1. SHOULDER IMPINGEMENT SYNDROME

2. INTRODUCTION
The term “Impingement Syndrome” was popularized by Charles Neer in 1972
• Neer defined impingement as pathologically compression of rotator cuff against the anterior structure of coracoacromial arch, anterior 1/3 of the acromion, coraco-acromial ligament & AC joint.
• Progression of syndrome is define by a narrowing of the sub-acromial outlet by spur formation in coracoacromial ligament & undersurface.

4. • Impingement causes Mechanical irritation of cuff tendons - resulting in haemorrhage and swelling (commonly known as tendonitis of rotator cuff) – The supraspinatus muscle is usually involved. • This also affect the bursa – resulting in bursitis. • Shoulder complex is susceptible to impingement injuries from overhead sports – Such as baseball, tennis, swimming, volleyball etc. • Impingement with rotator-cuff tendonitis is one of most common shoulder injuries seen in athletes.

5. SIGNS & SYMPTOMS Pain & tenderness in the gleno-humeral area
• Pain or weakness with active abd. in midrange
• Limited internal rotation compared to normal side
• Confirmation with special tests (Hawkins
impingement test)
• Tenderness to palpation in the sub-acromial area

6. TYPES OF IMPINGEMENT (site)
*Subacromial/External impingement:
A mechanical encroachment of soft tissue structures as bursa and rotator cuff tendons between humeral head and acromial arch.
Pain in midrange of abduction leading to painful arc.

7. TYPES OF IMPINGEMENT *Internal impingement:
Encroachment of rotator cuff tendons between humeral head and glenoid rim.

8. TYPES OF INTERNAL IMPINGEMENT
1. Anterosuperior glenoid impingement:
Entrapment of subscapularis retract after deep surface tears.
Pain provoked at shoulder flexion and internal rotation
2. Posterosuperior glenoid impingement:
Encroachment of supraspinatus tendon between greater tubercle of humerus and posterosuperior glenoid rim.
Pain provoked at maximal external rotation, horizontal abduction and abduction.

9. PRIMARY &SECONDARY IMP. (cause)
Pain caused by structural narrowing of subacromial space due to:
-AC arthropathy
-Type I/III acromion
-Swelling of soft tissue within the subacromial space.

10. PRIMARY &SECONDARY IMP.
*2nd Imp.:
No structural abnormalities, functional problems in specific positions
In subacromial space.
Internally in glenohumeral joint.

12. Factor development of External impingement
Anatomical abnormalities – e.g. beaked/ # acromion, osteophytes
• Poor scapular control
• Anterior instability
• Postural changes in upper quadrant – Forward head & rounded shoulder posture

13. Types of acromions

14. Factor development of internal impingement
• Overuse – repetitive trauma • Loose joint • Instability • Muscle imbalance • Superior labrum injury

15. Stages of Shoulder Impingement Syndrome (SIS)
*Stage I: (edema & inflammation) • Age – younger than 25 years (but may occur at any age) • Reversible lesion • Tenderness over greater tuberosity of humerus • Tenderness over anterior ridge of acromion • Painful arch 60 – 120 • (+) ve Neer impingement test • ROM may restricted with sub-acromial inflammation

16. Stages of Shoulder Impingement Syndrome (SIS)
*Stage II: (fibrosis & tendinitis) • Age – 25 – 40 years • Not reversible by modification of activities • Stage I signs + the following : – Soft tissue crepitus – Catching sensation at lowering arm (approx 100) – Limitation of active & passive ROM

17. Stages of Shoulder Impingement Syndrome (SIS)
*Stage III: (bone spur & tendon rupture) • Age > 40 years • Not reversible • Stage I + II signs + following : – Limited ROM more prominently – Atrophy of infra-spinatus – Weakness of abductor & external rotator – Bicep tendon involvement – AC joint tenderness

18. SPECIAL TESTS
• For impingement : – Neer impingement test – Hawkins impingement test • Rotator cuff test : – Supraspinatus – empty can – Subscapularis – Lift off – Drop arm – for full thickness rotator cuff

20. Treatment Goals To relieve pain & swelling
• To retard muscle atrophy & strengthen cuff
muscle
• To maintain & improve ROM
• To increase strength, endurance & power

21. Treatment Oral anti-inflammatory medication Cryotherapy:
-Over the tender area in early inflammation stage
-Duration – 10 – 15 min
-Greater effect along with medication.
Electrotherapy:
- TENS is useful in controlling pain
- US therapy with 0.8 w/cm2, 3MHz, 6 min – to decrease inflammation
- Other modalities like LASER, IF are also effective in pain control

22. Bio feed back:
- It may be appropriate if there is excessive laxity of humeral head.
-Helpful in athlete unable to gain control of the rotator cuff musculature
Manual therapy approach:
*Mobilization for GH :
-Grade I & II in early stage
- As symptoms response, can shift to even grade III & IV

23. Therapeutic exercise
Pendular exercises with light weight (1kg or Less)
Active assisted ROM exercises in pain free range e.g. Rope & Pulley
Capsular stretching
Stretching of upper trapezius, pectorals, biceps.
Towel exercise.

25. Strengthening exercises:
– Isometric exercises :
– Scapular stabilization exercises.
- Strengthening using theraband.
- Plyometric exercises.
– Isokinetic exercises.

27. Surgery:
-Arthroscopic subacromial decompression
- Capsulorrhaphy

28. Preventing Re-injury:
• Perform warming-up before & cooling-down after training, for no less than 15 minutes.
• Including stretching ex’s for the shoulder muscles and capsule.
• Perform strengthening exercises for the shoulder twice a week.
• Ensure you take adequate rest & avoid playing too many games in too short period.
• Fatigue plays an important role in occurrence of
this kind of injury.

29. SHOULDER INSTABILITY

30. Introduction
• Highest mobility, at the expense of stability • Most frequently dislocated -50 % of all dislocations -2 % incidence in general population • Factors predisposing to recurrent dislocation -Age -Return to contact sports -Hyper-laxity -Significant Bony defect in glenoid or humeral head

31. What is instability?
Inability to maintain the humeral head centered in the glenoid fossa and coracoacromial arch throughout ROM.
• Instability ≠ Joint laxity
• Laxity = Incomplete loss of glenohumeral articulation unassociated with pain
• Subluxation = Partial loss of glenohumeral articulation with symptoms
• Dislocation = Complete loss of glenohumeral articulation

32. Functional Anatomy

34. Gleno-humeral Stability
Static restraints
-Gleno-humeral ligaments
-Glenoid labrum
-Articular congruity & version.
-Negative intraarticular pressure
Dynamic restraints
-Rotator cuff muscles
-Rotator cuff interval
-Biceps long head
-Peri-scapular muscles

35. Static restraints

43. Dynamic restraints

53. Physical examination
• Atrophy or asymmetry around shoulder • Tenderness around anterior or posterior capsule • Active and passive ROM • Strengths of the deltoid, rotator cuff and scapular stabilizers. • Special tests: -Shift and load test -Sulcus test -Apprehension test

57. TREATMENT *ANTERIOR DISLOCATION 97% of recurrent dislocation
abduction, extension and external rotation
Subcoracoid
subglenoid
subclavicular
Associated Injuries:
Fractures of Head & Neck
Rotator Cuff Tears

58. TREATMENT *NONOPERATIVE Closed Reduction Immobilization-Sling
Analgesics
Rehabilitation

59. TREATMENT OF RECURRENT ANT. DISLOCATION
*Non-operative ttt:
Only 16% traumatic respond
80% atraumatic respond
Poor response to non operative ttt
*Surgical stabilization:
Open or arthroscopic

60. OPERATIVE TREATMENT *Capsulolabral Repair - Bankart - Modified Bankart
*Subscapularis Procedures
- Putti-Platt
- Magnuson-Stack
*Coracoid Transfer
Procedures
- Bristow
- Latarjet

61. POSTERIOR DISLOCATION
Incidence: < 5% of all shoulder dislocations
3% of recurrent

62. Mechanism of injury:
- Axial load
- Flexed/Adduction
-Swimming
-Rowing
-Football Offensive Lineman

63. TREATMENT Non Operative -Immobilization - Rehabilitation
% improve
- Functional disability improved
- Instability not eliminated

64. Operative Management
-Overall % success
*Soft Tissue Procedures
- Posterior Capsulorrhaphy
-Reverse Putti-Platt
*Bone Procedures
- Posterior Glenoid Osteotomy
-Posterior Bone Block

65. REHABILITATION *Phase I (Post op to 3 weeks)
Rest and immobilization. Pain control with nonsteroidal anti-inflammatory drugs and ice applied to the shoulder.
No ext rotation
Abduction less than 45°
*Phase II (3 to 6 weeks)
Isometric strengthening, Isotonic strengthening. Begin exercises with shoulder in adducted, forward- flexed position, progressing to abducted position.
Resistive exercises.

66. REHABILITATION *Phase III ( 6 weeks to 3 months)
Endurance building along with strengthening exercises.
Goal: the patient reaches 90% strength in the injured shoulder compared with the uninjured shoulder.
Non contact = 6 weeks
*Phase IV (3 months to 6 months)
Increase activity to sport- or job-specific activities
contact = 12 weeks