Subacromial impingement syndrome (SIS, shoulder

impingement)

Introduction :

 Compression of structures around the glenohumeral joint that

occurs with shoulder elevation ⭢ pain and dysfunction

 30-35 % of shoulder disorders

Risk factors :

 Repetitive activity at or above the shoulder during work or

sports

 Instability of the glenohumeral joint

 Scapular instability and dyskinesis

 particular acromion anatomy

 Age

Clinical anatomy :

 Compression occurs in acromion , acromioclavicular joint

(osteoarthritic),

and the coracoacromial arch

 Compression of structures within the shoulder

-Rotator cuff muscles

-Subacromial bursa

-Labrum

-Biceps tendon (long head)

Pathophysiology :

 Charles Neer in 1972

- Stage 1: Edema and hemorrhage (<25 years)

(圖一)
- Stage 2: Fibrosis and tendinopathy (圖一) (25 to 40
years)

- Stage 3: Rotator cuff tear, biceps tendon rupture, bony

 change(>40 years)

 Anatomic and mechanistic factors

(圖二)
- Increased translation of the humeral
head

- Acromion morphology that predisposes to impingement

(圖二)

- Decreased distance between undersurface of acromion

and humeral head

- Osteophytic change of the acromioclavicular joint (圖三)

(圖三)
Clinical presentation :

 Patients complain of pain with overhead activity

 Pain may localize to the deltoid area or lateral arm and often
occurs at night or when lying on the affected shoulder

Physical examination :

 No single examination maneuver is diagnostic for SIS

 Neer test and Hawkins-Kennedy internal rotation maneuvers

are
sensitive for
SIS

Hawkins-Kennedy test
Neer test

 Complete neck examination

 Inspection for atrophy or disfigurement

 Glenohumeral range of motion (painful arc testing and a

comparison of passive versus active motion)
  Rotator cuff strength testing (drop arm test and external
rotation strength testing)

 Specialty testing (painful arc, empty can, external rotation

resistance, and lift-off tests

 Three or more positive tests improve the diagnostic

likelihood

Patients with SIS can manifest the following findings :

 Neck exam within normal limits

 Tenderness present in the subacromial space or posterior

shoulder

 Glenohumeral range of motion limited by pain (eg, positive

painful arc test)

 Reproduction of pain with specialty testing (eg, Neer, Hawkins-

Kennedy)

 Atrophy of posterior shoulder musculature if impingement is

chronic

 Shoulder strength normal, except in some cases of long-

standing impingement

Differential diagnosis :

 Distinguish SIS from rotator cuff tear and adhesive capsulitis

Rotator cuff tear :

- Weakness and pain (supraspinatus)

- Positive drop arm test and weakness with resisted external

rotation

- Over 40 years of age and may be a complication of long-

standing subacromial impingement

Adhesive capsulitis (frozen shoulder) :

- Pain and dysfunction while performing activities of daily

living

- Restricted active and passive glenohumeral motion

 - Often give a history of recent shoulder injury or surgery and
may be diabetic

Biceps tendinopathy :

-Anterior shoulder pain in the region of the bicipital groove

-Focal tenderness of the tendon within the bicipital groove and

a positive Speeds test

Subcoracoid impingement :

-Complain of anterior shoulder pain

-Occurs with forward flexion, adduction, and internal rotation

of the shoulder

-Passively moving the shoulder flexion and internal rotation ⭢

pain

-Coracoid process “may be” tenderness

Shoulder labrum injury :

-Complain of "clicking" in the shoulder

-Superior labrum anterior-posterior tears (SLAP lesions)

-Chronic pain with overhead activity

-Weakness, instability, and sport-specific dysfunction

-Specific examination maneuvers (eg, anterior glide test,

compression rotation test)

Rehabilitation program :

1. Improve scapular stability :

 Low resistance , high repetitions : endurance ⭡ ,

improvements pain and function

 一組 25 次，組間休息 30 秒，重複 2 組

 數到二向後拉，數到四回到起始位置
-Row :

Shoulder
extension : elbow keeps extension

- Scapular
downward rotation and depression :

- Horizontal shoulder abduction :

 進行兩到三組、每
組 50 次重複而不增加疼痛時，可增加運動阻力
  需要兩到三週的時間才能完成全部重複次數並進入更困難的運動

2. Strengthen the rotator cuff :

 Supraspinatus : thumbs pointed upwards , avoid

elevating the arm too much in these exercises

-Isometric abduction :

 一組 15 次，一次停留 5 秒，組間休息 30 秒，

重複 3 組

 訓練至無痛再進行下一個動作

-Active abduction :

 一組 15 次，組間休息 30 秒，重複 3 組

 數到二上抬，數到四回到起始位置

 Shoulder elevation

-Active shoulder abduction against

resistance :

 Elbow keeps extension

 一組 15 次，組間休息 30 秒，重複 3 組

 數到二上抬，數到四回到起始位置

 External rotators :

-Isometric external rotators :

 一組 15 次，一次停留 5 秒，組間休息 30 秒，

重複 3 組

 訓練至無痛再進行下一個動作
-Active external rotation :

 一組 15 次，組間休息 30 秒，重複 3 組

-Active external rotation on sidelying :

 一組 15 次，組間休息 30 秒，重複 3 組

-External rotation against

resistance

 Elbow flexion , 手臂貼緊身體

 一組 15 次，組間休息 30 秒，重複 3 組

 數到二手朝前，數到四回到起始位置

 Internal rotators :

-Active internal rotation :

 一組 15 次，組間休息 30 秒，重複 3 組