External (Bursal Sided) Impingement Normal Anatomy  

The supraspinatus outlet is a space formed by acromion, coracioacriomial arch, humeral head and glenoid This is a relatively small space for a lot of soft tissue including the rotator cuff tendons

Pathology    

External impingement is the pinching of the rotator cuff tendons between the humeral head and the acromion or Coracoacromial ligament Often referred to ‘Bursal Sided’ Impingement Internal (Articular) Impingement is a different pathology and covered in a separate handout External impingement is normal and only pathological due to one of the following 1. Overuse 2. Trauma 3. Anatomy 4. Alignment 5. Soft Tissue Imbalances

Impingement Stages 

External impingement was categorised into 3 stages

Stage 1  < 25 years old  Acute inflammation and oedema of the rotator cuff  Reversible with conservative management Stage 2  25 – 40 years old  Tendinitis or fibrosis thickening of the rotator cuff  Usually reversible with conservative management  Sometimes requires injection or surgery management Stage 3  40+ year old  Mechanical disruption of rotator cuff tendons  Osteophyte formation under acromion  Thickening of coracoacromial arch  More likely to require surgery

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Primary and Secondary Impingement 

The underlying cause of impingement can be divided into primary or secondary factors

Primary Impingement  Result of direct compression of rotator cuff tendons between humeral head and superior structures  Due to the following 1. Anatomical variation of acromion 2. Acromioclavicular arthrosis 3. Coracoacromial ligament hypertrophy 4. Subacromial bursal thickening or fibrosis 5. Trauma 6. Repeated overhead activity Secondary Impingement  Secondary due to another problem that alters humeral head migration 1. Rotator cuff weakness 2. Neurological paralysis 3. Glenohumeral instability 4. Scapular Dyskinesia 5. Posterior Capsule Tightness

Subacromial Impingement and Coracoacromial Impingement  

The superior structure that the rotator cuff tendons are pinched against should be differentiated as it will affect management Coracoacromial impingement is more symptomatic into horizontal adduction, Subacromial impingement is more symptomatic into flexion

Examination Subjective      

History of instability History of impingement Sports or jobs with repeated overhead activity Usually insidious onset of pain although can be traumatic Pain anteriorly, superior and laterally in shoulder Pain in positions of flexion and internal rotation (Subacromial) or horizontal adduction (Coracoacromial)

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Objective        

Restricted and painful flexion, internal rotation OR horizontal adduction Painful arc through abduction Pain on resisted external rotation Weakness on external rotation Reduced thoracic extension Scapular dyskinesis (medial border winging, inferior angle winging, reduced scapular upward rotation most common) Tenderness palpation Subacromial, Coracoacromial space Tenderness palpation supraspinatus tendon

Special Tests     

Hawkins Kennedy Neer’s Empty Can Lateral Rotation Painful Arc

Further Investigation   

Diagnostic Injection MRI Arthroscopic surgery

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Management Conservative  

Usually successful Based on assessment findings 1. Restore Normal Mobility  Decrease inflammation if present with massage, ice, NSAID’s, rest from aggravating activities  Decrease tone of muscle spasm with soft tissue techniques (dry needling, MET, DSTM, Friction, MTrP release)  Pec Minor  Levator Scapulae  Rhomboids  Upper Trapezius  Subscapularis  Deltoid  Increase mobility of joint capsule with joint mobilisations to restrict superior migration of the humeral head  Inferior capsule  Posterior capsule 2. Restore Normal Motor Control and Strength  Posterior Rotator Cuff  Serratus Anterior  Lower Trapezius 3. Restore Dynamic Stability  Exercises that challenge the stability of the glenohumeral joint and humeral head migration in closed and open chain 4. Return to sport/activity specific exercises

Plan B Injection 

Corticosteroid injection of the area will be completed up to 3 times

Surgery 

If there is an anatomical cause for impingement a Subacromial Decompression is usually provided

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References (Bang & Deyle, 2000; Boyles et al., 2009; Bullock et al., 2005; Chang, 2004; Cools et al., 2013; Cools et al., 2003; Dickens et al., 2005; Ellenbecker & Cools, 2010; Ho et al., 2009; Hung et al., 2010; Kibler et al., 2013; Lewis et al., 2001; Ludewig & Braman, 2011; Ludewig & Cook, 2000; Ludewig & Reynolds, 2009; Muraki et al., 2010; Neer, 1983; Reinold et al., 2009; Roy et al., 2009; Schellingerhout et al., 2008; Seitz et al., 2011; Senbursa et al., 2007; Teys et al., 2008; Tyler et al., 2000; Wassinger et al., 2012) Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000; 30(3): 126-37. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther 2009; 14(4): 375-80. Bullock MP, Foster NE, Wright CC. Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Man Ther 2005; 10(1): 28-37. Chang WK. Shoulder impingement syndrome. Phys Med Rehabil Clin N Am 2004; 15(2): 493-510. Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med 2013. Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. Am J Sports Med 2003; 31(4): 542-9. Dickens VA, Williams JL, Bhamra MS. Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study. Physiotherapy 2005; 91(3): 159-64. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidencebased review. Br J Sports Med 2010; 44(5): 319-27. Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: a systematic review. Man Ther 2009; 14(5): 463-74. Hung CJ, Jan MH, Lin YF, Wang TQ, Lin JJ. Scapular kinematics and impairment features for classifying patients with subacromial impingement syndrome. Man Ther 2010; 15(6): 547-51. Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'scapular summit'. Br J Sports Med 2013; 47(14): 877-85. Lewis JS, Green AS, Dekel S. The Aetiology of Subacromial Impingement Syndrome. Physiotherapy 2001; 87(9): 45869. Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther 2011; 16(1): 33-9. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000; 80(3): 276-91. Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther 2009; 39(2): 90-104. Muraki T, Yamamoto N, Zhao KD, et al. Effect of posteroinferior capsule tightness on contact pressure and area beneath the coracoacromial arch during pitching motion. Am J Sports Med 2010; 38(3): 600-7. Neer CS, 2nd. Impingement lesions. Clin Orthop Relat Res 1983; (173): 70-7. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther 2009; 39(2): 105-17. Roy JS, Moffet H, Hebert LJ, Lirette R. Effect of motor control and strengthening exercises on shoulder function in persons with impingement syndrome: a single-subject study design. Man Ther 2009; 14(2): 180-8.

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Schellingerhout JM, Verhagen AP, Thomas S, Koes BW. Lack of uniformity in diagnostic labeling of shoulder pain: time for a different approach. Man Ther 2008; 13(6): 478-83. Seitz AL, McClure PW, Finucane S, Boardman ND, 3rd, Michener LA. Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clin Biomech (Bristol, Avon) 2011; 26(1): 1-12. Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2007; 15(7): 915-21. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Ther 2008; 13(1): 37-42. Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000; 28(5): 668-73. Wassinger CA, Sole G, Osborne H. The role of experimentally-induced subacromial pain on shoulder strength and throwing accuracy. Man Ther 2012; 17(5): 411-5.

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