Shoulder Impingement Diagnosis And Rehabilitat


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Peer reviewed research into the causes and rehabilitation of rotator cuff impingement.

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Shoulder Impingement Diagnosis And Rehabilitat

  2. 2. Rotator Cuff Impingement Syndrome AKA <ul><ul><li>Shoulder Impingement Syndrome </li></ul></ul><ul><ul><li>Rotator Cuff Tendinitis </li></ul></ul><ul><ul><li>Swimmer’s shoulder </li></ul></ul><ul><ul><li>Pitcher’s shoulder </li></ul></ul><ul><ul><li>Tennis shoulder </li></ul></ul>
  3. 3. Background <ul><ul><li>According to the Job Analysis of Chiropractors 2000 , upper extremity complaints account for 8.6% of chief complaints among chiropractic patients, not including secondary complaints.1 </li></ul></ul><ul><ul><li>Shoulder pain in the 3rd most common reason for patients seeking chiropractic care. 1st is Low back pain, 2nd is headaches.4 </li></ul></ul><ul><ul><li>Shoulder pain is the 2nd most common cause of occupational injury claims.2 The 1st being low back pain. </li></ul></ul>
  4. 4. <ul><ul><li>Of all potential shoulder injury types, rotator cuff impingement is the most common.3 </li></ul></ul><ul><ul><li>Rotator cuff impingement/tears occur secondary to repetitive overuse causing microtrauma.10 </li></ul></ul><ul><ul><li>Kalb et al. found 95% of all cases of shoulder pain is caused by impingement of rotator cuff tendons between the greater tuberosity and the anterior edge of the acromion especially in overhead ROMs.5 </li></ul></ul>
  5. 5. Causes of Rotator Cuff Tendinopathy7 <ul><ul><li>Extrinsic causes </li></ul></ul><ul><ul><li>Primary impingement    </li></ul></ul><ul><ul><li>Increased subacromial loading    </li></ul></ul><ul><ul><li>Acromial morphology (shape, slope, spur, os acromiale)    </li></ul></ul><ul><ul><li>Acromioclavicular arthrosis (inferior osteophytes)    </li></ul></ul><ul><ul><li>Coracoacromial ligament hypertrophy    </li></ul></ul><ul><ul><li>Coracoid impingement    </li></ul></ul><ul><ul><li>Subacromial bursal thickening and fibrosis    </li></ul></ul><ul><ul><li>Prominent humeral greater tuberosity    </li></ul></ul><ul><ul><li>Trauma (direct macrotrauma or repetitive microtrauma)    </li></ul></ul><ul><ul><li>Overhead activity (athletic and non-athletic)   </li></ul></ul><ul><ul><li>Secondary impingement    </li></ul></ul><ul><ul><li>Rotator cuff overload/soft tissue imbalance    </li></ul></ul><ul><ul><li>Eccentric activity    </li></ul></ul><ul><ul><li>Glenohumeral laxity/instability    </li></ul></ul><ul><ul><li>Biceps and biceps labral complex tears    </li></ul></ul><ul><ul><li>Long head of biceps tendon laxity/weakness    </li></ul></ul><ul><ul><li>Muscle imbalance    </li></ul></ul><ul><ul><li>Scapular dyskinesia    </li></ul></ul><ul><ul><li>Posterior capsular tightness    </li></ul></ul><ul><ul><li>Trapezius paralysis </li></ul></ul><ul><ul><li>Intrinsic causes   </li></ul></ul><ul><ul><li>Impaired cuff vascularity    </li></ul></ul><ul><ul><li>Ageing (primary)    </li></ul></ul><ul><ul><li>Impingement (secondary)   </li></ul></ul><ul><ul><li>Primary tendinopathy    </li></ul></ul><ul><ul><li>Intratendinous injury    </li></ul></ul><ul><ul><li>Articular-side partial-thickness tears    </li></ul></ul><ul><ul><li>Calcific tendinopathy </li></ul></ul>
  6. 6. Stages of Impingement <ul><ul><li>Charles Neer further classified Shoulder Impingement Syndromes into 3 stages:8 </li></ul></ul><ul><ul><li>Stage 1 – Inflammation, hemorrhage, and edema of the tendon. </li></ul></ul><ul><ul><li>Stage 2 – Fibrosing and thickening of the sub-acromial tissue with partial tearing of the supraspinatus tendon. </li></ul></ul><ul><ul><li>Stage 3 – Tearing of the rotator cuff with osteophyte formation </li></ul></ul>
  7. 7. Patient presentation <ul><ul><li>Pain in anterolateral deltoid region radiating to lateral upper arm. </li></ul></ul><ul><ul><li>Typically no radiation below elbow. </li></ul></ul><ul><ul><li>May be worst at night especially when lying on affected shoulder. </li></ul></ul><ul><ul><li>Aggravated by overhead movement (brushing hair, reaching for shelves). </li></ul></ul><ul><ul><li>Painful arc between 60-120 degrees of abduction (also found in SA Bursitis). </li></ul></ul><ul><ul><li>Possible crepitus, tenderness. </li></ul></ul>
  8. 8. Diagnosis <ul><ul><li>Codman’s Drop-arm - May only be present with injury to tendons. </li></ul></ul><ul><ul><li>Neer’s impingement test – full flexion </li></ul></ul><ul><ul><li>Hawkins-Kennedy Test – 90 deg. flexion, forced into internal rotation </li></ul></ul><ul><ul><li>Supraspinatus press test – pain with digital pressure </li></ul></ul>
  9. 9. Diagnosis <ul><li>Muscle testing </li></ul><ul><ul><li>Supraspinatus – Empty can test </li></ul></ul><ul><ul><li>Infraspinatus/Teres minor- Resisted external rotation </li></ul></ul><ul><ul><li>Subscapularis- Belly press test/Lift-off sign </li></ul></ul><ul><li>*Pain and/or weakness in any of these tests may indicate involved muscle(s) </li></ul>
  10. 10. Diagnosis <ul><ul><li>MRI may not be necessary to prove rotator cuff impingement. </li></ul></ul><ul><ul><li>Sher et al. performed MRI studies of 96 patients with asymptomatic shoulders. 9 </li></ul></ul><ul><ul><li>Of those 96, 15% of them had a complete tear of the rotator cuff and 20% demonstrated a partial tear. 9 </li></ul></ul><ul><ul><li>In the population over 60 years old, over 50% of those examined demonstrated either a complete or partial tear.9 </li></ul></ul>
  11. 11. Medical Treatment <ul><ul><li>NSAIDs </li></ul></ul><ul><ul><li>Cortisone injections </li></ul></ul><ul><ul><li>Physical Therapy </li></ul></ul><ul><ul><li>Manipulation under anesthesia </li></ul></ul><ul><ul><li>Arthroscopic surgery </li></ul></ul><ul><ul><li>Open surgery in severe cases </li></ul></ul>
  12. 12. Chiropractic Treatment <ul><ul><li>Cryotherapy </li></ul></ul><ul><ul><li>Mobilization </li></ul></ul><ul><ul><li>Manipulation </li></ul></ul><ul><ul><li>Manual Soft Tissue Mobilization </li></ul></ul><ul><ul><li>Instrument Assisted Soft Tissue Technique </li></ul></ul><ul><ul><li>Active Release Technique </li></ul></ul><ul><ul><li>Myofascial Release Technique </li></ul></ul><ul><ul><li>Nimmo/Ischemic Compression </li></ul></ul><ul><ul><li>Ultrasound therapy </li></ul></ul><ul><ul><li>Etc. </li></ul></ul>
  13. 13. Specific Areas of Concentration <ul><ul><li>Remember to avoid immobilization!! This can lead to adhesive capsulitis. </li></ul></ul><ul><ul><li>The rotator cuff muscles not only mobilize the humerus, but stabilize the glenohumeral joint. </li></ul></ul><ul><ul><li>Maintaining scapulothoracic motion is important in restoring proper biomechanics (where the rotator cuff muscles originate). </li></ul></ul><ul><ul><li>CMT-D to the Cervical and Thoracic spine to remove intersegmental dysfunction due to muscular imbalances. </li></ul></ul>
  14. 14. Rehabilitative Exercises <ul><ul><li>Stage one rotator cuff impingement can begin rehab exercises once inflammation has subsided focusing on internal rotation, external rotation, and abduction. </li></ul></ul><ul><ul><li>Athletes may want to perform repetitions with low weight of sport-specific motions (swimming, throwing, serving). </li></ul></ul><ul><ul><li>Light weight, high repetitions </li></ul></ul>
  15. 15. Exercises <ul><li>Least Invasive -> Most Invasive </li></ul><ul><ul><li>Pendulums, AROM to tolerance, Isometrics </li></ul></ul><ul><ul><li>Wall finger walks, pulleys, scapular retractions </li></ul></ul><ul><ul><li>Isotonics (low weight): internal/external rotation, abduction, oscillations. </li></ul></ul><ul><ul><li>Therabands/Isokinetic exercises </li></ul></ul><ul><ul><li>Full activity </li></ul></ul>
  16. 16. Conclusion <ul><ul><li>In a Systemic review of Manipulative Therapy for the Treatment of Shoulder Pain, 913 retrieved publications, 22 case reports, 4 case series and 4 randomized, controlled trials were evaluated for the effectiveness of treatment for shoulder pain.11 </li></ul></ul><ul><ul><li>“ The evidence for chiropractic management of shoulder pain is limited to low level evidence in the form of case reports and case series, and one controlled trial of good quality for short term use of manipulative therapy in subacromial impingement. The noteworthy factor of the chiropractic publications is the use of a multimodal approach.” 11 </li></ul></ul>
  17. 17. Conclusion <ul><ul><li>“ The results of the publications present a starting point for the design of focused future research, in the form of RCTs investigating a clinical diagnosis, with a particular modality compared to a control group. Such trials will help establish the evidence to promote better understanding of chiropractic management strategies and the credibility of its interventions for shoulder pain.”11 </li></ul></ul>
  18. 18. Bottom Line <ul><ul><li>Each patient will require a different approach to treating rotator cuff impingement. </li></ul></ul><ul><ul><li>No single therapy is proven effective, but a multi-modal approach specific to each patient’s presentation.11 </li></ul></ul><ul><ul><li>More research is needed in the area of chiropractic therapy and rotator cuff impingement. </li></ul></ul>
  19. 19. References <ul><ul><li>1. Christensen MG. Job Analysis of Chiropractic. National Board of Chiropractic Examiners 2000. Greeley, Co. p 78-79. </li></ul></ul><ul><ul><li>2. McDermott FT. Repetitive strain injury: a review of current understanding. Med J Australia 1986; 144:196-200. </li></ul></ul><ul><ul><li>3. K.J. Faber, S.B. Singleton and R.J. Hawkins, Rotator cuff disease: diagnosing a common cause of shoulder pain, J Musculo Med 15 (1998), pp. 15–25. </li></ul></ul><ul><ul><li>4. L.W. Shrode, Treating shoulder impingement using the supraspinatus synchronization exercise, JMPT 17 (1994) (1), pp. 43–53. </li></ul></ul><ul><ul><li>5. Kalb RL. Evaluation and treatment of shoulder pain. Hospital Practice 1998; 119-122. </li></ul></ul>
  20. 20. <ul><ul><li>6. Daigneault J, Cooney LM. Shoulder pain in older people. J Am Geriatr Soc 1998; 46:1144-1151. </li></ul></ul><ul><ul><li>7. P.J. Evans and A. Maniaci, Rotator cuff tendinopathy: many causes, many solutions, J Musculo Med 14 (1997), pp. 47–61. </li></ul></ul><ul><ul><li>8. Neer CS. Anterior acromioplasty for the clinic impingement syndrome in the shoulder. J Bone Joint Surgery 1972; 54:41-50. </li></ul></ul><ul><ul><li>9. Sher JS, Uribe JW, Posada A et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surgery 1995; 77A: 10-15. </li></ul></ul><ul><ul><li>10. Iannoti JP: Evaluation of the painful shoulder. J Hand Therapy 1994, 7: 77-83. </li></ul></ul><ul><ul><li>11. Pribicevic M, Pollard H, Bonello R, de Luca K. A Systematic Review of Manipulative Therapy for the Treatment of Shoulder Pain. JMPT 2010; 33(9): 679-689. </li></ul></ul>