2/2/05charlie cotterill differential diagnosis of shoulder impingement junior physiotherapist feb...

2/2/05 Charlie Cotterill

Differential Diagnosis of Differential Diagnosis of Shoulder ImpingementShoulder Impingement

Charlie Cotterill

Junior Physiotherapist

Feb 2006


AIMS

Anatomy/

Aetiology

Assessment

Treatment

Differential

Diagnosis


AnatomyAnatomy Subacromial joint. • Subacromial space 9-10mm

Force couple to counteract downward pull of deltoid Thompson et al (1996)

Jarjavay (1867) Neer (1972), anatomical

variations in build, strain and repetitive microtrauma.

Degeneration of the rotator cuff, oedema, bleeding, fibrosis and calcification → ruptures, osteophyte formation, and spur formation.


AetiologyAetiology

Primary/Secondary

Intrinsic/Extrinsic

Bigliani Classification (1991)


Aetiology Aetiology Aetiology of SIS is multifactoral (Lewis et al 2001).

• Mechanical/Anatomical• Primary mechanical impingement (Neer 1972, 1983)

• Acromial bone spurs (Neer 1972)

• Os acromiale (Neer 1972, 1983)

• Corocoacromial ligament (soslosky et al 1994)

• Postereosuperior glenoid impingement (Jobe 1997, Riand et al 1998)

• Rotator cuff• RC overuse (Jobe and Jobe 1983, Meister and Andrews 1993,

Frost et al 1999)

• Degenerative tendinopathy (Ozaki et al 1988)

• Instability/hypermobility• Secondary tensile disease (Meister and Andrews 1993)

• Secondary compressive impingement (Warner et al 1990)


Aetiology Aetiology

• Restrictive processes• Restricted glenhumeral capsule (Harryman et al 1990, Matsen

and Arntz 1990)

• Posture• Ayub 1991, Bowling et al 1986, Calliet 1991, Solem-Bertoft et al

1993)

• Functional scapular instability• Kibler 1991, 1998, 2002, 2003, Warner et al 1992, Lukasiewicz

1999, Ludewig and Cook 2000, Wandsworth, Bullock Saxton 1997)

• Lateral Kibler slide test


Scapula


Differential Diagnosis?Labrum tear Cervical/Thoracic spine RA Bursitis

Polymyalgia Rheumatica Rotator cuff tear #

Biceps tendon rupture/tendinopathy Calcific tendinitis

Adhesive capsulitis AC arthritis Glenohumeral arthritis

Septic arthritis Gout Lyme disease Long thoracic nerve injury

Visceral: PE, pleuritis, pericarditis, angina, MI, cholecystitis, pancreatitis, adnexitis.

Lupus erythematosus Spondylo-arthropathy AVN

Cervical radiculopathy Tumor/Malignancy Thoracic outlet Brachial plexus neuropathy Trigger points Post CVA

Glenohumeral instability Humeral subluxation


EvidenceEvidence Evidence suggests that the condition is not self-limiting.

Systematic review of manual and physical therapy treatment in SIS by Desmeules et al. revealed only 7 RCTs = Limited evidence to support the efficacy of physical therapy in SIS

Lack of uniformity in defining, evaluating, and treating SIS.

Supervised exercises appear to be preferable to arthroscopic surgery for patients with persistent shoulder impingement syndrome. Brox et al (1993)

A review of 8 RCTs evaluated the efficacy of corticosteroid injection in the rx of rotator cuff tendonitis (Koester et al). 2 of the 8 trials showed clinically relevant improvements in pain and range of motion in the injection groups as compared with placebo.

Two systematic reviews found ultrasound to be ineffective in the management of pain in the shoulder (Green and Heijden


Scapula Rehab

“Living within a window”


CONCLUSION

ASSESS

TREATEVALUATE


REFERENCESNeer CS. Impingement lesions. Clin Orthop Rel Res. 1983;173:70 –77.

Neer, C. S. II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J. Bone Joint Surg. 54A:41–50, 1972; 22.

Neer, C. S. II and R. P. Welsh. The shoulder in sports. Orthop. Clin. North Am. 8:583–591, 1977. Hawkins RJ, Brock RM, Abrams JS, Hobeika P. Acromioplasty for impingement with an intact Rotator cuff.

J Bone Joint Surg Br. 1988; 70:795–797.Michael C. Koester, MD, Michael S. George, MD, John E. Kuhn, MD Shoulder impingement syndromeThe

American Journal of Medicine (2005) 118, 452–455Brox JI et al Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease

(stage II impingement syndrome) BMJ 1993 Oct 9; 307:899-903. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD, Efficacy of injections of corticosteroids for

subacromial impingement syndrome. J Bone Joint Surg Am. 1996 Nov;78(11):1685-9. Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis. A double blind trial. Phys

Ther1986;66:194–9.Nykanen M. Pulsed ultrasound treatment of the shoulder. A randomised, double blind, placebo controlled

trial. Scand J Rehabil Med1995;27:105–8.Hasson S, Mundorf R, Barnes W, Williams J, Fujii M. Effect of pulsed ultrasound versus placebo on muscle

soreness perception and muscular performance. Scand J Rehabil Med1990;22:199–205. Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of

interventions for painful shoulder: selection criteria, outcome assessment and efficacy. Br Med J1998;316:354–60.


REFERENCESKibler, W. Ben MD a; Uhl, Tim L. PhD, ATC, PT b; Maddux, Jackson W. Q. MD c; Brooks, Paul V. MD a;

Zeller, Brian MS, ATC d; McMullen, John MS, ATC 2002. a Qualitative clinical evaluation of scapular dysfunction: A reliability study. Journal of Shoulder & Elbow Surgery. 11(6):550-556,

W. Ben Kibler, MD and John McMullen, ATC , 2003 Scapular Dyskinesis and Its Relation to Shoulder Pain, J Am Acad Orthop Surg, Vol 11, No 2,, 142-151.

Lewis. J, Green. A, Dekel. S, The Aetiology of subacromial impingement syndrome, Physiotherapy Sept 2001, vol 87, No 9, pg 453-468.

McKenna et al (2004) Inter-tester reliability of scapular pposition in junior elite swimmers, Physical therapy in sport 5, 146-155.

Van der Heijden GJMG, van der Windt DAWM, de Winter AF. Physiotherapy for patients with shoulder disorders: a systematic review of randomised controlled clinical trials. Br Med J1997;315:25–30.

C. A. Speed, Rheumatology 2001; 40: 1331-1336, Therapeutic ultrasound in soft tissue lesions P Frost and JH Andersen, shoulder impingement syndrome in relation to Shoulder intensive workOccup.

Environ. Med. 1999;56;494-498

2/2/05charlie cotterill differential diagnosis of shoulder impingement junior physiotherapist feb...

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