Shoulder External Impingement

Normal Anatomy

• The shoulder has a lot of soft tissue within a small amount of space

• Also a very mobile joint with lots of movement

• These 2 components increase the changes of ‘pinching’ during movement

Shoulder Impingement• “ These disparate findings are believed to be at least in part due

to the fact that mechanical impingement is probably a physical condition rather than a clearly identifiable diagnostic entity.”

(Kibler et al., 2013)

• “It is increasingly advocated that this diagnosis is no more specific than a diagnosis of anterior or posterior shoulder pain, and no more effective in directing treatment”

(Kibler et al., 2013; Schellingerhout et al., 2008)

Shoulder Impingement

External (Bursal Sided) Impingement

• Classic ‘Subacromial Impingement’ between humeral head and acromion or coracoacromial ligament

Internal (Articular) Impingement

• Pinching of the rotator cuff between humeral head and posterior superior glenoid

Shoulder Impingement

External Impingement

• Impingement of rotator cuff underneath acromion OR coracoaromial arch/ligament

• Impingement is NORMAL due to the small space available

• Pathology occurs due to – Overuse– Trauma– Alignment or Anatomy– Soft Tissue Imbalances

Impingement Stages• Stage 1– < 25 years old– Acute

inflammation and oedema and haemorrhage in the rotator cuff

– Reversible and Non operative

• Stage 2– 25 -40 years– Progression from

acute oedema and haemorrhage to fibrosis and tendinitis of the rotator cuff

– Usually responds to conservative management

(Neer, 1983)

• Stage 3– 40+ years– Mechanical

disruption of tendons (tear)

– Osteophytes under acromion

– Thickening of coracoacromial arch

– More likely to require surgery

Impingement Causes

Primary• Result of a direct compression of

the rotator cuff tendons between humeral head and overlying anterior third of the acromion/coracoacromial arch/ ligament– Change in anatomy of acromion– Acromioclavicular arthrosis– Coracoacromial ligament

hypertrophy– Subacromial bursa thickening or

fibrosis– Trauma– Repeated Overhead activity

Secondary• Secondary to another syndrome

which causes humeral head migration– Rotator Cuff weakness– Glenohumeral instability– Scapular Dyskinesia– Posterior Capsule tightness – Neurological paralysis

(Chang, 2004)

Subacromial Vs Coracoacromial

• Impingement of the rotator cuff tendon can occur against anterior aspect of the acromion OR the coracoacromial arch

• Coracoacromial impingement has more pain into horizontal adduction

• There is very subtle differences in presentation which will affect management

External Impingement- Assessment

• Subjective History– History of instability– History of impingement– Job or sport that requires

repeated overhead activity

• Subjective Symptoms– Insidious Onset– Pain anteriorly, superiorly

and laterally in shoulder– Pain in positions of flexion

and internal rotation (Sometimes horizontal adduction)

External Impingement- Assessment

• Objective– Painful arc– Pain resisted lateral

rotation– Hawkins Kennedy– Neer’s

• Global Assessment– Cervical– Scapula– Thoracic

Management

• Remember impingement is NORMAL and only pathological due to the following– Overuse– Trauma– Alignment or Anatomy– Soft Tissue Imbalances

• Treatment is used to modify the above• Anatomy cannot be changed, therefore

surgery required

Management

Soft Tissue Imbalances

Management- Soft Tissue Imbalances

• Rotator Cuff pull humeral head into glenoid• Should pull centrally• Muscle Imbalance can change the position of

the humeral head within the glenoid• Main imbalances– Big V Small (Deltoid V Rotator Cuff)– Posterior V Anterior (Subscapularis V Posterior

Cuff)

Deltoid V Rotator Cuff

• Deltoid pulls humeral head superior

• If rotator cuff are dysfunctional the net force of deltoid is increased

• Humeral head migrates superiorly during elevation

• Causing impingement

Deltoid V Rotator Cuff

• Pain free range exists because as elevation continues the pull of the deltoid changes

• Less superior pull is produced as elevation increases

• Pain at very end of range simply due to space available

Posterior Cuff V Subscapularis

• If subscapularis is dominant the humeral head will migrate anteriorly

• Increasing risk of humeral head impinging against coracoacromial arch and acromion

Posterior Cuff

• It therefore stands to reason that rehabilitation of the posterior cuff will be beneficial

• But what exercises are most effective for the posterior cuff?

Rationale For Exercises• A review paper in 2009 by

Mike Reinold looked various EMG studies of shoulder muscles

• Concluded the 3 best exercises for posterior cuff were – Side Lying ER – Prone ER at 90° Abduction– ER with Towel (30°

Abduction)

(Reinold et al., 2009)

Management- Soft Tissue Imbalances

• Posterior capsule tightness can alter shoulder arthrokinematics

• Tightness in the Posterior Capsule and Posterior Band of the inferior capsule reduce superior head migration

(Muraki et al., 2010; Tyler et al., 2000)

Management- Soft Tissue Imbalances

• Manual Therapy to soft tissue can improve pain, range of movement, function and strength

• Joint mobs, Soft tissue release, etc etc

(Bang & Deyle, 2000; Senbursa et al., 2007; Teys et al., 2008)

Management- Soft Tissue Imbalances

• HEP– Horizontal adduction– Sleeper Stretch (Is this

similar to Hawkins Kennedy?)

Management

Alignment

Management- Alignment

• Any deviation of the scapula will affect shoulder kinematics

• Points of impingement are coracoacromial ligament, or acromion

• Both parts of scapula

Management- Alignment

• Read the following paper for an in depth look at the biomechanics associated with shoulder impingement syndrome

Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther 2011; 16(1): 33-9.

Management- Alignment

• Restricted thoracic extension with elevation

• Increased thoracic kyphosis (try elevated the arms while sitting slumped)

(Seitz et al., 2011)(Bullock et al., 2005)

• Scapula Dyskinesis– Reduced scapular

upward rotation– Increased internal

rotation (Medial Border Winging)

– Increased anterior tilt

(Cools et al., 2003)

Management- Alignment

• Increase thoracic extension and rotation

• Thoracic mobilisation and manipulation

(Boyles et al., 2009)

• Increase scapular upward rotation, posterior tilt and external rotation

• Serratus anterior and Lower Trapezius Rehab

• (Cools et al., 2003; Ludewig & Cook, 2000; Ludewig & Reynolds, 2009; Ellenbecker & Cools, 2010; Roy et al., 2009; Hung et al., 2010; Cools et al., 2013; Dickens et al., 2005)

Rationale For Exercises

• Serratus Anterior– Push up Plus– Dynamic Hug– Serratus Punch 120°– Wall Slides

• Lower Trapezius– Prone Full Can– Prone ER at 90° Abduction– Bilateral ER (Shoulder W’s)

(Reinold et al., 2009)

Subacromial V Coracoacromial

Subacromial • Avoid Flexion

Coracoacromial• Avoid Horizontal Adduction

Management

• Mobility BEFORE Stability– Mobility

• Soft tissue release/MET– Pec Minor– Upper Trapezius– Subscapularis– Rhomboids– Levator Scapulae

• Joint Mobs– Posterior and Inferior

Capsule– Scapular Upward

Rotation

– Stability• Posterior Rotator Cuff• Serratus Anterior• Lower Trapezius

• Stability Principles1. Motor Control2. Isolated Strengthening3. Endurance4. Neuromuscular Control5. Functional/ Sport

Specific

References• Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical

therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000; 30(3): 126-37.

• Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther 2009; 14(4): 375-80.

• Bullock MP, Foster NE, Wright CC. Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Man Ther 2005; 10(1): 28-37.

• Chang WK. Shoulder impingement syndrome. Phys Med Rehabil Clin N Am 2004; 15(2): 493-510.

• Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med 2013.

• Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. Am J Sports Med 2003; 31(4): 542-9.

• Dickens VA, Williams JL, Bhamra MS. Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study. Physiotherapy 2005; 91(3): 159-64.

References• Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an

evidence-based review. Br J Sports Med 2010; 44(5): 319-27.• Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the management of musculoskeletal disorders

of the shoulder: a systematic review. Man Ther 2009; 14(5): 463-74.• Hung CJ, Jan MH, Lin YF, Wang TQ, Lin JJ. Scapular kinematics and impairment features for classifying

patients with subacromial impingement syndrome. Man Ther 2010; 15(6): 547-51.• Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular

dyskinesis in shoulder injury: the 2013 consensus statement from the 'scapular summit'. Br J Sports Med 2013; 47(14): 877-85.

• Lewis JS, Green AS, Dekel S. The Aetiology of Subacromial Impingement Syndrome. Physiotherapy 2001; 87(9): 458-69.

• Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther 2011; 16(1): 33-9.

• Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000; 80(3): 276-91.

• Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther 2009; 39(2): 90-104.

• Muraki T, Yamamoto N, Zhao KD, et al. Effect of posteroinferior capsule tightness on contact pressure and area beneath the coracoacromial arch during pitching motion. Am J Sports Med 2010; 38(3): 600-7.

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References• Neer CS, 2nd. Impingement lesions. Clin Orthop Relat Res 1983; (173): 70-7.• Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises

for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther 2009; 39(2): 105-17.• Roy JS, Moffet H, Hebert LJ, Lirette R. Effect of motor control and strengthening exercises on shoulder

function in persons with impingement syndrome: a single-subject study design. Man Ther 2009; 14(2): 180-8.

• Schellingerhout JM, Verhagen AP, Thomas S, Koes BW. Lack of uniformity in diagnostic labeling of shoulder pain: time for a different approach. Man Ther 2008; 13(6): 478-83.

• Seitz AL, McClure PW, Finucane S, Boardman ND, 3rd, Michener LA. Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clin Biomech (Bristol, Avon) 2011; 26(1): 1-12.

• Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2007; 15(7): 915-21.

• Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Ther 2008; 13(1): 37-42.

• Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000; 28(5): 668-73.

• Wassinger CA, Sole G, Osborne H. The role of experimentally-induced subacromial pain on shoulder strength and throwing accuracy. Man Ther 2012; 17(5): 411-5.

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