Subacrominal
Impingement
Andy Foster
Junior
Physiotherapist
NHS North Staffs
Aims
The aims of this presentation are to:
Review basic shoulder anatomy
Define shoulder impingement
Look @ the causes and mechanism
How to diagnose shoulder impingement
Management
Research
Shoulder Anatomy
Definition
Impingement is the trapping of soft
tissue leading to painful inflammation
(Peterson & Renstrom 1986)
Classification of the Impingement
Syndrome
Neer devised a classification
3 stages
Stage 1
< 25 years
Acute inflammation
Oedema In Rotator Cuff
Haemorrhage
Usually reversible conservatively.
Stage 2
25-40 year olds
Continuum of stage 1
Fibrosis and tendonitis of rotator cuff
Mechanical disruption of the rotator cuff
tendon with progression
Changes in the coracoacromial arch with
osteophytosis along the anterior acromion.
Requires operative intervention
Can be unresponsive to conservative Rx.
Stage 3
> 40 years
Frequently involves tendon rupture/tear
Some muscle attrition
Rotator cuff repair
Requires surgical
Anterior acromioplasty
Aetiology
Posture (Bullock et al 2005)
Trauma
Degeneration - Acromion Roughning
- Coracoacromial Ligt
- RSI (Soslowsky et al 2000)
- Adhesive capsulitis
Muscles Imbalance
Glenohumeral Instability
Rotator Cuff Pathology
Inflammation of Tendon = Spread to Bursitis
(Peterson & Renstrom 1986)
Common Culprit
Supraspinatus
Posterior Lateral
Coracoacromial
ligt
Sub Acromial Bursa
Sub-acromial
bursa
Posterior
Anterior
Subacromial Bursitis
Types of Acromion
Lewis, Green &
Dekel 2001
Mechanism of Injury
To Summarise
Small space between ligt and acromion
Tendons of Supraspin, infraspin, teres
minor, subscap, long head biceps
Bursa overlies supraspin tendon
Flexion 90 then MR reduces space
Repeated movement = irritation
Picture 1
Picture 2
Picture 3
Symptoms
Pain during abdn 80-120 (worst @ 90)
Occupational
ADL’s Overhead Activities
Sporting
‘Impingement sign’
Flexn and MR aggravate pain
Tenderness
Night pain & pain @ rest
Special Tests for
Neer Impingement Test (Neer 1983)
Sensitivity = 88.7%
Reliability = 98%
Hawkins Kennedy
Sensitivity = 92.1%
Accuracy = 72.8%
Resisted empty can sign
Accuracy = 70%
Abduction – Painful arc
Investigations
Radiography (angle)
MRI – 92% sensitive
- 100% specific
- 94% accuracy
(Horwitz & Fenlin 1989)
Arthroscopy
Aims of Rx
Decrease subacromial inflammation
Allow healing
Strengthen dysfunctional rotator cuff
Restore pain-free shoulder function
(Dickens, Williams & Bhamra 2005; Nitz 1986)
Conservative Treatment
Medication
Ultrasound (van der Heijden at al 1999)
Activity Modification
Joint Mobilization (Conroy & Hayes
1998)
Aspiration of Bursa
Steroid Injections (Winters et al 1997)
Conservative Treatment
Deep Friction Massage (Cyriax 1993)
Re-education of the Rotator Cuff (Thein
& Greenfield 1997)
Taping (Host 1995)
Exercises:
Scapular Stabilizing Muscles (Schmitt &
Snyder-Mackler 1999)
Active Assisted
Surgery
Subacromial decompression
Arthroscopic is comparable to open
acromioplasty (Nicholson 2003)
Successful with high rate of return to work
(Misamore, Ziegler & Rushton 1995)
Coraco-acromial ligt resection / removal
Removal of a bursa
Surgery
It involves
cutting the
ligament and
shaving away
the bone spur
on the
acromion
bone.
Differential Diagnosis
Many conditions can mimic impingement.
Calcific Tendinitis
Acromioclavicular Arthritis
Subluxing / Dislocating Shoulder
Adhesive Capsulitis
Research 1
Acupuncture vs U/S (continuous)
85 participants with impingement syndrome -
2 groups
Both groups received home exs
Rx x2 weekly for 5/52
3 shoulder disability scores used
Measured over 12/12
Acupuncture > U/S
Effects of Acupuncture Versus Ultrasound in Patients With Impingement
Syndrome: Randomized Clinical Trial
Research 2
1 surgeon performed arthroscopic
acromioplasty
106 pts (mean age 44.7)
Two groups (Workers / non workers)
Mean follow up 32/12
No sig diff in post-op outcome scores
Return to full function in months:
Workers (13.7) Non Workers (9.1)
Arthroscopic Acromioplasty: A Comparison Between Workers’ Compensation
and Non-Workers’ Compensation Populations
Research 3
43 physio 41 arthroscopic
19 sessions in 12/52 physio (upto
60mins)
Bursectomy and partial resection of
anteroinferior acromion and
coracoacromial ligt
Both methods have similar effects
Arthroscopic Decompression and Physiotherapy Have Similar Effectiveness
for Subacromial Impingement
Research 4
172 pts
Divided into 2 groups:- Shoulder girdle
group (n = 58) / Synovial group (n =
114)
Manipulation and Physiotherapy
Synovial group duration of complaints
was shortest after corticosteroid
injection
Comparison of physiotherapy, manipulation, and corticosteroid injection for treating
shoulder complaints in general practice: randomised, single blind study
Conclusion
Physiotherapy should be considered the
first line of Rx for Sh impingement
(Dickens, Williams & Bhamra 2005)
Exs and mobilisations are effective @
reducing pain & functional loss
(Sauers 2005)
References
van der Heijden GJ, Leffers P, Wolters PJ, Verheijden JJ, van
Mameren H, Houben JP, et al. No effect of bipolar interferential
electrotherapy and pulsed ultrasound for soft tissue shoulder
disorders: a randomised controlled trial. Ann Rheum Dis
1999;58:530–40.
Nitz AJ. Physical therapy management of the shoulder. Phys Ther
1986;66:1912–9.
Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom de
Jong B. Comparison of physiotherapy, manipulation, and
corticosteroid injection for treating shoulder complaints in general
practice: randomised, single blind study. BMJ 1997;314:1320–5.
Neer CS. Impingement lesions. Clin Orthop 1983;173:70–7.
Neer CS. Anterior acromioplasty for the chronic impingement of
the shoulder. Journal ofBone and Joint Surgery 1972;54A:41.
References
Schmitt L, Snyder-Mackler L. Role of the scapular stabilizers in
etiology and treatment of impingement syndrome. Journal of
Orthopaedic and Sports Physical Therapy 1999;29(1):31–8.
Thein LA, Greenfield BH. Impingement syndrome and impingement
related instability. In: Donatelli R editor. Physical therapy of the
shoulder 3rd ed. New York: Churchill; 1997. p. 229 (Chapter 9).
Cyriax J. Cyriax’s illustrated manual oforthopaedic medicine, 2nd
ed.Oxford: Butterworth Heinemann; 1993. p. 33 (Chapter 3).
Conray DE, Hayes KW. The effect of joint mobilisation as a
component of comprehensive treatment for primary shoulder
impingement. Journal of Orthopaedic and Sports Physical Therapy
1998;28(1):3–11.
Host HH. Scapula taping in the treatment of anterior shoulder
impingement. Physical Therapy 1995;75:803–12.
References
Nicholson GP 2003 Arthroscopic Acromioplasty: A Comparison
Between Workers’ Compensation and Non-Workers’ Compensation
Populations. The Journal of Bone and Joint Surgery 85(4) 682-689
Misamore GW, Ziegler DW, Rushton JL 2nd. Repair of the rotator
cuff. A comparison of results in two populations of patients. J
Bone Joint Surg Am. 1995;77:1335-9.
Haahr JP, Ostergaard S, Dalsgaard J, Norup K, Frost P, Lausen S,
et al. Exercise versus arthroscopic decompression in patients with
subacromial impingement: a randomised, controlled study in 90
cases with a one year follow up. Ann Rheum Dis 2005;64: 760-4.
Horwitz BR, Fenlin JM, Bartolozzi AR 1989 Correlation of MRI and
arthography with surgical findings in rotator cuff disease, abstract
study, Department of Orthopaedic Surgery, Department of
Radiology, Thomas Jefferson University, Philadelphia.
References
Sauers EL 2005 Effectiveness of Rehabilitation for Patients with
Subacromial Impingement Syndrome Journal of Athletic Training
40(3):221–223
Dickens VA, Williams JL, Bhamra MS 2005 Role of physiotherapy
in the treatment of subacromial impingement syndrome: a
prospective study. Physiotherapy 91, 159–164
Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom de
Jong B 1997 Comparison of physiotherapy, manipulation, and
corticosteroid injection for treating shoulder complaints in
general practice: randomised, single blind study. BMJ
314:1320–5.
Thanks for Listening!!
