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

2. Anatomy

3. Anatomy

4. 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

5. Anatomy

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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 (+)

13. 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 (+)

14. 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 (+)

15. 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

16. References
Chang, W. (2004). Shoulder impingement syndrome. Physical Medicine and RehabilitationClinics of North America,15, 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, 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), doi: / 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), Thompson, D. (2000, November 5). Shoulder elevation involves. Retrieved April 17, 2013, from Shoulder elevation involves: 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).