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.
Rotator cuff tendinitis
: It encompasses
impingement, and result from acute rotator cuff
overload, intrinsic rotator cuff degeneration, or
chronic overuse.

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.

6. 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. B-
Soft tissue factors
Examples
include
•
Subacromial bursitis
•
Thickened coracoacromial ligament.
2.
a.
b.
Intrinsic causes
Degenerative cuff failure :
Traumatic cuff failure:

9. 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

10. 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.

12. 2. SPECIAL TESTS:
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.

14. 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.

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

17. Management:
There are three ways of approaching
impingement syndrome:
І-Physical therapy rehabilitation,
ІІ-subacromial injections of cortisone,
and
ІІІ-surgical intervention.
Acute phase
І -Physical therapy rehabilitation in :
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.

18. 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 carryover should be monitored


19. 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.

20. 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
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.

21. 2-Normalization of strength and
dynamic muscle control
Perform strengthening in a painfree 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.

22. 
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.

31. 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.

32. 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

33. 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.

34. 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 36 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