overview of conservative management of shoulder impingement

1. Shoulder
Impingement
A Conservative Overview
Mrinal Joshi
MBBS MD DNB MNAMS GCMskMed
drmrinaljoshi.com

2. Shoulder Impingement Syndrome
• Soft tissue entrapped in shoulder joint
• Pain in elevating arm/lying on affected arm
• Usually, no preceding trauma
• May have a trivial injury
• May lead to partial or full thickness tear
• Patients usually older than 40 years
• Subacromial impingement with RC tendinitis is commonest
• Restore pain free and powerful movement

3. Shoulder Impingement
• External anatomic impingement
• Acromial morphology
• Glenohumeral instability
• Anatomical abnormalities
• ACJ separation
• Os acromiale
• Fracture acromion
• Fracture greater tuberosity

4. Shoulder Impingement
• Internal anatomic impingement
• SLAP lesion
• Deep surface rotator cuff tear
• Functional overload
• Overuse strain
• Partial thickness tear
• Intrinsic tendinopathy
• Degenerative process
• Secondary anatomic impingement

5. Shoulder Impingement
• Anatomical basis
• Subacromial impingement
• Subcoracoid impingement
• Postero-superior inner impingement
• Antero-inferior inner impingement

8. • During elevation force couple
develops between deltoid and rotator
cuff muscles
• Deltoid contracts, pulls humeral head
up and begins elevation
• In absence of depressors, humerus
abuts under acromion and beyond 90
degrees elevation becomes difficult
• Space between the greater tuberosity
and under surface of acromion is
approximately 6-7mm
• Thickness of rotator cuff is 5-6mm
• Little clearance between cuff and
acromion

9. Evaluation
• Clinical History
• Examination
• Special clinical tests
• X-rays
• Ultrasonography
• Diagnostic infiltration
• Magnetic resonance imaging
• Computed tomography

10. Empty Can
Test
• Specificity for pain/weakness 50%
• Sensitivity for pain/weakness 89%
• Positive likelihood pain/weakness
1.78
• Negative likelihood pain/weakness
0.22

11. Hawkins-
Kennedy Test
• Specificity 25%
• Specificity for impingement 73%
• Sensitivity 92%
• Sensitivity impingement 65%
• Positive likelihood for impingement
2.41

12. Neer Impingement
Test
• Specificity 30.5%
• Specificity for impingement 73%
• Sensitivity 88.7%
• Sensitivity impingement 65%
• Positive likelihood for impingement
2.41

13. Critical
Shoulder
Angle
• Measured in AP view
• Incorporates both inclination of
glenoid and the extent of coverage
by the acromion
• Risk of RC lesion if angle is more
than 35 degrees
• Risk of shoulder arthritis is higher if
less than 35 degrees

14. Acromiohumera
l Distance
• Measured in AP view
• Lower edge of acromion to humeral
head
• 7-14mm in men
• 7-12mm in women
• Abnormally low indicates defect in
more than one RC

15. Acromiohumera
l Index
• Characterizes lateral extension of
the acromion
• AI = GA/GH
• Higher AI indicates marked lateral
extension of the acromion
• Associated with rotator cuff tears
GA
GH

16. Antero-posterior 25° ↓ (outlet
projection-calcified tendons)

17. Lateral-oblique 15° ↓ (outlet
projection-calcified tendons)

18. Conservative treatment options
• Immobilization
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Cortisone injection
• PRP injection
• Physical therapy
• Ultrasound therapy
• Heat and electrical therapy
• Manual therapy
• Elastic therapeutic taping

22. Therapeutic exercises-simplistic
approach
• Passive and active-assistive capsular stretching in scapular plane
• Strengthening of humeral head depressors
• Strengthening of scapular balancing muscles
• Strengthening of prime humeral positioners
• Exercise equipment modifications
• 70% success rate with chronic subacromial impingement

23. References
• Orthopaedic Clinics of North America Vol31.Number2.April 2000
• Deutsches Arzteblatt International 2017;114:765-76
• The Americal Journal of Medicine 2005;118:452-455
• Visible Body 2021
• Medscape 2021
• Sonoaccess 2021
• Archives of PMR 2019;100(11):2119-2128
• Orthopaedics Physical Assessment , David J Magee, Elsevier
• Clark’s positioning in radiography, 13th edition , CRC press

24. Thank you
for patient
listening