Shoulder Impingement Algorithm Ann Bonsignore Brianna Cowley Angie Moody Laura Sweeney Brittany Youngers

Anatomy http://www.drnickcampos.com/health-newsletter/Shoulder%20Impingement%20Syndrome.htm

Anatomy http://www.orthogate.org/patient-education/shoulder/impingement-syndrome.html

Biomechanics The shoulder complex is designed for mobility The Rotator Cuff (RTC) muscles snub the humeral head into the shallow glenoid fossa during arm elevation Glenohumeral ligaments and capsule provide stability and limit excessive motion Congenital or degenerative changes can cause the acromion process to become curved or hooked

Anatomy http://ptindia.tripod.com/oct/article2.htm

Biomechanics Scapulohumeral rhythm results from movement at four joints Glenohumeral Scapulothoracic Acromioclavicular Sternoclavicular Correct scapulohumeral rhythm is a 2:1 ratio of glenohumeral to scapulthoracic motion during arm abduction Preserves the length tension relationship of the muscles of the glenohumeral joint (GHJ) Prevents impingement between the humerus and acromion

Impingement Types Internal Abnormal contact between the undersurface of the RTC and the posterior superior glenoid External Primary Decreased subacromial space causing compression of bursae or RTC tendons External Secondary Compression of the bursae or RTC tendons 2° to humeral head migration from instability or RTC weakness

Mechanism of Injury Internal Insidious onset due to weak scapular external rotators and scapular weakness Hyperlax glenohumeral ligaments anteriorly External Primary Insidious onset with repetitive overhead activities Changes in the acromion External Secondary Insidious onset due to overhead activity and weak RTC muscles and humeral head migration

Who is at Risk Internal Throwers Overhead athletes Swimmers External Primary Older adults Those with acromion congenital or degenerative changes External Secondary Hypermobile athletes Young individuals

Patient Presentation Internal Posterior shoulder pain with abduction and max ER Increased ER and decreased IR Recurrent symptoms States they “can’t get loose” Scapular weakness Weak in ER and scaption External Primary Anterior shoulder or lateral upper arm pain with overhead activities Inability to sleep on affected side Shoulder weakness and difficulty with overhead activities Loss of motion secondary to pain Poor posture, rounded shoulders External Secondary Anterior or lateral shoulder pain Altered ER/IR ratio GHJ instability Tight pectoralis major Weak serratus anterior Weak RTC and imbalance with deltoid Tight posterior capsule Pain with overhead motions Poor posture

Positive/Negative Tests Internal Neers (+) Apprehension (+) Jobe (-) Hawkins (-) External Primary Jobe (+) Neer (+) Hawkins (+) Yocum (+) Relocation (-) Full Can (-) Painful Arc (-) External Secondary Relocation (+) Hawkins (+/-) Jobe (+/-)

Differential Diagnosis Rotator Cuff Pathology Presents similar to Primary External Impingement Full Can (+) Painful Arc (+) GIRD Presents similar to both Secondary External and Internal Decreased Internal Rotation (+)

Differential Diagnosis Biceps/SLAP Lesion Presents similar to both Secondary External and Internal O’Brien’s (+) Speed’s (+) Instability Load and Shift (+) Sulcus Sign (+) Apprehension/Relocation (+)

Rotator Cuff Pathology Impingement Symptoms External Impingement Primary Rotator Cuff Pathology Secondary GIRD Biceps/SLAP Lesion Instability Internal Impingement Impingement Algorithm Jobe (+) Neer (+) Hawkins (+) Apprehension (+) Yocum (+) Neer (+) Apprehension (+) Hawkins (-) Jobe (-) Relocation (-) Relocation (+) Release pain (+) Relocation (+) Release pain (+) Full Can (+) Painful Arc (+) Internal rotation is decreased (+) O’Brien (+) Speed’s (+) Load and Shift (+) Sulcus Sign (+) Apprehension/Relocation (+)

Take Home Message Shoulder pain is very common Don’t limit your hypothesis to impingement only, rule out other pathologies Using this algorithm can help you quickly and accurately rule in and out the diagnosis Selecting the correct impingement type will help guide your treatment plan

References Chang, W. (2004). Shoulder impingement syndrome. Physical Medicine and RehabilitationClinics of North America,15, 493-510. Cools, A.M. & C. D. (2008). Screening the athlete's shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British Journal of Sports Medicine, 42, 628-635. Dutton, M. (2008) Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York, New York: McGraw Hill Incorporated. Heyworth, B. (2008). Internal impingement of the shoulder. American Journal of Sports Medicine, 37(5),1024-37. doi: 10.1177/0363546508324966 Impingement Syndrome: Primary & Secondary impingement. (n.d.). Retrieved April 17, 2013, from North Austin Sports Medicine. Kamkar, A., Irrgang, J. J., & Whitney, S. L. (1993). Nonoperative Management of Secondary Shoulder Impingement Syndrome. Journal of Orthopaedic and Sports Physical Therapy, 17(5), 212-224. Thompson, D. (2000, November 5). Shoulder elevation involves. Retrieved April 17, 2013, from Shoulder elevation involves: http://moon.ouhsc.edu/dthompso/namics/scapryme.htm Vind, M., Bogh, S., Larsen, C., Knudsen, H., Sogaard, K, & Juul-Kristensen, B. (2011). Inter- examiner reproducibility of clinical tests and criteria used to identify subacromial impingement syndrome. British Medical Journal, 1(1).