of the acromion and the
upper surface of the humerus is normally narrow because of all the structures that run through
here. This space is maximally narrowed when the arm is moved out to the side (abducted).
Therefore, any condition that further decreases this space can cause an impingement to occur.
(Allen et al., 1998)
 Glenohumeral Joint Kinematics

The glenohumeral joint possesses six degrees of freedom, three rotations and three translations.
With active in vivo glenohumeral abduction in the scapular plane (approximately 30-40º anterior
to the frontal plane), the humerus concomitantly externally rotates. External rotation is important
for clearance of the greater tuberosity and its associated tissues as it passes under the
coracoacromial arch, as well as for relaxation of the capsular ligamentous constraints to allow
maximum glenohumeral elevation. Translation of the humeral head in the magnitude of 1-3 mm in
the superior direction occurs in the first 30-60º of active glenohumeral scapular plane elevation.
After the initial phase of elevation in the scapular plane or frontal plane abduction, the humeral
head remains somewhat centered on the glenoid cavity with fluctuations between inferior and
superior translations
of typically less than 1 mm. The glenohumeral joint demonstrates essentially ball and socket
kinematics above approximately 60º of glenohumeral elevation. Superior humeral translation that
occurs during the initial phase of elevation appears to be due in part to the cranially directed pull
on the head of the humerus by the deltoid muscle. Humeral head translations in the anterior-
posterior directions have been less well investigated. Anterior humeral head translations in the
magnitude of 2-5 mm have been demonstrated during passive glenohumeral flexion. During active
glenohumeral flexion, anterior humeral head translation of less than 1 mm occurs over the course
of motion.
 Scapulothoracic articulation kinematics:

Scapula and thoracic cage form the scapulothoracic articulation. This articulation is assessed
kinematically either two-dimensionally or three-dimensionally. The joint is typically described
with five degrees of freedom, three rotations and two translations. The scapula demonstrates a
pattern of upward rotation, external rotation, and posterior tilting during glenohumeral elevation.
The three-dimensional analysis of scapular motion by van der Helm and Pronk describe scapular
upward rotation occurring about an anterior posterior axis, with the inferior angle of the scapula
moving laterally, external rotation occurring about a superior-inferior axis, with the lateral border
of the scapula moving posteriorly; posterior tilt occurring about a medial lateral axis, with the
inferior angle moving anteriorly. Less well examined are scapular translations, depicted as
scapular positions. Scapular position scan be represented by clavicular rotations about the
sternoclavicular joint in two different planes: clavicular elevation/depression for superior/inferior
translation and clavicular protaction/retraction for anterior/posterior translation. The assumption is
made that motion of the clavicle at the sternoclavicular joint will be in direct relationship to
scapular translation, because of the interposed rigid bone (clavicle) between these two joints and
the lack of significant motion occurring at the acromioclavicular joint. During glenohumeral
elevation the clavicle retracts posteriorly and elevates, putting the scapula in essentially a more
superior and posterior position. Subjects with subacromial impingement generally have decreased
scapular posterior tilting, decreased upward rotation and increased internal rotation compared to
healthy subjects. Weak or dysfunctional scapular musculature, fatigue of the infraspinatus and
teres minor and changes in thoracic and cervical spine posture have all demonstrated a change in
scapular kinematics. (Allen et al., 1998)
Chapter 2
Pathophysiology
Pathophysiology of SIS is complex and multifactorial, involving a combination of anatomical,
biomechanical, and physiological factors.
The shoulder joint is composed of the humerus (upper arm bone), scapula (shoulder blade), and
clavicle (collarbone), along with several ligaments, tendons, and muscles. SIS occurs when the
soft tissues of the rotator cuff and subacromial bursa become compressed or irritated between the
humeral head and the acromion, a bony projection of the scapula.
There are several factors that contribute to the development of SIS, including:
 Abnormal anatomy: Certain anatomical variations, such as a hooked or curved acromion,
can decrease the amount of space available for the rotator cuff tendons and subacromial
bursa, leading to compression and irritation.
 Poor posture: Slouching or hunching forward can cause the scapula to tilt forward,
narrowing the subacromial space and increasing the risk of impingement.
 Muscle imbalances: Weakness or tightness in the muscles that control the shoulder blade
and rotator cuff can alter the position of the humeral head and increase the likelihood of
impingement.
 Overuse or trauma: Repetitive overhead activities or traumatic events can cause
inflammation and swelling in the rotator cuff tendons and subacromial bursa, further
narrowing the subacromial space. (Nicole, 2015)
2.1 Mechanism:
Intrinsic mechanisms involve pathologies of the rotator cuff tendons due to tension, including:
 Muscular weakness: Weakness in the rotator cuff muscles can lead to muscular
imbalances resulting in the humerus shifting proximally towards the body
 Overuse of the shoulder: Repetitive microtrauma can result in soft tissue inflammation of
the rotator cuff tendons and the subacromial bursa, leading to friction between the tendons
and the coracoacromial arch
 Degenerative tendinopathy: Degenerative changes of the acromion can lead to tearing of
the rotator cuff, which allows for proximal migration of the humeral head
Extrinsic mechanisms involve pathologies of the rotator cuff tendons due to external
compression, such as:
 Anatomical factors: Congenital or acquired anatomical variations in the shape and
gradient of the acromion
 Scapular musculature: A reduction in function of the scapular muscles, particularly the
serratus anterior and trapezius, that normally allow the humerus to move past the acromion
on overhead extension, may result in a reduction in the size of the subacromial space
 Glenohumeral instability: Any abnormality of the glenohumeral joint or weakness in the
rotator cuff muscles can lead to superior subluxation of the humerus, causing an increased
contact between the acromion and subacromial tissues.
Fig 1: Pathophysiology (March 24, 2015, Nicole Geier)
These factors can lead to mechanical irritation and inflammation of the rotator cuff tendons and
subacromial bursa, resulting in pain, weakness, and limited range of motion. In some cases,
chronic impingement can lead to rotator cuff tears or other structural damage to the shoulder joint.
Overall, the pathophysiology of SIS is complex and involves a combination of anatomical,
biomechanical, and physiological factors. Proper diagnosis and treatment of SIS require a
thorough understanding of the underlying pathophysiology and an individualized approach to
management based on the specific needs of each patient. (Yousaf et al., 2016)
Chapter 3
Etiology
SAIS is an encroachment of the subacromial tissues as a result of narrowing of the subacromial
space. Mechanisms of rotator cuff (RC) tendinopathy have been classically described as extrinsic,
intrinsic or a combination of both. Intrinsic impingement, theorizes that partial or full thickness
tendon tears occur as a result of the degenerative process that occurs over time with overuse,
tension overload, or trauma of the tendons. An alternative theory is that of extrinsic impingement,
where inflammation and degeneration of the tendon occur as a result of mechanical compression
by structures external to the tendon. A unique subset of extrinsic impingement, internal
impingement occurs due to compression of the articular side rather than the bursal side of the RC
tendons, between the posterior superior glenoid rim and humerus when the arm is in full external
rotation, abduction, and extension. Although internal impingement can be considered an extrinsic
mechanism, narrowing of the subacromial space is not a hallmark finding. Extrinsic Impingement
Extrinsic mechanisms of RC tendinopathy that result in bursal sided RC tendon compression due
to narrowing of the subacromial space include anatomical factors, biomechanical factors, or a
combination. The acromion-humeral distance (AHD), a linear measure between the acromion and
the humeral head used to quantify the subacromial space, has been studied in patients with RC
disease using magnetic resonance imaging, ultrasonography, and radiographs. AHD is normally
between 7 and 14 mm in healthy shoulders. It is reduced in SAIS patients with the muscles at rest
or during muscle activation which functionally narrow the subacromial space. Furthermore, AHD
less than 7 mm with the arm at rest is a predictive indicator of less favorable surgical outcome.
(Masood et al., 2012)
 Anatomical factors: Anatomical factors that may excessively narrow the subacromial
space and outlet to the RC tendons include variations in shape of the acromion, orientation
of the slope/angle of the acromion or prominent osseous changes to the inferior aspect of
the acromio-clavicular (AC) joint or coracoacromial ligament. A widely used classification
system for acromial shape is flat (type I), curved (type II), or hooked (type III), which was
developed from observations of shoulder specimens. Whether acromial shape is congenital
or acquired with age remains controversial. Another possible culprit of encroachment into
the subacromial space is thickening of the coracoacromial ligament. Significant
relationships have been demonstrated between acromion morphology and patient’s self-
reported shoulder function and the severity of the rotator cuff pathology. However,
surgical decompression of coracoacromial arch has only been demonstrated to produce
comparable level of successful outcome as non-operative treatment. This suggests that
direct encroachment of the subacromial space by the coracoacromial arch soft tissue or
bony changes is not the only mechanism of impingement. On the other hand, these coraco-
acromial arch changes have significant effect on tendon injury when combined with
overuse activity. Supporting this theory of a requisite overuse exposure, symptomatic RC
disease is more often present in dominant than nondominant shoulders.
 Biomechanical factors: Biomechanical mechanism of extrinsic SAIS is based on dynamic

narrowing of the subacromial space leading to RC tendon compression secondary to
superior translation of the humeral head or aberrant scapular motion that causes the
acromion to move inferiorly. These include shortening of the posterior-inferior
glenohumeral joint capsule and decreased RC muscle performance.
 Posterior capsule: Posterior capsular tightness may cause changes in glenohumeral
kinematics leading to SAIS. When posterior capsular tightness was surgically induced in
cadavers, there was an in increase in superior and anterior humeral head translations during
passive glenohumeral flexion. Excessive superior and anterior humeral head translations
can decrease the size of the subacromial space, leading to increased mechanical
compression of the subacromial structures. Glenohumeral internal rotation range of motion
and horizontal adduction at 90° of elevation are reliable clinical measures that potentially
assess posterior capsule length. Furthermore, stretching to address impairments of
posterior shoulder tightness has been identified as an important component to
rehabilitation for patients with RC tendinopathy.
 Scapular musculature: Aberrant scapular muscle activity has been identified in patients
with SAIS and been directly linked to abnormal scapular kinematics. Of particular interest
are the relative contributions of the upper and lower serratus anterior muscles and trapezius
muscles, found to stabilize the scapula and induce scapular upward rotation, external
rotation, and/or posterior tilt to potentially allow the humeral head to clear the acromion
with elevation. These individuals have decreased muscle performance of the trapezius and
serratus anterior in terms of force output, muscle balance/ ratios, electromyographical
activity. Relatively small changes in the muscle performance of the scapulothoracic
muscles can alter the position of the scapula at a fixed angle of humeral elevation and, in
theory, affect the length-tension relationship (point on the length-tension curve) of the RC
muscles and the subacromial space.
 Spine: A relatively small increase in thoracic spine flexion has resulted in a more elevated
and anteriorly tilted scapula at rest, and less upward rotation and posterior tilt during
glenohumeral elevation. An increase in thoracic spine flexion has also resulted in a
decrease in the amount of elevation of the glenohumeral joint and a decrease in the amount
of force generated at 90º of glenohumeral scapular plane abduction.
 Rotator cuff musculature: The supraspinatus along with the other rotator cuff muscles of
teres minor, infraspinatus, and subscapularis serve to maintain the congruent contact
between the humeral head and the glenoid fossa by producing a compressive force during
glenohumeral movements. Weakness or dysfunctional rotator cuff musculature can lead to
changes in glenohumeral and scapulothoracic kinematics. Excessive superior translation of
the humeral head resulting from rotator cuff weakness can lead to a decrease in the
subacromial space during elevation, and thus increased mechanical compression of the
subacromial contents. (Masood et al., 2012)
3.1 Causes:
Pain from impingement is common and the pain may either be close to the joint or may radiate
down the arm. It is often caused by a compression of soft tissue structures under the acromion
which as a result may become inflamed, resulting in impingement. As the arm is moved into
certain positions, or load is taken through the arm, the structures become more compressed and the
pain increases, often feeling quite sharp. The reduction in the space between the head of the arm
bone and acromion (roof of shoulder joint) can be due to a number of factors namely; muscle
imbalances, bony spurs, changes in the shape of the acromion or inflammation of the bursa.
Certain muscles around your shoulder may be used too much and others not enough, causing an
alteration in the way your joint moves. This is what is known as a muscle imbalance. Even
seemingly minor changes in the coordination between these muscles can have serious affects on
the soft tissue within your shoulder. Pain from impingement may start following some type of
injury but often begins slowly as a result of the way in which you move and the way in which you
hold your upper body and arm. Continuous working with the arms raised overhead, repeated
throwing activities, or repeated actions of the shoulder can all cause impingement in the shoulder.
Your whole posture can affect your shoulder and treatment will therefore need to address not just
the local shoulder area but also your neck, upper back and sometimes even your lower back and
legs. (Nicole, 2015)
Impingement syndrome can be classified into three stages:
 Stage I: This stage involves swelling and/or bleeding due to an injury. This stage generally
occurs in patients less than 25 years of age and is frequently associated with an overuse
injury.
 Stage II: This stage is more advanced and generally tends to occur in patients 25 to 40
years of age. The changes that are now present involve hardening (fibrosis) and thickening
of the tendons.
 Stage III: This generally occurs in patients over 50 years of age and frequently involves a
tendon rupture or tear. (Nicole, 2015)
Chapter 4
Sign and Symptoms
Shoulder impingement syndrome is a common condition that occurs when the tendons or bursae
in the shoulder become compressed or pinched, causing pain and discomfort. Symptoms usually
develop gradually over weeks to months.
Here are some signs and symptoms of shoulder impingement syndrome:
 Pain in the shoulder: The most common symptom of shoulder impingement syndrome is
pain in the front or side of the shoulder. The pain may be sharp or dull and may worsen
when you lift your arm or reach overhead.
 Weakness in the shoulder: You may experience weakness in the shoulder, making it
difficult to perform everyday tasks such as lifting objects or reaching for items.
 Limited range of motion: You may find that you have limited range of motion in the
shoulder joint. This may make it difficult to perform certain activities, such as reaching
behind your back.
 Shoulder stiffness: The shoulder may feel stiff or tight, especially after periods of rest or
inactivity.
 Swelling or inflammation: You may experience swelling or inflammation around the
shoulder joint, which can cause further pain and discomfort.
 Clicking or popping sensations: You may hear clicking or popping sensations when you
move your shoulder. This can be a sign of tendon or muscle impingement.
 Restricted shoulder motion with weakness in movements such as reaching overhead,

behind the body, or out to the side.
 Shoulder pain when moving the arm overhead, out to the side, and beside the body.
 Pain and discomfort when attempting to sleep on the involved side.
 Pain with throwing motions and other dynamic overhead movements.

 Pain when arms are extended above the head.
 Pain when lifting the arm, lowering arm from a raised position or when reaching.
 Pain and tenderness in the front of shoulder.
 Pain that moves from the front of shoulder to the side of arm.
 Pain when lying on the affected side.
 Pain or achiness at night, which affects ability to sleep.
 Pain when reaching behind back, like reaching into a back pocket or zipping up a zipper.
 Shoulder and/or arm weakness and stiffness. (William, 2018)
Chapter 5
Investigation
Shoulder impingement syndrome is a common cause of shoulder pain that occurs when the
tendons of the rotator cuff muscles become compressed or pinched as they pass through the
subacromial space in the shoulder joint. To diagnose shoulder impingement syndrome, therapist
may perform a physical examination and may also recommend one or more of the following
investigations:
History: Although impingement symptoms may arise following trauma, the pain more typically
develops insidiously over a period of weeks to months. The pain is typically localized to the
anterolateral acromion and frequently radiates to the lateral mid-humerus. Patients usually
complain of pain at night, exacerbated by lying on the involved shoulder, or sleeping with the arm
overhead. Normal daily activities such as combing one’s hair or reaching up into a cupboard
become painful. Weakness and stiffness may also be encountered, but they are usually secondary
to pain. (Dhillon ,2019)
5.1 Diagnostic Procedures

There are anatomical factors which may influence the narrowing of the subacromial space,
such as:
1. The presence of a subacromial bone spur (potential thickening or calcification of the
coracoacromial ligament)
2. The shape of the acromion (type I (flat) / type II (curved)/ type III (hook)/ type IV
(upward oriented acromion))
3. AC joint arthrosis (degeneration of surrounding tissues)
4. Instability of the humeral head (of the GH joint)
5. Radiographs may be used to detect anatomical variants, calcific deposits or
acromioclavicular joint arthritis. The three recommended views are:
 Antero-posterior View with the arm at 30 degrees external rotation which is useful
for assessing the glenohumeral joint, subacromial osteophytes and sclerosis of the
greater tuberosity.
 Outlet Y View is useful because it shows the subacromial space and can differentiate
the acromial processes.
 Axillary View is helpful in visualizing the acromion and the process coracoid, as well
as coracoacromial ligament calcifications.
Imaging:
Standard radiographs including internal and external rotation anteroposterior, scapular Y, axillary,
and Supraspinatus outlet views are important for the thorough evaluation of shoulder pain. These
plain radiographs may show characteristic changes of rotator cuff disease, including subacromial
osteophytes, subacromial sclerosis, cystic changes of the greater tuberosity, and narrowing of the
acromio-humeral distance, they are not definitive.
 Magnetic resonance imaging (MRI) provides detail of potential sites of subacromial
impingement through the supraspinatus outlet. MRI can show full or partial tears in the
tendons of the rotator cuff, and inflammation to weak structures. Ossification of the
coracoacromial ligament (CAL) or presence of a subacromial spur can be best identified in
the sagittal oblique plane; however, differentiation of a pathologic spur and the normal
CAL can be difficult. MRI also may demonstrate findings of subacromial/subdeltoid
bursitis. Findings that indicate this condition include bursal thickness >3 mm, the presence
of fluid medial to the acromioclavicular joint, and the presence of fluid in the anterior
aspect of the bursa. Typically, MRI is performed with the arm adducted; however, this
position does not recreate the position of impingement.
 Ultrasound: Ultrasound uses high-frequency sound waves to create images of the inside
of your shoulder. It can be used to identify any inflammation or damage to the tendons of
the rotator cuff. The diagnostic accuracy of ultrasound is considered good and
comparable to that of conventional MRI for identification and quantification of
complete (full-thickness) rotator cuff injuries.
 Computed tomography (CT) scan: CT scans use a combination of X-rays and computer
technology to create detailed images of the inside of your shoulder. This can be helpful in
identifying bone abnormalities or other structural problems.
 Electromyography (EMG): EMG is a test that measures the electrical activity of your
muscles and can be used to determine if there is any damage or weakness in the rotator
cuff muscles.
 X-rays: X-rays can help to rule out other conditions such as arthritis or fractures. (Michael
et al., 2012).
Physical Examination
 Detailed History and clinical examination are necessary for the diagnosis of SAPS. No
single test alone is accurate to diagnose SAPS or sufficiently differentiate between
various shoulder disorders, but using a combination of specific tests increases the
post-test probability of the diagnosis of SAPS.
 The Dutch Orthopaedic Association Guidelines, for diagnosis and treatment of
subacromial pain syndrome recommend a combination of the following tests (pain
provocation tests) to aid in the diagnosis;
 Hawkins-Kennedy Test
 Painful Arc Test
 Infraspinatus (External Rotation) Resistance Tests
 The combination of the Hawkins-Kennedy Test, the Painful Arc and the Infraspinatus
Resistance Test have a considerably higher predictive value.
 The following additional test should also be used to rule out a Rotator Cuff Tear;
 Drop Arm Test: To test the integrity of the Supraspinatus.
 Neer Impingement Test, which evaluates a subacromial impingement specifically,
while the Hawkins-Kennedy Test evaluates the presence of a coracoacromial
impingement. (Michael et al., 2012)
Chapter 6
Medical Treatment
Conservative management of internal impingement is an appropriate initial approach, particularly
in patients who do not report an acute traumatic event. We can divide the medical management in
two categories:
 NON-SURGICAL TREATMENT
Initial treatment of SIS generally involves conservative measures such as physical therapy and
pain-relieving medications. Most patients benefit from a course of physical therapy focused on
stretching the shoulder and strengthening the rotator cuff and scapular muscles, as well as postural
exercises to address the position of the shoulder blade.
Doctors often prescribe a course of nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen. Another anti-inflammatory option may be to inject a local anesthetic and cortisone into
the shoulder. Platelet-rich plasma injections are a more recent treatment that some patients
consider, though many insurance plans do not cover them.
 SURGICAL TREATMENT
For patients whose pain doesn't respond to conservative measures, our orthopaedic surgeons have
expertise in shoulder impingement. As with any kind of surgery, there are risks and possible
complications, so we generally explore these options only if nonsurgical therapies have failed.
In the most common surgical treatment, a minimally invasive procedure called subacromial
decompression, the goal is to relieve the compression on the rotator cuff and bursas by creating
more space between the humeral head and the acromion. Performed with an arthroscope (an
endoscope for use in joints), the surgeon passes a tiny camera and slender instruments through a
small incision and removes the portion of the acromion causing impingement along with some of
the bursas. If the shoulder has other conditions needing repair (such as a rotator cuff tear), the
surgeon may address these at the same time.
 POSTSURGICAL RECOVERY
To facilitate healing, patients usually use a sling for the first one to two weeks after surgery.
During that time, they shouldn't drive. After this period, they begin a physical therapy program,
focusing first on regaining passive range of motion and later on active range of motion. Between
six and eight weeks after surgery, patients can progress to strengthening exercises, and a full
return to activities is generally achieved three to four months after surgery. (Thomas et al., 2018)
Chapter 7
Physiotherapy Management
Treatment will consist of the treatments below to reduce the inflammation and pain with an
exercise / postural programme to retrain the rotator cuff and repair the imbalance:
 Massage – Encompassing a variety of techniques and is given with sufficient pressure
through the superficial tissue to reach the deep lying structures. It is used to increase blood
flow, decrease swelling, reduce muscle spasm and promote normal tissue repair.
 Taping/Strapping – May be used if thought necessary to restrict abnormal movement and
prevent further damage, or to facilitate the function of the affected muscles.
 Deep friction – Is an aggressive massage technique applied across the tissue fibres as
deeply as possible. This technique is initially painful but can cause a numbing effect. It can
be used to break down scar tissue, restore normal movement and prepare the injured
structure for mobilisation.
 Mobilisation – Is a manual technique where the joint and soft tissues are gently moved by
the therapist to restore normal range, lubricate joint surfaces and relieve pain.
 Ultrasonic therapy – Transmits sound waves through the tissues stimulating the body’s
chemical reactions and therefore healing process, just as shaking a test tube in the
laboratory speeds up a chemical reaction.
 Interferential therapy – Introduces a small electrical current into the tissues and can be
used at varying frequencies for differing treatment effects. E.g., pain relief, muscle or
nerve stimulation, promoting blood flow and reducing inflammation. (Thomas et al., 2018)
EARLY MANAGEMENT
If an overhead athlete report feelings of tightness, stiffness, or not loosening up, the pitcher
should be removed from participation and started in a rehab program. It is important, before
treatment is undertaken, to rule out other anterior instability pathology, including SLAP
lesions, labral tears, and partial rotator cuff tears.
 Closed kinetic chain exercises for stabilizing the rotator cuff muscles.
 GIRD (Glenohumeral internal rotation deficit)
 Strengthening program for posterior capsule
 Muscle imbalance and/or improper neuromuscular control of the shoulder complex
 Strengthening periscapular musculature and the rotator cuff muscles to prevent over -
angulation in the late cocking phase of throwing .
ROUTINE MANAGEMENT
PHASE 1
 Soft tissue mobilization such as massage, relaxation, contract-relax and low-energy, high
repetition kinetic training
 Scapula setting: retraction, elevation, depression
 Joint mobilization: oscillation, hold stretch, and scapular side-lying distraction tonic and
phasic muscle coordination
 Increase shoulder ROM
 Decrease posterior capsule tightness
 Strengthening to rebuild soft tissue support
 Neuromuscular re-education to prevent recurrence
 Restore proper muscle balance and endurance
 Proprioceptive training and dynamic stability exercises
 Closed chain exercises: are suggested because axial compression exercises that put stress
through the joint in a weight-bearing position result in joint approximation and improved
co-contraction of the rotator cuff muscles.
 Ultrasound and electrostimulation: for reducing the pain and inflammation.
PHASE 2
 Improve dynamic stability-restoration muscle balance: more complex and activity

specific exercises. With muscle imbalances already addressed, the therapist can begin to
add dynamic movements into rehab using “tactile cueing” to ensure the patient is
engaging the scapular musculature before beginning a movement. Progress to verbal
cueing.
 Strengthening exercises: Target all shoulder and scapular musculature. Start introducing
eccentric and open kinetic chain exercises in order to begin preparing for specific athletic
overhead movements.
 Mobilizations. (Rafael et al., 2014)
Chapter 8
Precautions
PRECAUTIONS ARE AS FOLLOW:
 AVOID, LIFTING, PULLING, OR PUSHING: For about 4-6 weeks, avoid any
movements with the affected shoulder that require exertion and effort. During your
shoulder impingement treatment, use only your unaffected arm when opening doors,
reaching for things and lifting items (such as bags). Activities such as rearranging canned
food on an overhead shelf will put a strain on your shoulder, so do not perform this type of
activity for this short period of time. It is better to keep commonly used objects within
height level; otherwise, ask someone else to help you. Of all the shoulder movements you
should be sure to avoid doing, do not attempt to reach behind your back. If you need to
reach behind your back, such as when bathing, use your other arm instead. It is a good idea
to get a long-handled bath sponge, but use your other arm to manipulate it on your back
when bathing.
 AVOID LYING FLAT ON YOUR BACK: Lying flat on your back when sleeping can
worsen the pain you feel in your shoulder, making it harder to sleep. Try to use pillows to
keep your arm slightly elevated and away from your torso.
 AVOID DRIVING: Yes, driving can technically be done using only one arm – but if a
police officer sees you driving while wearing a sling, you could get pulled over. Ask
someone else to drive, or get a taxi, Uber, or Lift. Orthopaedic will let you know when it’s
safe for you to drive again. (Stephens, 2021)
Chapter 9
Ergonomic Advice
Subacromial Impingement Syndrome (SAIS) is a common shoulder problem that occurs when the
tendons and bursa in the subacromial space become compressed or pinched. Ergonomic
modifications can help manage the symptoms of SAIS and prevent further injury. Here are some
ergonomic tips to consider:
 Maintain good posture: Sit or stand with your shoulders relaxed and down, avoiding
slouching or rounding your shoulders forward.
 Adjust your workspace: Ensure your desk or workstation is at the right height so that
your shoulders are relaxed and not hunched up.
 Use proper lifting techniques: When lifting heavy objects, keep the weight close to your
body and use your legs rather than your arms and shoulders.
 Use ergonomic equipment: Consider using ergonomic equipment, such as a shoulder
brace or ergonomic mouse, keyboard, and chair.
 Take breaks: Take frequent breaks to stretch and move your shoulders, neck, and arms.
It is important to note that these ergonomic tips may not cure SAIS, but they can help manage the
symptoms and prevent further injury. For a more comprehensive treatment plan, it is
recommended to consult with physiotherapist. (Dhillon, 2019)
Chapter 10
References
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 Dela Rosa TL, Wang AW, Zheng MH. Tendinosis of the rotator cuff: a review. J
Musculoskel Res 2001; 5:143.
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CONSENT FORM
I………………………………………………………… voluntarily declare to participate
in the project on “SHOULDER IMPINGEMENT SYNDROME” conducted by
Prafful Singh, Physiotherapy Internee, at Sarvodaya Hospital.
The internee has explained me about the project, its purpose in detail, and he
has also answered all my questions and queries regarding the project work to the best
of my satisfaction. I voluntarily agree to participate in the project and I grant my
permission to use my personal information & pictures related to my
health/assessment/treatment for the academic purpose only.
(Signature) (Date)
I have explained to Ms. /Mr. the purpose of

the project work, the process required for the project in the language she/ he could
understand to the best of my ability.
(Internee) (Date)
ORTHOPAEDIC ASSESSMENT
Code: 01 Date:
Name: Mr. Shivraj Sharma

Age: 33 years
Sex: Male
Occupation: Tennis player
Father’s/Husband’s Name: Mr. Omprakash
Address: Sector 15, Spring Field colony, Faridabad
Phone: 9868******
Chief Compliant: Patient complaints of pain in right shoulder and difficulty in doing ADLs
because of limited range of motion.
History of Present illness: Patient presents with a complaint of right shoulder pain for the 1
week. The pain is primarily located in the front of the shoulder and has been worsening over time.
He reports that the pain is exacerbated by overhead activities and playing tennis. He denies any
specific injury or trauma to the shoulder. He has tried over-the-counter pain medications and rest,
which have not provided significant relief.
History of Past medical illness: The patient has a history of hypertension for which he takes
medication. He denies any other medical conditions or surgeries.
Personal History:
 Non smoker
 Non alcoholic
 Not addicted to drugs.
Family History: Cooperative and well-educated family.

Psychological History: Conscious
Socio-economic status: He is married and blessed with 1 kid. He is financially stable.
Pain History:
1. Site: Right shoulder (anterior aspect).
2. Onset: Gradual onset
3. Nature: Dull aching
4. Severity: Severe
5. Aggravating Factor: lifting up the arm.
6. Relieving Factor: At rest
7. Radiation: Yes
8. VAS: 8/10
On Observation:
1. Redness: Absent
2. Swelling: Absent
3. Posture: Normal
On Palpation:
1. Warmth: Present
2. Tenderness: Present
3. Swelling: Absent
4. Vital signs:
• Blood Pressure: 128/90 mmhg
• Pulse Rate: 82 beats/min
• Respiratory Rate: 17 breaths/ min
On Examination:
1. Sensory Examination:
Sno Sensation Right Left
1 Superficial: Touch/Temperature/Pain Normal Normal
2 Deep: Proprioception/Kinesthesia/Vibration Normal Normal
3 Cortical: Stereognosis/2 Point Discrimination Normal Normal

2. Motor Examination:
A. Reflex: Absent/Diminished/Normal/Exaggerated
Sno. Reflex Right Left
1 Superficial Reflex Corneal Reflex Normal Normal
Abdominal Reflex Normal Normal
Gag Reflex Normal Normal
2 Deep tendon Reflex Jaw Jerk Normal Normal
Biceps Jerk Diminished Diminished
Triceps Jerk Diminished Diminished
Brachioradialis Jerk Diminished Diminished
Supinator Jerk Normal Normal
Knee Jerk Normal Normal
Medial Hamstrings Jerk Normal Normal
Ankle Jerk Normal Normal

B. Range of Motion:
Sno. Movements Active Passive
1. Flexion 110 125
2. Extension 35 45
3. Abduction 70 85
4. Medial Rotation 50 60
5. Lateral Rotation 20 30
Special Tests:
Sno. Test Result
1. The Neer Test Positive
2. The Hawkins-kennedy Test Positive
Radiological Investigations:
Sno. Investigation & Findings Right
1. X- ray Right shoulder shows mild AC joint

arthrosis and no other significant
abnormalities.
2. MRI MRI confirms the presence of subacromial
impingement with no evidence of rotator
cuff tear.
Diagnosis: Based on the patient's history and physical examination findings, the diagnosis of
shoulder impingement syndrome is made.
Differential Diagnosis: Adhesive capsulitis, Rotator cuff tear, Acromioclavicular joint sprain,
Trapezius muscle spasm.
Physiotherapy Treatment:
Aim:
1. To reduce pain:
 SWD x15 days (10 mins over right shoulder)
 USx15 days (7 mins on pulse mode).
 IFTx15 days (10 mins).
 Hot pack for 10 mins twice a day at home.
2. To maintain mobility of shoulder joint:

 Relaxed passive movements (shoulder flexion, extension, abduction, lateral
rotation and medial rotation) x 10 repetitions
 Codman's pendular exercise in flexion, extension and abduction and adduction x 3
min.
 Rope & pully x 3 min. (flexion, abduction)
 Isometric exercises for shoulder flexors, extensors, abductors, lateral and medial
rotators x 10 repetitions with 10 sec. hold
3. To increase extensibility of thickened and contract capsule:
 Anterior and posterior capsular stretching x 3 repetitions with 30 sec. hold
 Active assisted ROM exercise of shoulder flexors, extensors, abductors, lateral and
medial rotators x 10 repetitions
 Shoulder wheel x 7 min.
 Finger ladder x 15 repetitions (flexion, abduction)
4. To improve mobility of shoulder (5 days onwards) :
 Mobilization glides- anterior, posterior & inferior
5. To maintain properties of muscles:
Home exercise protocol:
 Codman's pendular exercise (flexion and abduction) x 3 min. thrice a day.

 Active assisted ROM exercise for flexion, extension, abduction, lateral and medial
rotation x10 repetitions thrice a day.
 Isometric exercise (for flexors, extensors, abductors, external & internal rotation)
x10 repetitions thrice a day with 10 sec. hold.
 Capsular stretch (anterior and posterior).
 Finger ladder (flexion and abduction).
CONSENT FORM
(Signature) (Date)

(Internee) (Date)
Code: 02 Date:
Name: Ms. Shivani

Age: 23 years
Sex: Female
Occupation: Tennis player
Father’s/Husband’s Name: Mr. Sahdev Sharma
Address: Spring Field colony, Faridabad
Phone: 8527******
Chief Compliant: Patient complaints of chronic right shoulder pain and dysfunction
History of Present illness:
History of Past medical illness: N/A
Personal History:
 Non smoker
 Non alcoholic
 Take proper sleep and good diet
Pain History:
11. Nature: Dull aching
12. Severity: Severe
14. Relieving Factor: At rest
15. Radiation: Yes
16. VAS: 8/10
On Observation:
4. Redness: Absent
5. Swelling: Absent
6. Posture: Normal
On Palpation:
5. Warmth: Present
7. Swelling: Absent
8. Vital signs:
On Examination:
C. Reflex: Absent/Diminished/Normal/Exaggerated
1 Deep tendon Reflex Biceps Jerk Normal Normal
A. Range of Motion:
1. Flexion 110 125
2. Extension 35 45
3. Abduction 70 85
Special Tests:
Sno. Test Result
2. The Hawkins-kennedy Test Positive

abnormalities.
impingement with no evidence of rotator
cuff tear.
Diagnosis: High grade partial thickness supraspinatus tear with internal impingement.
Trapezius muscle spasm.
Aim:
6. To reduce pain:
 SWD x15 days (10 mins over right shoulder)
 USx15 days (7 mins on pulse mode).
 IFTx15 days (10 mins).
 Hot pack for 10 mins twice a day at home.
min.

 Finger ladder (flexion and abduction).
CONSENT FORM
(Signature) (Date)

(Internee) (Date)
Code: 03 Date:19/11 2022
Name: Mr. Satish sharma

Age: 38 years
Sex: Male
Occupation: Engineer
Father’s/Husband’s Name: Mr.Ram prasad
Address: Sector 09, tirkha colony, Faridabad
Phone: 9868******
Chief Compliant: Patient complaints of pain in his left shoulder while doing exercises in gym
since 1 month.
History of Present illness: Patient was apparently well one month back but then he is
complaining of pain his left shoulder, primarily located in front of shoulder while doing overhead
activity during the gyming. The pain gets reduced during rest and using hot fermentation.
Personal History:
 Smoker
 Alcoholic

Pain History:
19. Nature: shooting pain
22. Relieving Factor: At rest and hot fermentation
23. Radiation: Yes
24. VAS: 8/10
On Observation:
7. Redness: Absent
8. Swelling: Absent
9. Posture: Normal
On Palpation:
9. Warmth: Present
11. Swelling: Absent
12. Vital signs:
On Examination:
D. Reflex: Absent/Diminished/Normal/Exaggerated
1 Deep tendon Reflex Biceps Jerk Normal Diminished
B. Range of Motion:
1. Flexion 130 150
2. Extension 35 50
3. Abduction 110 140
Special Tests:
Sno. Test Result
2. The Empty Can Test Positive

abnormalities.
impingement with rotator cuff tear.
Diagnosis: Based on the patient's history and physical examination findings, the diagnosis of
shoulder impingement syndrome is made.
Trapezius muscle spasm
Aim:
11. To reduce pain:
 USx 5 min (Intensity-0.8 w/cm2 on pulse mode).
 IFT x 15 mins
 Hot pack x 10 mins .
min.

CONSENT FORM
(Signature) (Date)

(Internee) (Date)
Code: 04 Date:19/11 2022
Name: Mr. Munna Khan

Age: 45 years
Sex: Male
Occupation: Painter
Father’s/Husband’s Name: Mr. Harish Chand
Address: Fatehgarh, Faridabad
Phone: 9868******
Chief Compliant: Patient complaints of pain in his right shoulder while doing painting and in
night during the sleep since 2 months.
History of Present illness: Patient was apparently well two months back but then he was feeling
pain in his right shoulder during his work and it increased in night while sleeping.
History of Past medical illness: H/o tennis elbow in 2019
Personal History:
 Smoker
 Non- Alcoholic
Family History: Cooperative and has 2 kids.

Socio-economic status: He is financially unstable.
Pain History:
28. Severity: Moderate
30. Relieving Factor: At rest and medication.
31. Radiation: Yes
32. VAS: 7/10
On Observation:
10. Redness: Absent
12. Posture: kyphotic
On Palpation:
13. Warmth: Present
15. Swelling: Present
16. Vital signs:
On Examination:
E. Reflex: Absent/Diminished/Normal/Exaggerated
1 Deep tendon Reflex Biceps Jerk Normal Normal
Triceps Jerk Normal Normal
Brachioradialis Jerk Normal Normal
C. Range of Motion:
1. Flexion 160 165
2. Extension 40 45
Special Tests:
Sno. Test Result

abnormalities.
impingement.
Diagnosis: Based on the patient's history and physical examination findings, the diagnosis is
shoulder impingement syndrome .
Differential Diagnosis: Adhesive capsulitis, Rotator cuff tear, Acromioclavicular joint sprain.
Aim:
16. To reduce pain:
 IFT x 15 mins
min.

 Strengthening exercise of rotator cuff muscles with 1kg weight.
CONSENT FORM
(Signature) (Date)

(Internee) (Date)
Code: 05 Date:19/11 2022
Name: Mr. Sachin

Age: 32 years
Sex: Male
Occupation: Tennis Player
Father’s/Husband’s Name: Mr. Rameshwar
Address: Sector 45, Faridabad
Phone: 9868******
Chief Compliant: Patient presents with complaints of right shoulder pain and limited range of
motion, affecting his performance on the court.
History of Present illness: Patient reports that he has been experiencing right shoulder pain for
the past six months, gradually worsening over time. He attributes the pain to his overhead serves
and overhead shots, which require repetitive and forceful movements of the shoulder joint. The
pain is localized to the front and outer aspect of the shoulder, sometimes radiating down the arm.
He also notices weakness and difficulty in raising his arm overhead.
Personal History: Well educated.
Family History: Cooperative and financially stable.

Socio-economic status: He is financially unstable.
Pain History:
38. Relieving Factor: At rest and medication.
39. Radiation: Sometimes
40. VAS: 8/10
On Observation:
13. Redness: Absent
15. Posture: Normal
On Palpation:
17. Warmth: Present
20. Vital signs:
On Examination:

F. Reflex: Absent/Diminished/Normal/Exaggerated
1 Deep tendon Reflex Biceps Jerk Diminished Diminished
Brachioradialis Jerk Normal Normal
D. Range of Motion:
1. Flexion 140 145
2. Extension 40 45
Special Tests:
Sno. Test Result
2. Empty Can Test Positive

impingement.
Diagnosis: Based on the patient's history, physical examination, and specific tests, the diagnosis is
shoulder impingement syndrome. It is likely caused by repetitive overhead movements and strain
on the rotator cuff tendons, particularly the supraspinatus tendon, during tennis activities.
Differential Diagnosis: Adhesive capsulitis, Rotator cuff tear, Acromioclavicular joint sprain.
Aim:
1. To reduce pain:
 IFT x 15 mins
 Relaxed passive movements (shoulder flexion, extension, abduction, lateral rotation and
medial rotation) x 10 repetitions
 Codman's pendular exercise in flexion, extension and abduction and adduction x 3 min.
 Isometric exercises for shoulder flexors, extensors, abductors, lateral and medial rotators x
10 repetitions with 10 sec. hold
 Active assisted ROM exercise of shoulder flexors, extensors, abductors, lateral and medial
rotators x 10 repetitions
 Isometric exercises for shoulder flexors, extensors, abductors, lateral and medial rotators x
10 repetitions with 10 sec. hold

 Active assisted ROM exercise for flexion, extension, abduction, lateral and medial rotation
x10 repetitions thrice a day.
 Isometric exercise (for flexors, extensors, abductors, external & internal rotation) x10
repetitions thrice a day with 10 sec. hold.
 Strengthening exercise of rotator cuff muscles with 1kg weight.

P Rafful

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SHOULDER IMPINGEMENT SYNDROME

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

Jan,2023 Prafful Singh

Date: Signature of Supervisor

Place: Faridabad Dr. Divya Goyal

Dr. Dheerja Babbar,

 SAIS: Subacromial Impingement Syndrome

CHAPTER 4: SIGN AND SYMPTOMS

CHAPTER 6: MEDICAL TREATMENT

CHAPTER 7: PHYSIOTHERAPY MANAGEMENT

CHAPTER 9: ERGONOMIC ADVICE

CHAPTER 10: REFERENCES

Neer’s Classification of Impingement identified four types of shoulder impingement

 Type I: <25 years old, Reversible, Swelling, Tendonitis, No Tears, Conservative

 Long head of the biceps tendon.

1.1 Shoulder Anatomy

 Glenohumeral Joint Kinematics

 Scapulothoracic articulation kinematics:

Fig 1: Pathophysiology (March 24, 2015, Nicole Geier)

 Biomechanical factors: Biomechanical mechanism of extrinsic SAIS is based on dynamic

 Restricted shoulder motion with weakness in movements such as reaching overhead,

 Pain and discomfort when attempting to sleep on the involved side.

 Pain with throwing motions and other dynamic overhead movements.

5.1 Diagnostic Procedures

 Improve dynamic stability-restoration muscle balance: more complex and activity

I………………………………………………………… voluntarily declare to participate

in the project on “SHOULDER IMPINGEMENT SYNDROME” conducted by

Prafful Singh, Physiotherapy Internee, at Sarvodaya Hospital.

of my satisfaction. I voluntarily agree to participate in the project and I grant my

permission to use my personal information & pictures related to my

health/assessment/treatment for the academic purpose only.

I have explained to Ms. /Mr. the purpose of

Name: Mr. Shivraj Sharma

Family History: Cooperative and well-educated family.

Socio-economic status: He is married and blessed with 1 kid. He is financially stable.

1 Superficial: Touch/Temperature/Pain Normal Normal

2 Deep: Proprioception/Kinesthesia/Vibration Normal Normal

3 Cortical: Stereognosis/2 Point Discrimination Normal Normal

1 Superficial Reflex Corneal Reflex Normal Normal

Abdominal Reflex Normal Normal

Gag Reflex Normal Normal

2 Deep tendon Reflex Jaw Jerk Normal Normal

Biceps Jerk Diminished Diminished

Triceps Jerk Diminished Diminished

Brachioradialis Jerk Diminished Diminished

Supinator Jerk Normal Normal

Knee Jerk Normal Normal

Medial Hamstrings Jerk Normal Normal

Ankle Jerk Normal Normal

Sno. Movements Active Passive

1. Flexion 110 125

Sno. Test Result

1. The Neer Test Positive

2. The Hawkins-kennedy Test Positive

Sno. Investigation & Findings Right

1. X- ray Right shoulder shows mild AC joint

2. To maintain mobility of shoulder joint:

 Codman's pendular exercise (flexion and abduction) x 3 min. thrice a day.

I………………………………………………………… voluntarily declare to participate

in the project on “SHOULDER IMPINGEMENT SYNDROME” conducted by

Prafful Singh, Physiotherapy Internee, at Sarvodaya Hospital.

of my satisfaction. I voluntarily agree to participate in the project and I grant my