Impingement Syndrome Overview

Impingement Syndrome, Supraspinatus Tendinitis, and Cuff Disruption

• Pain and/or weakness during certain movements of the shoulder.
• Referred pain or paresthesias into the region of the deltoid insertion and upper lateral arm.
• A thorough examination of the upper extremity and axial spine is necessary to rule out other pathology.
• Rotator cuff impingement alters muscular function of the cuff and results in diminished dynamic control of the glenohumeral (GH) joint.

Stages of Impingement Syndrome

• Stage 1: Edema and inflammation.
• Stage 2: Fibrosis and Tendinitis.
• Stage 3: Tears and Tendon Degeneration

Primary Impingement

• Primary subacromial impingement is the result of an abnormal mechanical relationship between the rotator cuff and the coracoacromial arch (acromion, coracoacromial ligament, and/or coracoid process).
• Primary impingement can also be caused by congenital anomalies, degenerative spur formation, unfused acromion (Os acromiale), degenerative spurs on the undersurface of the acromion, malunion/nonunion of fracture, abnormal shape after surgery or trauma, thickening of tendon from calcific deposits, tendon thickening after surgery or trauma, increased prominence of the greater tuberosity from anomalies or malunions.
• Symptoms include anterolateral shoulder and upper lateral arm pain, inability to sleep on the affected side, shoulder weakness, and difficulty performing activities at or above the level of the shoulder.

Special Tests for Diagnosis

• Hawkin’s sign
• Neer impingement sign
• Empty can sign (Jobe’s test)
• Painful arc
• External and internal rotation resistance
• Strength tests
• O’Brien’s test

Secondary Impingement

• Secondary impingement is a clinical phenomenon that results from a “relative narrowing” of the subacromial space.
• Contributing factors include excessive GH joint mobility or scapular dyskinesis.
• Symptoms are caused by excessive demands placed on the rotator cuff to dynamically stabilize the shoulder.

Internal Impingement

• Posterior shoulder pain produced by contact of the greater tuberosity with the posterosuperior aspect of the glenoid when the shoulder is abducted to approximately 90 degrees and fully externally rotated, produces impingement of the posterior rotator cuff, capsule, and labrum.
• Internal impingement is often present in normal physiologic motion but can become pathologic with repetitive overhead activities.
• Pathology consists of undersurface tears of the posterior supraspinatus and/or anterior aspect of the infraspinatus tendon and often includes superior labrum anterior to posterior (SLAP) tears.
• Patients are typically under 35 years of age, involved in repetitive overhead abduction and external rotation demand activities.

Physical Therapy Rehabilitation

• A comprehensive rehabilitation program for shoulder impingement should follow a progression of phases based on functional improvement and pain reduction.
• Modalities such as heat applied before exercise may facilitate gains in ROM. Ice application following resistance exercises.
• Active and active-assisted ROM in the scapular plane, posterior capsule stretching, and manual therapy techniques should be used to address specific GH joint capsular, scapulothoracic joint, or spinal mobility limitations.
• Strength training should progress through initial, intermediate, and late phases.
• Initial phase focuses on scapular neuromuscular control, closed chain exercises, rotator cuff isometrics, and limited range isotonics.
• Intermediate phase progresses strengthening and attains full range of motion.
• Late phase focuses on restoration of shoulder girdle strength, neuromuscular control, and maintenance of normal mobility.
• Gradually return to traditional weightlifting exercises; Caution is recommended when returning to barbell pressing movements (bench, incline, and military presses) and dips because these movements can result in a return of symptoms. Behind the neck pull-downs and military press should be avoided.

Jobe’s Relocation Test

• A test that helps diagnose posterior impingement.