Shoulder impingement syndrome

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Shoulder Impingment Syndrome: Clinical understanding, management, physiotherapy management

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Shoulder impingement syndrome

  1. 1. Dr. P. Ratan khuman (PT) M.P.T., (Ortho & Sports)
  2. 2. Anatomy of shoulder Left Anterior Shoulder 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 2
  3. 3. Scapula Anterior View Posterior View 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 3
  4. 4. rotator cuff Muscles 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 4
  5. 5. Muscle Force Couple • Two forces of equal magnitude, but in opposite direction, that produce rotation an axis. 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 5
  6. 6. Muscles of Shoulder Girdle 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 6
  7. 7. introduction • The term “Impingement Syndrome” was popularized by Charles Neer in 1972 • Neer defined impingement as pathologically compression of rotator cuff against the anterior structure of coracoacromial arch, anterior 1/3 of the acromion, coraco-acromial ligament & AC joint. • Progression of syndrome is define by a narrowing of the sub-acromial outlet by spur formation in coracoacromial ligament & undersurface. 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 7
  8. 8. 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 8
  9. 9. Definition: • Shoulder impingement: – It is compression & mechanical abrasion of supraspinatus as they pass beneath the coracoacromial arch during elevation of the arm. • Rotator Cuff Tendinitis: – It encompasses impingement & result from acute rotator cuff overload, intrinsic rotator cuff degeneration, or chronic overuse. • Rotator cuff syndrome: – It is the term used to describe the process whereby tendinitis & impingement are ongoing simultaneously. • Painful arc syndrome: – Pain in the shoulder and upper arm during the midrange of glenohumeral abduction, with freedom from pain at extremes of the range due to supraspinatus damage 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 9
  10. 10. • Impingement causes Mechanical irritation of cuff tendons - resulting in haemorrhage and swelling (commonly known as tendonitis of rotator cuff) – The supraspinatus muscle is usually involved. • This also affect the bursa – resulting in bursitis. • Shoulder complex is susceptible to impingement injuries from overhead sports – – Such as baseball, tennis, swimming, volleyball etc. • Impingement with rotator-cuff tendonitis is one of most common shoulder injuries seen in athletes. 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 10
  11. 11. Signs and Symptoms • Pain & tenderness in the gleno-humeral area • Pain or weakness with active abd in midrange • Limited internal rotation compared to normal side • Confirmation with special tests (Hawkins impingement test) • Tenderness to palpation in the sub-acromial area 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 11
  12. 12. ETIOLOGY OF IMPINGEMENT External Primary Outlet Obstruction Rotator Cuff Dysfunction Secondary Instability Rotator Cuff Dysfunction Internal (Glenoid) Repetitive Trauma Instability Rotator Cuff Dysfunction 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 12
  13. 13. Factor development of External impingement • Anatomical abnormalities – e.g. beaked/ # acronion, osteophyte • Poor scapular control • Anterior instability • Postural changes in upper quadrant – Forward head & rounded shoulder posture 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 13
  14. 14. Types of acromions 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 14
  15. 15. Factor development of internal impingement • Overuse – repetitive trauma • Loose joint • Instability • Muscle imbalance • Superior labrum injury 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 15
  16. 16. stage of shoulder impingement syndrome (Sis) 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 16
  17. 17. Stage-I: edema & inflammation • Age – younger than 25 years (but may occur at any age) • Reversible lesion • Tenderness over greater tuberosity of humerus • Tenderness over anterior ridge of acromion • Painful arch 600 – 1200 • (+) ve Neer impingement test • ROM may restricted with sub-acromial inflammation 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 17
  18. 18. Stage-II: fibrosis & tendinitis • Age – 25 – 40 years • Not reversible by modification of activities • Stage-I signs + the following – – Soft tissue crepitus – Catching sensation at lowering arm (approx 1000) – Limitation of active & passive ROM 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 18
  19. 19. Stage-III: bone spur & tendon rupture • Age > 40 years • Not reversible • Stage I + II signs + following – – Limited ROM more prominently – Atrophy of infra-spinatus – Weakness of abductor & external rotator – Bicep tendon involvement – AC joint tenderness 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 19
  20. 20. Common test • For impingement – – Neer impingement test – Hawkins impingement test – Crossover impingement test • Rotator cuff test – – Intraspinatus – external rotation – Supraspinatus – empty can position & resistance – Subscapularis – hand behind back (Lift off) – Drop arm – for full thickness rotator cuff 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 20
  21. 21. Common test for impingement 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 21
  22. 22. Treatment goal • To relieve pain & swelling • To decrease inflammation • To retard muscle atrophy & strengthen cuff muscle • To maintain & improve ROM • To increase neuromuscular control • To increase strength, endurance & power • Unrestricted symptom free activities • To modified activity & prevent 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 22
  23. 23. Treatment approaches 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 23
  24. 24. Functional modification • Complete restriction of painful movt • Analysis of aggravating exercises & motion will help in modification of training programs • A logical approach to restriction of activity & gradually return • Activity from painful column should not reintroduce until pain free 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 24
  25. 25. Pharmacological approach • Oral anti-inflammatory medication • Subacromial steroid in early inflammation stage • Medication combine with therapeutic modalities like – LASER, TENS, US etc 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 25
  26. 26. Cryotherapy • Over the tenderness in early inflammation stage • Duration – 10 – 15 min • Greater effect along with medication 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 26
  27. 27. Electrotherapy • TENS is useful in controlling muscular pain • US therapy with 0.8 w/cm2, 3MHz, 6 min – to restore inflammation • Other modalities like LASER, IFT & heat therapy are also effective in pain control 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 27
  28. 28. Bio feed back • It may be appropriate if there is excessive laxity of humeral head • Helpful in athlete unable to gain control of the rotator cuff musculature 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 28
  29. 29. Manual therapy approach • Maitland’s concept – – Mobilization for GH & ST joint – Grade – • I & II in early stage • As symptoms response, can shift to even grade III & IV – Glide – • AP & inferior in scapular plane • Combine glide as per requirement – Oscillation – Usually 10 oscillation, 3 set is used. 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 29
  30. 30. Manual therapy approach • Cyriax’s concept – Transvers friction massage is useful – Better effect when combine with other modalities & medications • Mulligan’s concept – Movement with mobilization (MWM) is effective 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 30
  31. 31. Therapeutic exercise • ROM exercise – – Penduler exercises with light weight (1kg or Less) – Active assisted ROM exercises in pain free range • E.g. Rope & Pulley – flexion – Anterior & posterior capsular stretching – Stretching of upper trapezius, pectorals, biceps etc. – Towel exercise – Codman's exercises 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 31
  32. 32. Stretching exercises Posterior Complex Pectoralis Internal Rotator 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 32
  33. 33. Therapeutic exercise • Strengthening exercise – – Isometric exercises – • External & internal rotators • Biceps • Deltoid (all 3 fibers) – Scapulo-thoracic stability exercise – • Important for primary & secondary impingement • OKC & CKC scapular stabilizing exercises – Arm aerometry for endurance exercise 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 33
  34. 34. • Strengthening exercise – – Plyometric shoulder strengthening using therabend – Isokinetic exercise for • Supraspinatus, prone extension & horizontal abduction 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 34
  35. 35. 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 35
  36. 36. Strengthening exercises Adductor Strengthening 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 36
  37. 37. Deltoid Strengthening 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 37
  38. 38. Extensor Strengthening 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 38
  39. 39. Medial Rotator Strengthening 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 39
  40. 40. Lateral Rotator Strengthening 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 40
  41. 41. taping • Taping for scapular abnormal movt or dyskinesia • Taping + strengthening 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 41
  42. 42. Mechanical correction taping 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 42
  43. 43. Kinesio-taping for impingement 1 2 3 4 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 43
  44. 44. Surgery • Arthroscopic subacromial decompression • Capsulorrhaphy 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 44
  45. 45. Preventive measures • Perform warm-up exercises & flexibility training • Exercise the whole kinetic chain, including strength training. • Avoid abuse (pain-causing situations). 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 45
  46. 46. Preventing Re-injury • Perform warming-up before & cooling-down after training, for no less than 15 minutes. • Include stretching ex for the posterior shoulder. • Perform preventative strengthening exercises for the shoulder twice a week. • Ensure you take adequate rest & avoid playing too many games in too short period. • Fatigue plays an important role in occurrence of this kind of injury. 7/27/2013 Ratan Khuman (MPT Ortho & Sports) 46

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