Complete descripition of the shoulder impingement syndrome and its management (both clinical and physical therapy intervention ) is explained in this slideshare,

1. SHOULDER
IMPINGEMENT
SYNDROME
sumasree

2. CONTENTS
ANATOMY
INTRODUCTION
DEFINITION
ETIOLOGY
STAGES
TYPES
CLINICAL FEATURES
SPECIAL TESTS
DIAGNOSIS
TREATMENT

3. Anatomy of shoulder joint

4. ROTATORY CUFF MUSCLES

6. 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 defined by a narrowing of the sub-acromial outlet
by spur formation in coracoacromial ligament.

8. 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 : affects the tendons and muscles
which are responsible for the movement of shoulder joint,
it is caused due to over use and injury.
Rotator cuff syndrome : It is the term used to describe
the process whereby tendinitis & impingement are
ongoing simultaneously.

9. 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

11. Painful arc syndrome : Pain in the shoulder and upper arm
during the midrange of glenohumeral abduction(45-120 degrees)
with freedom from pain at extremes of the range due to
supraspinatus damage.

12. ETIOLOGY OF IMPINGEMENT
EXTERNAL INTERNAL
PRIMARY SECONDARY REPETITIVE TRAUMA
Outlet Instability Instability
obstruction
Rotatorcuff dysfunction Rotatorcuff dysfunction

13. Causes of external impingement
Anatomical abnormalities
e.g. beaked/ # acromion, osteophyte
Poor scapular control
Anterior instability
Postural changes in upper quadrant
Forward head & rounded shoulder posture

15. Causes of internal impingement
Overuse – repetitive trauma
Loose joint
Instability
Muscle imbalance
Superior labrum injury

19. TYPES OF IMPINGEMENT

20. PRIMARY IMPINGEMENT
Intrinsic Extrinsic

21. The structures passing beneath the coracoacromial arch
Becomes enlarged
Resulting in abutment against arch
Causes impingement
EXAMPLES OF THIS CONDITION INCLUDE:
Thickening of rotator cuff
Calcium deposits within the rotator cuff
Thickening of subacromial bursa
INTRINSIC

22. EXTRINSIC
When the space available for the rotator cuff diminished
Examples include;
1) Subacromial spurring
2) Acromial fracture
3) Osteophyte formation at AC joint
4) Exostoses at greater tuberosity

23. Secondary impingement occurs when there is instability
of gleno humeral joint allowing translation of humeral head,
typically anteriorly, resulting in contact of rotator cuff against
against the coracoacromial arch.
SECONDARY IMPINGEMENT

24. Subcoracoid impingement
Pain in the shoulder caused by contact between the
roatorcuff and the coracoid process
Internal impingement
In this condition, internal contact of rotator cuff occurs with
the posterosuperior aspect of the glenoid when the arm is
abducted, extended and externally rotated as in the cocked
position of the throwing motion.

25. CLINICAL FEATURES
PAIN : more in active than passive motion,
Sleep disturbance,
Pain and tenderness in glenohumeral area,
Pain during active abduction in mid range.
WEAKNESS
LOSS OF MOTION : Limited internal rotation
CLICKS AND CREPITUS

26. IMPINGEMENT SIGN
● A mixture of anaesthesia amd anti inflammatory medication is injected
into the space between the acromion and head of the humerus, if the
pain subsides then it is confirmed as impingement syndrome.

27. Special tests
● For impingement –
Neer impingement test
Hawkins impingement test
Crossover impingement test
● Rotator cuff test – Infraspinatus – external rotation
Supraspinatus – empty can position & resistance
Subscapularis – hand behind back (Lift off)
Drop arm – for full thickness rotator cuff

30. DROP ARM TEST

31. IMAGING
X-RAYS
Ap view
Axillary view
Supraspinatus view
ARTHROGRAM

33. MRI

34. 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.

35. CLINICAL MANAGEMENT
● Oral anti-inflammatory drugs.
● Subacromial steroid in early inflammation stage .
● Medication combine with therapeutic modalities like – LASER, TENS, US
etc

36. PT MANAGEMENT
MODALITIES :
Cryotherapy
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

37. Manual therapy
• 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 oscillations, 3 sets are used
Cyriax’s concept - Transverse friction massage is useful and is effective when
combined with other modalities and medications.
Mulligan’s concept - movement with mobilization is effective.

38. Therapeutic Exercises
• ROM exercise –
Pendular 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

40. stretching
Posterior capsule stretch pectoralis stretch internal rotator

41. • strengthening exercises
Isometric exercises –
Scapulo-thoracic stability exercise –
Important for primary & secondary impingement
OKC & CKC scapular stabilizing exercises
External and
internal rotators.
Biceps
Deltoid(all 3 fibres)

44. ARM ERGOMETRY
For endurance
exercise.
PLYOMETRICS
ISOKINETIC
EXERCISES

46. STRENGTHENING EXERCISES

48. EXTENSORS STRENGTHENING

49. MEDIAL ROTATOR STRENGTHENING

50. LATERAL ROTATOR STRENGTHENING

52. TAPING
● Taping for scapular abnormal movt or dyskinesia
● Taping + strengthening

53. Mechanical correction taping

54. Kinesio-taping for impingement

55. surgery
● Arthroscopic subacromial decompression
● Capsulorrhaphy

56. 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

57. THANK YOU