impingement syndrome rehabilitation

SHOULDER IMPINGEMENT SYNDROMEIli Diyana Binti Nor Azni

ANATOMY OF THE SHOULDER

SHOULDER IMPINGEMENT SYNDROME

Definition : Occurs when the rotator cuff tendons, long head of the biceps tendon, glenohumeral joint capsule, and/or subacromial bursa become impinged between the humeral head and anterior acromion.

MECHANISM OF INJURY

Shoulder instability- rotator cuff weakness A radiographic study of normal subjects has

shown that the humeral head migrates proximally when the cuff is fatigued (Chop et al 2010)

Bony anatomical pathological factors

Type 3 hooked shaped acromion

Capsular Tightness A correlation has been shown between

impingement and posterior capsular tightness (Tyler et al, 2000)

Impaired scapulohumeral rhythm and scapular instability Scapula motion is impaired with people with

shoulder impingement. This is linked to decreased serratus anterior activity and scapular instability (Ludewig and Cook, 2000)

Capsulo-ligamentous laxity Consequent minor subluxation of glenohumeral

joint, underlie impingement in the younger population.

Postural Factors The potential link between posture and

impingement may be illustrated by elevation of the arm in a coronal plane while slouching. It causes a painful arc, presumably by depressing the point of the acromion and lowering the acromial arch.( Lin et al., 2010)

CLINICAL PRESENTATION Pain

Pain is typically localised to the anterolateral acromion and frequently radiates to the lateral mid-humerus

Patients usually complain of pain at night, exacerbated by lying on the involved shoulder, or sleeping with the arm overhead.

Normal daily activities such as combing hair or reaching up into a cupboard become painful, and a general loss of strength may be noted.

Painful arch syndromeQuality of pain (eg, sharp, dull, radiation, throbbing,

burning, constant)

Painful clicking sound Apprehension of dislocation on overhead

movement Feeling of heaviness of hand.

DR MX.1.Conservative Rest and avoid overhead

activities Anti-inflammatory drugs

http://www.shouldersurgeon.com/shoulder_impingement/

2. Surgical

- A small incision is made- Shave off a tiny portion of the acromion process- Allowing a pain free movement in the shoulder joint

PT MANAGEMENT

Modalities Manual therapy Stretching Mobilizing exercise Strethening exercise

STRETCHES

Codman’s Pendulum Swings

Triceps Stretch

Horizontal Adduction Stretch

Internal Rotation Stretch

http://www.athleticadvisor.com/images/Acrobat/Impingement.pdf

STRETCHES CONT..

External Rotation

Standing Adduction Stretch


Chest and Biceps Stretch

EXERCISES TO STRENGTHEN SITS MUSCLES

Bent over rows


Seated Dips

Active Flexion

CASE STUDY-

Demographic Data Name : Mr. H. Age : 67 Gender : Male Race : Malay Doctor’s Diagnosis : Sh. Pain secondary to old

injury Date of PT assessment : 25/3/2014

Pt.’s Problems c/o inability to fully lift up his Lt sh. and on

overhead movement Claim had difficulty removing shirt and inability

lift heavy (>5kg objects)

Pain Assessment

Area : ant. aspect of Lt. sh.

Nature : throbbing, catching pain

Agg. : Lift hand >90deg, remove off shirt, carry heavy

objects >5kg, do exercise (VAS : 5/10)

Ease : Rest, hand in normal position (VAS : 0/10)

24 hrs: Depend on activity, more pain at night if

sleep on Lt. sd. but not disturbing sleep

Irritability : non-irritable (pain will subside

immediately after agg. factor removed )

Severity : not severe

AREA OF PAIN

Special QuestionGeneral health : GoodOther health condition : HPT and DM since past 2 yrsMedication : HPT and DM medicationX-ray : NilDominant hand : Lt. hand

Current Hx.Pt referred to physio HKK after receiving physio

treatment at KK Cheras for 3/52 Past Hx. : Pt had Lt sh. pain since past 6/12 after

knitting fruit. The pain gradually increase and

pt referred dr. on Jan 2014 as the pain

became unbearable. Pt then referred to do

physio at KK Cheras

Past Hx. : Pt had h/o Lt ant sh. dislocation 10 yrs ago

Social Hx. : Occ: Retired estate manager

Dominant hand : Lt hand

OBJECTIVE ASSESSMENT

ObservationGeneral :

Pt medium sized Malay man came into dept. with normal gait.

Posture : - Slightly kyphotic - ears slightly anterior than shoulder

- Lt. Sh. and scapula lower than Rt.

- No winging of scapula - Pelvic same level - Kn. same level

Local :No swelling at shoulder regionNo redness at shoulder region

Palpation Muscle spasm noted on Lt upper trapezius Pain on palpation over biceps long head,

supraspinatus and subscapularis tendon.

ROM

Joint Motion Left Right

Active Passive Active Passive

Sh. Flex. 0-100° 0-110°

FROM

Ext FROM FROM

Abd 0-90° 0-95°

Int. Rot. 0-15° 0-15°

Ext. Rot. 0-45° 0-45°

Elb. Flex. FROM FROM

Ext. FROM FROM

UL Muscle strength 30 secs biceps curl

Reading Lt Rt

1st 23 25

2nd 22 24

3rd 21 24

Average 22 24

CLEARING TEST

Scapula physiological movement –

Neck - AFROM

movement

Lt. Rt


Elevation normal normal normal normal

Depression

normal normal normal normal

Protraction


Retraction


SPECIAL TEST

Neer’s test: +ve indicate impingement Hawkin Kennedy : +ve indicate impingement Speed test : +ve indicate bicipital tendinitis Empty can test: +ve indicate supraspinatus

tendinitis Anterior drawer test : -ve Posterior drawer test : -ve

FUNCTIONAL ACTIVITY

DASH Diasability Symptom scoreScore: 42.5% - moderate disability

ANALYSIS

Impairment Pain at Lt anterior and lateral sd. of Lt. sh d/t

subacromial inflammation Reduced ROM of Lt. glenohumeral jt. d/t pain Recduced Lt Sh. Muscle power d/t reduced mobility Muscle spasm of upper trapezius d/t protective

mechanism of muscle

Functional limitation Difficulty to remove off shirt Difficulty on reaching high objects (overhead

movement) Unable to carry heavy objects (>5kg)

Participation rx Restricted sports and recreational activity with

friends and family members

SHORT TERM GOAL

To reduce pain in 1/7 To improve ROM in 1/52 To increase muscle power in 2/52 To reduce upper trap muscle spasm in 1/7

LONG TERM GOAL

To maximize functional activity of daily living To prevent secondary complication

PLAN OF TX

Pain mx. Mobilizing exe Strengthening exe Stretching MFR HEP Pt. edu

INTERVENTION U/S at biceps long head, supraspinatus , and subscapularis tendon; 1MHz, 0.8 W/cm X 5min

MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;

rep 10 X every movt. Std.; put hands on hips, lean back, hold 15 sec.;

rep 5X Std.; pull sh. Up and back; hold 15s; rep 5X Sitt.;horizontal add. Lt sh.;hold and push Lt

elbow backward using Rt. Arm; hold 5s; rep 5X Sitt.; ext rot sh. With 1kg dumbell ;rep 10X Sitt.; int rot sh. With 1kg dumbell ;rep 10X Hot pack at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day

Evaluation : Pt able to do exercise with minimal pain.

Review : To reasess ROM and painscale on next visit

2ND VISIT ON 26TH MAR 2014 Subjective Ax: Pt. claim VAS still same Objective Ax:








Sh. Flex. 0-100° 0-110°

FROM

Ext FROM FROM

Abd 0-90° 0-95°

Int. Rot. 0-15° 0-15°

Ext. Rot. 0-45° 0-45°


Ext. FROM FROM

Analysis : no significant improvement Plan :

Pain mx. Mobilizing exe Stretching Strengthening exe MFR HEP Pt. edu

INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ;

10X; 6 cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.;

abd.;add.; rep 10 X every movt. Sitt.;horizontal add. Lt sh.;hold and push Lt elbow

backward using Rt. Arm; hold 5s; rep 5X Std.;place hand at sh. Level on room corner; lean fwd;

hold 15 s; rep 5X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X Hot pack at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day

3RD VISIT ON 31ST MAR 2014

Subjective Ax: Pt. claim VAS still same Objective Ax:

Observation General :







Sh. Flex. 0-120° 0-125°

FROM

Ext FROM FROM

Abd 0-90° 0-95°

Int. Rot. 0-15° 0-15°

Ext. Rot. 0-45° 0-45°


Ext. FROM FROM

Analysis :Sh. flex ROM improved by 10 ° Plan :

Pain mx. Mobilizing exe Stretching Strengthening exe MFR HEP Pt. edu

INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ; 10X; 6

cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;

rep 10 X every movt. Sitt.;neck stretching; hold 5s; rep 5X Std.;place hand at sh. Level on wall; wall push up; hold 10 s;

rep 10X Std.; bend elbows at sh. Level using elastic cord; hold 10s; rep

10 X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X SWD at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day

4TH VISIT ON 3 APR 2014 Subjective Ax: Pt. claim VAS still same Objective Ax:




PalpationMuscle spasm noted on Lt upper trapeziusPain on palpation over biceps long head,




Sh. Flex. 0-140° 0-145°

FROM

Ext FROM FROM

Abd 0-90° 0-95°

Int. Rot. 0-15° 0-15°

Ext. Rot. 0-45° 0-45°


Ext. FROM FROM

Analysis : no significant improvement Plan :

Pain mx.Mobilizing exeStretchingStrengthening exeMFRHEPPt. edu

INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ;

10X; 6 cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.;

abd.;add.; rep 10 X every movt. Sitt.;horizontal add. Lt sh.;hold and push Lt elbow

backward using Rt. Arm; hold 5s; rep 5X Std.;place hand at sh. Level on room corner; lean fwd;

hold 15 s; rep 5X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X Hot pack at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day

5TH VISIT ON 7TH APR 2014

Subjective Ax: Pt. claim VAS still same Objective Ax:

Observation General :



Palpation No spasm noted on Lt upper trapezius Pain on palpation over biceps long head tendon.



Sh. Flex. 0-150° 0-155°

FROM

Ext FROM FROM

Abd 0-100° 0-105°

Int. Rot. 0-20° 0-20°

Ext. Rot. 0-45° 0-45°


Ext. FROM FROM

Analysis : Increased Sh. ROM and reduced VAS to 4/10 on agg condition.

Plan : Pain mx. Mobilizing exe Stretching Strengthening exe HEP Pt. edu

INTERVENTION Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ; 10X; 6

cycle MFR at upper trap muscle X 10 min Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;

rep 10 X every movt. Sitt.;neck stretching; hold 5s; rep 5X Std.;place hand at sh. Level on wall; wall push up; hold 10 s;

rep 10X Std.; keep elb. Straight and pull elastic band posteriorly; hold

10s; rep 10X Sitt.; ext rot sh. Using theraband;rep 10X Sitt.; int rot sh. Using theraband;rep 10X SWD at Lt Sh.; X 20min Educate pt. to do exe as taught at home 3X/ day

CONCLUSION

Manual technique and exercise is beneficial in order to reducing pain and improving function on patient with shoulder impingement syndrome

Review on articles found that ultrasound is either not give a significant benefit or giving no benefit at all for impingement cases.

Grade 1 oscillatory joint mobilization technique can be used in order to relieve pain in impingement syndrome only but not necessary to improve mobility and function when combined with modalities, stretching strengthening exercise and patient education.

REFERENCES Atalar, Hakan, Yilmaz, Cengiz, Polat, Onur, Selek, Hakan, Uras, Ismail, & Yanik, Burcu. (2009).

Restricted scapular mobility during arm abduction: implications for impingement syndrome. Acta Orthopaedica Belgica, 75(1), 19.

Boileau, Pascal, Moineau, Grégory, Roussanne, Yannick, & O’Shea, Kieran. (2011). Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clinical Orthopaedics and Related Research®, 469(9), 2558-2567.

Faber, Elske, Kuiper, Judith I, Burdorf, Alex, Miedema, Harald S, & Verhaar, Jan AN. (2006). Treatment of impingement syndrome: a systematic review of the effects on functional limitations and return to work. Journal of occupational rehabilitation, 16(1), 6-24.

Hughes, PC, Green, Rodney A, & Taylor, Nicholas F. (2012). Measurement of subacromial impingement of the rotator cuff. Journal of Science and Medicine in Sport, 15(1), 2-7.

Jia, Xiaofeng, Ji, Jong Hun, Pannirselvam, Vinodhkumar, Petersen, Steve A, & McFarland, Edward G. (2011). Does a positive neer impingement sign reflect rotator cuff contact with the acromion? Clinical Orthopaedics and Related Research®, 469(3), 813-818.

Kelly, Susan M, Wrightson, Patricia A, & Meads, Catherine A. (2010). Clinical outcomes of exercise in the management of subacromial impingement syndrome: a systematic review. Clinical rehabilitation, 24(2), 99-109.

Michener, Lori A, Walsworth, Matthew K, & Burnet, Evie N. (2004). Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. Journal of Hand Therapy, 17(2), 152-164.

Patel, Bhavesh, Bamrotia, Praful, Kharod, Vishal, & Trambadia, Jagruti. (2013). Effects of Scapular Stabilization Exercises and Taping in Improving Shoulder Pain & Disability Index in Patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis. Indian Journal of Physiotherapy & Occupational Therapy-An International Journal, 7(1), 191-195.

Senbursa, Gamze, Baltacı, Gul, & Atay, Ahmet. (2007). Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee surgery, sports traumatology, arthroscopy, 15(7), 915-921.

impingement syndrome rehabilitation

Health & Medicine

normal gait

pain agg

area of pain

pain secondary

irritable pain

shoulder joint

pain free movement

pain assessment area