| | | |  | | © Reed Group | | |
Impingement syndrome is a term used to describe a disorder in which one or more soft tissues (rotator cuff tendons, bursa and biceps tendons) surrounding the ball of the shoulder joint get pinched, or impinged, on the bony surface under a portion of the shoulder blade (the acromion).
The shoulder is made up of three bones (humerus, scapula, clavicle). The tendons that attach four muscles in the shoulder area to the humerus fuse together to form the rotator cuff. The lateral extension of the shoulder blade is the acromion, and the area underneath it is the subacromial space. A lubricating sac of tissue protects the tendons as they move between the acromion and the glenohumeral joint (subacromial bursa). Usually there is enough room between the acromion/acromioclavicular joint and the glenohumeral joint for the rotator cuff and biceps tendons to slide easily underneath the acromion as the arm is raised. However, when the space is made smaller, either by changes in the shape (hypertrophy) of the acromion and/or acromioclavicular joint or by bone spurs, the rotator cuff is forced to rub against the arch of the acromion. Impingement is thought to be a precursor to a rotator cuff tear. Impingement can also cause the bursa or tendons to become inflamed, resulting in bursitis and tendinitis, respectively.
Age, repetitive overhead activity, shoulder looseness (laxity), sleeping with the shoulder abducted, previous injury, osteoarthritis with resulting bone spurs (osteophytes), and anatomical abnormalities are all causative factors. Shoulder laxity that allows the head of the upper arm bone (humerus) to ride high in the shoulder joint will force the rotator cuff against the arch, resulting in impingement. Instability simulating impingement is usually seen in young athletes with a history of significant shoulder injury. As people age, some structures slowly enlarge. Thickening of the acromion and the acromioclavicular joint that occur with age, and the development of osteophytes (spurs) on the underside of the acromion and acromioclavicular joint, are the most common causes of shoulder impingement.
Usually, the acromion has a flat inferior or lower surface (Type I acromion). Some individuals have a congenital anomaly in which the underside of the acromion is hooked or curved (Type II or III), meaning there is less room for the rotator cuff because of a congenital difference in the space available for the cuff tendons.
Risk: Excluding impingement that results from sports that stress the shoulder (competitive swimming, throwing, etc.), impingement syndrome more commonly develops after the age of 30. Individuals who are at risk of developing impingement syndrome include athletes (e.g., baseball players), assembly-line workers, warehouse workers, and others who perform repetitive work with the arms raised above shoulder height.
Conditions that predispose individuals to impingement syndrome include bone spurs, osteoarthritis, and shoulder injuries or degenerative disease. Incidence and Prevalence: No documented information on the occurrence of shoulder impingement syndrome exists (DeBerardino). |
Source: Medical Disability Advisor
| History: The hallmark symptom of impingement syndrome is shoulder pain that is most often gradual and progressive. In the early stages, individuals will experience pain only when the arm is held out from the side or in front of the body with the elbow at or above shoulder level, and the pain will be relieved with rest. There may be a "catching" sensation when the arm is lowered. As the impingement syndrome becomes more chronic, pain is felt most with shoulder activity but will not be relieved with positional change or rest. Shoulder pain may be so severe that it prevents the individual from moving his or her shoulder, which can lead to adhesive capsulitis. Pain is also frequently felt at night and may be severe enough to interfere with sleep, particularly when the individual rolls onto the affected shoulder. There may be a clicking or popping sensation felt with arm motion. The individual may have an occupation that requires repetitive arm motions. Complaints of weakness or the inability to raise the arm may indicate that the rotator cuff tendons are actually torn. Physical exam: Pain will be evident in individuals as the physician elevates the arm and positions the shoulder in a 90-degree forward-flexed and then internally rotated position (Hawkins impingement sign) or in maximal forward flexion (Neer impingement sign). Pain may occur at a particular point in the arc of motion but disappear as motion proceeds (called “painful arc”). Pain may also be elicited by resisted arm elevation during muscle strength testing. Range of motion testing will reveal limitations, most commonly in abduction and internal rotation. Individuals may exhibit total relief of symptoms after injection of a local anesthetic into the subacromial space (injection test). Pressure on the subacromial region produces pain. Tests: Routine shoulder x-rays, including special views of the acromial arch, are used to evaluate the shape of the arch and rule out other diagnoses. For most individuals, MRI is the imaging study of choice for shoulder pathology (DeBerardino). It is noninvasive and can be used to measure the amount of room for the rotator cuff, determine whether tendinitis is present in the cuff tendons (increased signal), determine whether osteophytes or acromioclavicular joint hypertrophy are producing impingement, detect rotator cuff tears, and detect other pathology (biceps tendinitis or rupture, labrum tear, etc.). Diagnostic ultrasound or shoulder joint arthrography (x-rays obtained after injecting a contrast medium, such as iodine solution) are alternatives that examine the integrity of the rotator cuff. |
Source: Medical Disability Advisor
| In the early stages, impingement syndrome will resolve when the aggravating activity and any overhead work are avoided. Physical therapy to increase range of motion and strengthen shoulder stabilizers may also be helpful. Application of ice (cryotherapy) can relieve pain. Medications to control pain and inflammation are usually prescribed. Injection of corticosteroid and anesthetic agents into the subacromial space is often part of conservative treatment. If the shoulder becomes stiff (complicating adhesive capsulitis), manipulation of the shoulder under anesthesia can be helpful to improve flexibility.
Surgical intervention is an option when individuals fail to improve after several months of physical therapy and subacromial injections. The goal of surgery is to increase the size of the subacromial space and remove inflamed tissue. Reshaping the acromion (acromioplasty) combined with removing the subacromial bursae and cutting the coracoacromial ligament are common procedures. Removal (excision) of any bone spurs and inflamed rotator cuff tissue (débridement) may also be needed. This combination of procedures is often called subacromial decompression. These procedures can be performed either through open surgery (arthrotomy) or arthroscopically. Frequently an excisional arthroplasty of the acromioclavicular joint is also performed. If a labrum tear is present, it can be repaired or débrided at the time of the shoulder surgery. Typically, these are outpatient procedures. |
Source: Medical Disability Advisor
| The outcome for impingement syndrome is usually excellent. Three to six months of conservative treatment improves symptoms in 60% to 90% of individuals (DeBerardino). Only a very small percentage of individuals require surgical intervention such as subacromial decompression, which results in a return to previous levels of function in 85% to 90% of individuals (DeBerardino). Even in more chronic situations, recovery is expected, but it may be prolonged due to surgical intervention. Since the rotator cuff is intact, once the space for the cuff tendons has been surgically increased, the shoulder should function better. |
Source: Medical Disability Advisor
| Note on research and authorship Impingement syndrome is often classified into three stages (Morrison, "Non-Operative Treatment"). In all three stages the early goals are to decrease pain and inflammation and reduce the pressure on the irritated tendon and/or tissues (Morrison, "Shoulder Impingement"; Rubin). In conjunction with pharmacological management, the therapist will instruct the individuals in the use of cold treatments to the shoulder to decrease inflammation. Reduction of stress to the irritated tissue is often achieved through patient education, ergonomic adjustments and/or activity modifications aimed at reducing the offending activities. These offending activities often include repetitive movements or sustained positions where the elbow is raised above the shoulder level. Stiffness may be prevented by passive range of motion exercises conducted during supervised rehabilitation and a home exercise program.
Stage I occurs in individuals who are less than 25 years old. Treatment focuses on improving strength and stability of the muscles of the shoulder girdle. These muscles include those that attach from the upper arm to the shoulder blade, as well as those that attach from the shoulder blade to the upper back (i.e., thoracic spine) (Morrison, "Shoulder Impingement"; Rubin). These exercises will help to restore the normal glenohumeral (scapula and humerus) motion pattern and often involve resistance in the form of elastic, weights or manual resistance provided by the therapist. The individual may also perform some stretching exercises (Morrison, "Non-Operative Treatment").
Stage II occurs in individuals between 25 and 40 years of age. Strengthening exercises are performed as in stage I. However, because the joint capsule becomes stiffer with age, a greater emphasis is placed on flexibility and stretching exercises. In addition, the therapist may apply manual stretching techniques to the patient's arm, shoulder blade, and the upper portion of the thoracic spine. These techniques are aimed at improving the mobility in and around the shoulder to restore the normal glenohumeral motion pattern so the subacromial space can be maintained during movement. Some recent evidence from randomized controlled trials suggests that the addition of manual therapy to a program of strengthening and stretching is superior to patient strengthening and stretching alone (Bang).
Stage III occurs in individuals over age 40. Because these individuals are older and stiffer as mentioned in stage II, the role of patient self-stretching and manual stretching treatments is often greater. Strengthening exercises are performed as in stages I and II.
The impingement at any stage may progress to a partial or full tear of the rotator cuff tendon. In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily, and continued independently after the completion of rehabilitation (Ludewig).
Past research does not support the benefit of ultrasound for the treatment of impingement syndrome (Philadelphia Panel). Modalities may be beneficial for palliative relief of symptoms. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical or Occupational Therapist | | Up to 16 visits within 8 weeks | | | | | | | | Surgical | |
| Physical or Occupational Therapist | | Up to 8 visits within 4 weeks | |
|
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Rotator cuff degeneration and tear, biceps tendinitis, frozen shoulder (adhesive capsulitis), and reflex sympathetic dystrophy could complicate impingement syndrome. |
Source: Medical Disability Advisor
| Aggravating activities need to be avoided until symptoms have been relieved. During early treatment, the individual should not lift, carry, push, or pull heavy objects. Individuals should not use the arm with the hand above shoulder level. These restrictions may become permanent. An ergonomic evaluation of the workplace may be necessary. A change in job duties, sharing or alternating tasks, a reduced work rate, more frequent rest breaks, and limits on the time and frequency of repetitive activities are important accommodations. Work-site modifications can include forearm rests for individuals who use computer keyboards frequently, headsets for those who answer telephones, and modifications to repetitive activities so that they can be done without raising the arms. Individual attention and education can encourage recognition and avoidance of aggravating activities, awareness of shoulder mechanics and early signs of impingement syndrome, and use of proper warm-up techniques. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have any risk factors or predisposing conditions such as work or sports that stress the shoulder, bone spurs, osteoarthritis, shoulder injuries, or degenerative disease?
-
Did the shoulder pain appear suddenly (suggests another diagnosis) or was the onset gradual and progressive (suggests impingement)?
-
Was there pain following an injury?
-
What symptoms does individual have?
-
What were the findings on physical exam?
-
Has individual undergone shoulder x-rays, MRI, ultrasound, or arthrography to establish the diagnosis?
-
Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Has individual responded favorably to conservative treatment?
-
Did individual undergo shoulder manipulation under anesthesia for complicating adhesive capsulitis? Was surgery performed? What type? Were there complications from surgery?
Regarding prognosis:
- Is recovery prolonged due to surgery?
-
Is individual active in physical therapy? In a home exercise program?
-
Is individual's employer able to accommodate the necessary restrictions?
-
Does individual have osteoarthritis, rheumatoid arthritis, shoulder injuries, shoulder instability, or shoulder degeneration?
-
Does individual have complications such as rotator cuff tear, biceps tendinitis, bursitis, or frozen shoulder?
-
Is the affected shoulder on the individual’s dominant or nondominant side?
|
Source: Medical Disability Advisor
| Bang, M. D., and G. D. Deyle. "Comparison of Supervised Exercise with and without Manual Physical Therapy for Patients with Shoulder Impingement Syndrome." Orthopedic and Sports Physical Therapy 30 3 (2000): 126-137. National Center for Biotechnology Information. National Library of Medicine. 10 May 2008 <PMID: 10721508>.DeBerardino, T. M., and Wing K. Chang. "Shoulder Impingement Syndrome." eMedicine. Eds. A. D. Perron, et al. 20 Jul. 2006. Medscape. 22 Dec. 2008 <http://emedicine.com/sports/topic119.htm>. Ludewig, P. M., and J. D. Borstad. "Effects of a Home Exercise Programme on Shoulder Pain and Functional Status in Construction Workers." Occupational and Environmental Medicine 60 11 (2003): 841-849. National Center for Biotechnology Information. National Library of Medicine. 10 May 2008 <PMID: 14573714>. Miller, Robert H., and Jeffrey A. Dlaback. "Shoulder and Elbow Injuries." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beatty. 11th ed. Philadelphia: Mosby Elsevier, 2008. Morrison, D. S., A. D. Frogameni, and P. Woodworth. "Non-Operative Treatment of Subacromial Impingement Syndrome." Journal of Bone and Joint Surgery 79 5 (1997): 732-737. National Center for Biotechnology Information. National Library of Medicine. 5 Oct. 2008 <PMID: 9160946>. Morrison, D. S., B. S. Greenbaum, and A. Einhorn. "Shoulder Impingement." Orthopedic Clinics of North America 31 2 (2000): 285-293. National Center for Biotechnology Information. National Library of Medicine. 5 Oct. 2008 <PMID: 10736397>. Philadelphia Panel. "Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Shoulder Pain." Physical Therapy 81 10 (2001): 1719-1730. National Center for Biotechnology Information. National Library of Medicine. 10 May 2008 <PMID: 11589645>. Rubin, B. D., and W. B. Kibler. "Fundamental Principles of Shoulder Rehabilitation: Conservative to Postoperative Management." Arthroscopy 18 9 Suppl 2 (2002): 29-39. National Center for Biotechnology Information. National Library of Medicine. 10 May 2008 <PMID: 12426529>. |
Source: Medical Disability Advisor
| Feedback |
| Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must
include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment.
If you are seeking medical advice, please contact your physician. Thank you! |
Send this comment to:
Sales
Customer Support
Content Development
|
|
| |
|
|
|
|
|
This publication is designed to provide accurate and authoritative information in
regard to the subject matter covered. It is published with the understanding that
the author, editors, and publisher are not engaged in rendering medical, legal,
accounting or other professional service. If medical, legal, or other expert assistance
is required, the service of a competent professional should be sought. We are unable to respond to requests for advice.
Any Sales inquiries should include an email address or other means of
communication.
|