Dr. Pushpendra Yaduvanshi

1. PAINFUL ARCH
SYNDROME
PRESENTED By:- Dr. Pushpendra Yaduvanshi
Asst. prof, Physiotherapy
Career point University, Kota

2. INTRODUCTION

4.  Supraspinatus tendinitis or painful arc syndrome occurs in
the shoulder.
 The shoulder joint owes its stability to the 'rotator cuff'
muscles - which are four small muscles located around the
shoulder joint which help with movement, but importantly
their tendons stabilise the head of the humerus within the
joint capsule.

5.  The tendon of one of these muscles - the supraspinatus
commonly impinges on the acromion (the bone forming the
tip of the shoulder) as it passes between the acromion and
the humeral head.
 The supraspinatus muscles helps abduct (lift up sideways)
the arm.

6.  Any friction between the tendon and the acromion is
normally reduced by the subacromial bursa - a fluid filled
sac between the supraspinatus tendon and the acromion.
 Sometimes, with wear and tear supraspinatus tendinitis
results, which is commonly associated with inflammation
of the bursa - subacromial bursitis.

7.  There may even be little tears in the tendon fibres - partial
tears or sometimes even complete tears.
 Tendinitis and partial tears in the supraspinatus tendon
causes a 'painful arc' since as the person elevates his arm
sideways.
 The tendon begins to impinge under the acromion throught
the middle part of the arc, and this is usually relieved as
the arm reaches 180 degrees (vertical).

8.  There may be other causes of a painful arc.
 Arthritis of the acromio-clavicular joint (at the tip of the
shoulder) may also cause pain but that is typically at the
end of the arc - when the arm is almost vertical.
 Supraspinatus tendinitis is very common, it the most
common inflammatory problem encountered around the
shoulder joint. It is typically seen in people aged 25-60.

9. DEFINITION
 Impingement syndrome also called painful arc
syndrome, supraspinatus syndrome, swimmer's
shoulder, and thrower's shoulder, is a clinical syndrome
which occurs when the tendons of the rotator cuff muscles
become irritated and inflamed as they pass through the
subacromial space, the passage beneath the acromion.
 This can result in pain, weakness and loss of movement at
the shoulder.

10. SIGN & SYMTOMS
 The most common symptoms in impingement
syndrome are pain, weakness and a loss of
movement at the affected shoulder.
 The pain is often worsened by shoulder overhead
movement and may occur at night, especially if the
patient is lying on the affected shoulder.
 The onset of the pain may be acute if it is due to an
injury or may be insidious if it is due to a gradual
process such as an osteoarthritic spur.

11.  Other symptoms can include a grinding or popping
sensation during movement of the shoulder.
 The range of motion at the shoulder may be limited by
pain. A painful arc of movement may be present during
forward elevation of the arm from 60° to 120°
 Passive movement at the shoulder will appear painful
when a downwards force is applied at the acromion but the
pain will ease once the downwards force is removed.

12. CAUSES
 The rotator cuff muscle tendons pass through a narrow
space between the acromion process of the scapula and
the head of the humerus.
 Anything which causes further narrowing of this space can
result in impingement syndrome.

13.  This can be caused by bony structures such as
subacromial spurs (bony projections from the acromion),
 osteoarthritic spurs on the acromioclavicular joint, and
variations in the shape of the acromion.

14.  Thickening or calcification of the coracoacromial ligament
can also cause impingement.
 Loss of function of the rotator cuff muscles, due to injury or
loss of strength, may cause the humerus to move
superiorly, resulting in impingement.
 Inflammation and subsequent thickening of the
subacromial bursa may also cause impingement.

15. DIAGNOSIS
 Impingement syndrome can usually be diagnosed
by history and physical exam.
 Plain x-rays of the shoulder can be used to detect
some joint pathology and variations in the bones,
including acromioclavicular arthritis, variations in
the acromion, and calcifcation.

16.  Ultrasonography, arthrography and MRI can be
used to detect rotator cuff muscle pathology.
 Due to lack of understanding of the pathoaetiology,
and lack of diagnostic accuracy in the assessment
process by many doctors,several opinions are
recommended before intervention.

17. MRI FINDINGS OF IMPINGEMENT
 A = acromion, Cl =
clavicle,
 B = subacromial
bursa,
 Su = supraspinatus
muscle,
 H = proximal portion
of humerus.
Diagram shows inferiorly oriented osteophyte producing
impingement (arrow).

18.  Neer test: Forcefully elevate an internally rotated
arm in the scapular plane, causing the supraspinatus
tendon to impinge against the anterior inferior
acromion.

19.  Hawkins-Kennedy test: Forcefully internally rotate a 90°
forwardly flexed arm, causing the supraspinatus tendon to
impinge against the coracoacromial ligamentous arch. Note:
Pain and a grimacing facial expression indicate impingement of
the supraspinatus tendon, indicating a positive Neer/Hawkins
impingement sign.

20.  Cross-Arm Test
Patients with acromioclavicular joint dysfunction often have
shoulder pain that is mistaken for impingement syndrome. The
cross-arm test isolates the acromioclavicular joint.
 The patient raises the affected arm to 90 degrees. Active
adduction of the arm forces the acromion into the distal end of
the clavicle.Pain in the area of the acromioclavicular joint
suggests a disorder in this region.

21.  Supraspinatus isolation test/empty can test:
 The supraspinatus may be isolated by having the patient
rotate the upper extremity so that the thumbs are pointing
to the floor and apply resistance with the arms in 30° of
forward flexion and 90° of abduction (assimilates emptying
of a can).
 This test is positive when weakness is present (compared
to the unaffected side), suggesting disruption of the
supraspinatus tendon.

22. Supraspinatus examination ("empty can" test). The patient attempts to elevate
the arms against resistance while the elbows are extended, the arms are
abducted and the thumbs are pointing downward

23.  Drop-Arm Test
A possible rotator cuff tear can be evaluated with the drop-
arm test. This test is performed by passively abducting the
patient's shoulder, then observing as the patient slowly
lowers the arm to the waist. Often, the arm will drop to the
side if the patient has a rotator cuff tear or supraspinatus
dysfunction.
 The patient may be able to lower the arm slowly to 90
degrees (because this is a function mostly of the deltoid
muscle) but will be unable to continue the maneuver as far
as the waist.

24.  Impingement test: Inject 10 mL of 1% lidocaine solution
into the subacromial space.
 Repeat testing for an impingement sign. Elimination or
significant reduction of pain constitutes a positive
impingement test.

25. INSTABILITY TESTS
 Apprehension Test
The anterior apprehension test is performed with
the patient supine or seated and the shoulder in a
neutral position at 90 degrees of abduction. The
examiner applies slight anterior pressure to the
humerus (too much force can dislocate the
humerus) and externally rotates the arm.
 Pain or apprehension about the feeling of
impending subluxation or dislocation indicates
anterior glenohumeral instability.

27.  Relocation Test
The relocation test is performed immediately after a
positive result on the anterior apprehension test.
 With the patient supine, the examiner applies posterior
force on the proximal humerus while externally rotating the
patient's arm. A decrease in pain or apprehension
suggests anterior glenohumeral instability.

28.  Sulcus Sign
With the patient's arm in a neutral position, the examiner
pulls downward on the elbow or wrist while observing the
shoulder area for a sulcus or depression lateral or inferior
to the acromion. The presence of a depression indicates
inferior translation of the humerus and suggests inferior
glenohumeral instability.
 The examiner should remember that many asymptomatic
patients, especially adolescents, normally have some
degree of instability.

30. TREATMENT
 Impingement syndrome is usually treated
conservatively, but sometimes is treated with
arthroscopic surgery or open surgery.
 Conservative treatment includes rest, cessation of
painful activity, and physiotherapy focused at
maintaining range of movement and avoid shoulder
stiffness.
 NSAID's and ice packs may be used for pain relief.

31.  Therapeutic injections of corticosteroid and local
anaesthetic may be used for persistent
impingement syndrome.
 The total number of injections is generally limited to
3 due to possible side effects from the
corticosteroid.

32.  Corticosteroids actually cause musculoskeletal
disorders,which explains the low success rate of cortisone
injections.
 Research has shown that over 90% of tendinopathies have
no inflammation, thus the term tendinosis is more
appropriate than tendinitis for most diagnoses.
 For tendinosis, prolotherapy injections or cross-fiber
(transverse) friction massage can be very effective.

33. SURGICAL TREATMENT
 When nonsurgical treatment does not relieve pain,
the doctor may recommend surgery.
 The goal of surgery is to remove the impingement
and create more space for the rotator cuff.
 This allows the humeral head to move freely in the
subacromial space and to lift the arm without pain.

34.  The most common surgical treatment is
subacromial decompression or anterior
acromioplasty.
 This may be performed by either arthroscopic or
open techniques:

35.  Arthroscopic technique: In an arthroscopic
procedure, two or three small puncture wounds are
made.
 The joint is examined through a fiberoptic scope
connected to a television camera. Small
instruments are used to remove bone and soft
tissue.

36.  Open technique: Open surgery requires
placement of a small incision in the front of the
shoulder.
 This allows for direct visualization of the acromion
and rotator cuff.
 In most cases, the front (anterior) edge of the
acromion is removed along with some of the bursal
tissue.

37.  Techniques to treat anterior acromioplasty. Left,
arthroscopic repair. Right, Open surgical procedure

38.  The surgeon may also treat other conditions
present in the shoulder at the time of impingement
surgery.
 These can include acromioclavicular arthritis,
biceps tendonitis, or a partial rotator cuff tear.

39.  Left, Arthroscopic view of the anterior edge of the acromion.
An instrument is positioned beneath to begin the
acromioplasty.
 Right, Impingement may result in a partial rotator cuff tear
(RC), shown by the three arrows. The surface of the humeral
head (HH) lies below the rotator cuff.

40. PROGNOSIS
 Around 70% of patients with tendinitis will improve over 5-
20 days and mobilize the joint themselves, though
treatment with physiotherapy and steroid injections will
help.
 Further tendinitis and even partial or complete tears may
occur in the future.

41.  Complete tears are treated surgically in young people,
though this may be harder in older people or patients with
other causes such as rheumatoid arthritis.
 Chronic trauma and impingement may lead to
osteoarthritis of the shoulder in the long term.

42. REFERENCES
 Clinical References.
 orthopaedic rehablitation S. brent brotzman.
 Orthopeadic physical Assessment David j. magee.
 Essentials of orthopeadics & applied physiotherapy.
Jayant joshi.
 www.google.com