Impingement syndrome

Background

• Refers to subacromial bursitis, rotator cuff tendinitis, supraspinatus tendinitis, and painful arc syndrome
  • All are due to repetitive subacromial impingement due to overhead use of the arm
• Shoulder range of motion should be intact

Stages

• Stage 1
  • Classically seen in young athletes <25yr
  • Reversible edema and hemorrhage about the rotator cuff
  • Dull ache over anterolateral shoulder aggravated by activity and improved by rest
• Stage 2
  • Seen in pts 25-40yr
  • Occurs if pts continue the aggravating activity without treatment
  • Edema and hemorrhage advance to rotator cuff tendinitis
  • Prolonged pain (weeks to months) or recurrence of symptoms
  • Chronic aching pain w/ daily activities and night pain
• Stage 3
  • Rotator cuff tear
  • Often requires surgical decompression of the subacromial space

Clinical Features

• Pain
  • Develops insidiously over period of weeks-months
  • Located over anterolateral acromion; radiates to lateral mid-humerus
  • Exacerbated by activities that require overhead arm use
  • Night pain

Diagnosis

• Rotator Cuff Tests
  • Supraspinatus Test
    • Abduct arm to 90', forward flex it 30' w/ thumb down ("empy beer can position")
    • Test for pain/weakness against resistance to continued abduction
  • Infraspinatus and Teres Minor Test
    • Stabilize the elbow against the pt's waist and bend the elbow to 90'
    • Test for pain/weakness against resistance to external rotation
  • Subscapularis Test
    • Place hand behind lower back
    • Test for pain/weakness as pt attempts to push examiner's hand away by moving dorsum of hand away from back
• Impingement Tests
  • Maneuver of Neer
    • Prevent scapular rotation w/ one hand while rasing pt's straightened arm in full forward flexion to overhead
    • Positive sign is pain in the arc bewtween 70-120'
• Hawkins Impingement Test
  • Position the shoulder at 90' of abduction and elbow at 90' of flexion
  • Then rotate shoulder internally bringing the arm across the front of the pt
  • Positive sign is pain during this maneuver

Treatment

1. Relative rest and activity modification
   1. Avoid the aggravating activity and minimize all overhead activities
2. NSAIDs and opioids as needed for pain
3. Cryotherapy
   1. Apply ice to affected shoulder for 10-15min TID-QID
4. Range of motion exercises
   1. Pendulum swings
      1. Pt bends slightly at waist w/ arm hanging freely in front of body
      2. Arms should be swung in gentle arcs of motion both clockwise and counter-clockwise
      3. Swing to level of pain tolerance x 5-10min TID-QID

Disposition

• Refer to PMD within 2 weeks

Source

• Tintinalli