1. SHOULDER IMPINGEMENT
SYNDROME

2. Definition:
Shoulder impingement has been defined as
compression and mechanical abrasion of the supraspinatus
as they pass beneath the coracoacromial arch during
elevation of the arm.
Related terms:
Rotator cuff tendinitis : It encompasses impingement, and
result from acute rotator cuff overload, intrinsic rotator cuff
degeneration, or chronic overuse.
Rotator cuff syndrome: It is a term used to describe the
process whereby tendinitis and 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 . The term shoulder impingement
syndrome has largely replaced what used to be called
painful arc syndrome.

3. Functional anatomy:
The rotator cuff (Figure 21) comprises four muscles
The subscapularis, the supraspinatus, the
infraspinatus and the teres minor and their
musculotendinous attachments.
The subscapularis muscle is innervated by the
subscapular nerve and originates on the scapula. It
inserts on the lesser tuberosity of the humerus.
The supraspinatus and infraspinatus are both
innervated by the suprascapular nerve, originate
in the scapula and insert on the greater tuberosity.

4. The teres minor is innervated by the axillary nerve,
originates on the scapula and inserts on the
greater tuberosity.
A bursa in the subacromial space provides
lubrication for the rotator cuff.

5. The rotator cuff is the dynamic stabilizer of the
glenohumeral joint. The static stabilizers are the
capsule and the labrum complex, including the
glenohumeral ligaments. Although the rotator cuff
muscles generate torque, they also depress the
humeral head. The deltoid abducts the shoulder.
Without an intact rotator cuff, particularly during
the first 60 degrees of humeral elevation, the
unopposed deltoid would cause cephalic migration
of the humeral head, with resulting subacromial
impingement of the rotator cuff.
In patients with large rotator cuff tears, the
humeral head is poorly depressed and can migrate
cephalad during active elevation of the arm.

6. Figure 21: Rotator cuff muscles

7. Etiology:
1. Extrinsic causes:
A- Bony factors:
 The type I acromion, which is flat, is the "normal"
acromion.
 The type II acromion is more curved and downward
dipping,
 The type III acromion is hooked and downward
dipping, obstructing the outlet for the supraspinatus
tendon and therefore may impinge on the rotator cuff
on elevation of the arm.
• Osteophytes under the acromioclavicular joint
reduces the subacromial space and can also lead to
cuff impingement and therefore failure" '

8. Type I Type II Type III
Figure 22 : Types of anatomical acromion variation: Flat
acromion, curved and hoocked

9. B- Soft tissue factors Examples include
• Subacromial bursitis
• Thickened coracoacromial ligament.
2. Intrinsic causes
a. Degenerative cuff failure :
This constitutes the commonest cause of cuff failure and
usually occurs in the older individual. Degeneration of the cuff
may later result in partial tears which may progress to complete
tears. The precise cause of degenerative cuff tear is unknown.
One possible theory relates to the 'critical vascular zone' of the
cuff tendon where the blood supply is precarious, and relative
ischemia leads to degenerative changes.
b. Traumatic cuff failure:
This may occur when the upper limb is subject to a violent
force and the rotator cuff sustains a traumatic tear. In the
younger individual where the tendinous part of the cuff-bone
complex is stronger than the bony part, the tendons may avulse
with a piece of bone.

10. c. Reactive cuff failure:
Calcific rotator cuff tendinitis is an example of
reactive cuff failure. The calcifying mass inside the
tendon may give rise to a swelling which leads to
impingement under the subacromial arch, hence
resulting in cuff failure.

11. Classification of the Impingement Syndrome
Neer divided impingement syndrome into three stages:
1. Stage I involves edema and/or hemorrhage. This stage
generally occurs in patients less than 25 years of age
and is frequently associated with an overuse injury.
Generally, at this stage the syndrome is reversible.
2. Stage II is more advanced and tends to occur in
patients 25 to 40 years of age. The pathologic changes
that are now evident show fibrosis as well as
irreversible tendon changes.
3. Stage III generally occurs in patients over 50 years of
age and frequently involves a tendon rupture or tear.

12. History :
1-Pain: It is exacerbated by overhead or above the
shoulder activities. A frequent complaint is night pain,
often disturbing sleep, particularly when the patient
lies on the affected shoulder. The onset of symptoms
may be acute, following an injury, or insidious,
particularly in older patients, where no specific injury
occurs. In the acute stage I, there is a painful arc of
abduction between 60 and 120 degrees increased
with resistance at 90 degrees.
2-Loss of motion : Prolonged shoulder pain causes the
patient to restrict instinctively the range of use and
often results in an initial adhesive capsulitis.
3-weakness and inability to raise the arm may indicate
that the rotator cuff tendons are actually torn.

13. Physical examination:
1. Manual motor testing for the rotator cuff muscles:
Geber's lift-off test for subscapularis
External rotation with adducted and elbow
flexed 90 degrees for test of the infraspinatus
and teres minor.
Arm abduction 90 degrees in the scapular plane
(30 degrees anterior to the coronal plane of the
body and internal rotation for test of the
supraspinatus.

14. Figure 23: Lift off test for subscapularis, external rotation for
teres minor and infraspinatus and abduction with internal
rotation for supraspinatus test

15. 2. The key feature of the physical examination is an
assessment for signs of impingement:
a-Neer impingement sign: With the patient seated
or standing place one hand on the posterior aspect
of the scapula to stabilize the shoulder girdle, and,
with the other hand, take the patient's internally
rotated arm by the wrist, and place it in full
forward flexion. If there is impingement, the
patient will report pain in the range of 70 degrees
to 120 degrees of forward flexion as the rotator
cuff comes into contact with the rigid
coracoacromial arch.

16. Figure 24:Neer impingement sign

17. b-Hawkins impingement sign:
With the patient sitting or standing, the examiner
places the patient's arm in 90 degrees of forward
flexion and forcefully internally rotates the arm,
bringing the greater tuberosity in contact with the
lateral acromion. A positive result is indicated if
pain is reproduced during the forced internal
rotation at the supraspinatus site.
C-AROM of shoulder : Forward flexion, abduction,
external rotation and internal rotation.

18. Figure 25: Hawkin's impingement sign 3

19. Figure 26: AROM of shoulder flexion, abduction, ext.
rotation with 90 abduction and neutral the last is Apleys
scratch test for internal rotation.

20. Management:
There are three ways of approaching
impingement syndrome:
І-Physical therapy rehabilitation,
ІІ-subacromial injections of cortisone, and
ІІІ-surgical intervention.
І -Physical therapy rehabilitation in : Acute phase
1- Pain control and inflammation reduction by:
 Relative rest: A sling may be used but it is
crucial that the sling be removed several times
daily to perform exercises.

21.  Icing (20 min, 3-4 times per day): It decreases the
size of blood vessels in the sore area.
Have the patient sleep with a pillow between the
trunk and arm to decrease tension on the;
upraspinatus tendon (that is the arm is little
abduction, flexion and internal rotation) and
prevent blood flow comprise in its watershed
region.
 Patients are instructed to continue the pain
control techniques at home, work, or vacation as
part of their exercise program. The home exercise
program builds on itself through each phase of the
rehabilitation process, and carry-over should be
monitored

22. Recovery Phase
The recovery phase from a rotator cuff injury
must include several components to be successful.
These include the following:
(1)Restoration of shoulder ROM,
(2)Normalization of strength and dynamic muscle
control, and
(3)Proprioception and dynamic joint stabilization.

23. 1-Restoration of shoulder range of motion
After the pain has been managed, restoration of
motion can be initiated:
 Codman pendulum exercises.
 Wall walking
 Stick or towel exercises
 Address any posterior capsular tightness because this
can lead to anterior and superior humeral head
migration, resulting in impingement:
Stretching of the posterior capsule. The focus of
treatment in this early stage should be on improving
range, flexibility of the posterior capsular postural
biomechanics, and restoring normal scapular motion.
Each stretch should be held for a minimum of 30
seconds, although stretching for 1 minute is
encouraged.

24. 2-Normalization of strength and dynamic muscle control
a. Perform strengthening in a pain-free range only. Begin
with the Scapulothroracic stabilizers to help return
smooth motion allowing normal rhythm between scapula
and GH joint. The scapular stabilizers include the
rhomboids, levator scapulae, trapezius, and serratus
anterior.:
 Shoulder shrugs.
 push-ups.
b. Then, turn attention toward strengthening the rotator
cuff muscles. Position the arm at 45° and 90° of abduction
for exercises to prevent the wringing out phenomenon, in
which hyperadduction can be caused, stressing the
tenuous blood supply to the tendon of the exercising
muscle. Avoid the thumbs down position with the arm in
greater than 90° of abduction and internal rotation to
minimize subacromial impingement.

25.  Many ways to strengthen muscles are available. The
rehabilitation program usually starts with isometric
progresses to concentric contractions, and finally
incorporates eccentric contractions as part of the
preparation for return to sports.
Additional strengthening techniques that can be used are
progressive resistive exercises (PREs), Thera-Band, and
plyometrics. Use of isokinetic exercises has been debated
because they are not performed in a functional manner.
Probably the best use for isokinetic exercise machines is
for objective side-to-side comparison of strength and
progress made in strength rehabilitation. Incorporate
endurance training into the program as it advances.

26. Stick exercise
Figure 27: Shoulder stretching exercises include gentle pendulum
exercises, stick exercises, the use of overhead pulley.

27. Flexion Extension Internal Rotation

28. Overhead Bar Pulley

29. Wail Walking Posterior Stretching Door Handing

30. Figure 28:The shoulder strengthening program is designed to improve strength in the
remaining rotator cuff and improved strength of the deltoid. The five theraband exercises
provide resistance against internal rotation and external rotation , abduction, adduction,
extension and forward flexion to strengthen the rotator cuff muscles and the three distinct
portions of the deltoid muscle.

31. Shoulder strengthening exercise

32. 1-Wall Push-Up 2-Knee Push-Up

33. Shoulder press up ups
Figure 29: Scapular stabilizer are strengthened by shoulder shrug,
push-up and shoulder press

34. 3-Proprioception
Proprioceptive training is important to retrain
neurologic control of the strengthened muscles,
providing improved dynamic interaction and
coupled execution of tasks for harmonious
movement of the shoulder and arm. Begin tasks
with closed kinetic chain exercises to provide joint
stabilizing forces. Then as the muscles become
reeducated, one can progress to open chain
activities, In addition, proprioceptive
neuromuscular facilitation (PNF) is designed to
stimulate muscle/tendon stretch receptors for
reeducation.

35. Maintenance Phase
Return to task-specific or sport-specific
activities is the last phase of rehabilitation. This
phase is an advanced form of proprioceptive
training for the muscles to relearn prior activities.
It is an important phase of rehabilitation and
should be supervised properly to minimize the
possibility of re injury. At the conclusion of formal
therapy sessions, patients should be independent
in a ROM and strengthening program and should
continue these exercises. Athletes are often
tempted to return to their overhead throwing
sport too soon after recovery of the acute phase.

36. ІІ-Subacromial injections of cortisone:
Although these injection do not cure the
underlying pathology, they decrease swelling of
the inflamed bursa and rotator cuff tissue and
allow for more room in the sudacromial space for
the rotator cuff to move.
Corticosteroids delivered directly to the
subacromial space via injection can be considered.

37. ІІІ -Surgical Intervention
Indications for operative treatment of rotator
cuff disease include partial-thickness or full-
thickness tears in an active individual who does
not improve pain and/or function within 3-6
months with a supervised rehabilitation program.
An acromioplasty is usually performed in the
presence of a type II (curved) or type III (hooked)
acromion with an associated rotator cuff tear.
In surgical candidates, early repair is useful to avoid
fatty degeneration and retraction of the remnant
rotator cuff musculature