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 Haemorrhage

Usually reversible conservatively.

In Rotator Cuff

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)

Supraspinatus

Posterior Lateral

Common Culprit

Coracoacromial ligt

Sub Acromial Bursa

Sub-acromial bursa

Anterior Posterior

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 Sporting

Overhead Activities

‘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

Exs and mobilisations are effective @ reducing pain & functional loss

(Dickens, Williams & Bhamra 2005)

(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.

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

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!!