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Inside Physio
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08 May 2011
this issue Shoulder Impingement Syndrome P.1&2 Pro fe ssi o n a l De ve l o p me n t Physio Professionals prides itself in its continuing staff education initiatives.
Shoulder Impingement Syndrome
Sta ff Michelle Peauril Senior Physiotherapist Level III Sports Physio AIS
Shoulder Impingement Syndrome (SIS)
Other types of shoulder impingements
During elevation of the shoulder, the humeral tuberosities pass close to the coracoacromial arch. Little clearance is left for intervening soft tissue, which comprise of the subacromial bursa, rotator cuff tendons and long head of biceps. If for any reason available space reduces, these soft tissue structures are liable to become pinched.
Two other types of shoulder impingements exist.
Iona MacInnes
Underlying mechanisms for shoulder impingement syndrome
Physiotherapist Andrew Crew Remedial/Sports Massage Performance Bike Fit Analysis
Bony anatomical and pathological factors Shoulder instability: rotator cuff weakness, capsuleligamentous laxity Impaired scapulohumeral rhythm and scapular instability Capsular tightness: correlation shown between impingement and posterior capsule tightness (Tyler et al 2000) Postural factors
Soft tissue changes
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1.
Posterior Superior Glenoid Impingement (PSGI) results from repetitive microtraumas sustained in the throwing position (extension, abduction and external rotation).
2.
Superior Labrum Anterior to Posterior (SLAP) Lesions may result from trauma or degeneration, but more typically from throwing. The biceps helps decelerate the arm at end of range of the cocking phase, and large traction forces develop at its attachment to superior part of glenoid labrum. As a result the labrum may peel off underlying bone, often resulting in features of impingement.
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Mode of Onset SIS mode of onset varies, and therefore may be insidious or related to a specific incident. PSGI is most commonly seen in sportsmen, especially throwers, but is not limited to this group. SLAP lesions are mainly seen in throwers who have recalled a traumatic event. Age SIS occurs in all age groups. PSGI tends to be seen in under 35s according to Cavallo & Speer (1998) but in Jobe’s (1995) study the age was somewhat higher (mean 36, range 20-55). SLAP lesions have a similar distribution to PSGI with a mean of 34 years reported by Liu et al (1996). Exercise is a large component when treating shoulder impingement.
Physiotherapy exercise program have been shown in studies to significantly improve recovery function and shoulder range of motion.
Pain The pain felt in SIS, felt in the shoulder region or radiating down the arm, has been characterised as sharp and catching or a chronic ache after activity and aggravated by overhead work. Placing the hand behind the back may also be painful. Classically there is a painful arc on elevating and/or lowering the arm as the humeral tuberosities pass under the coracoacromial arch. Night pain is commonly associated with rotator cuff tears. Pain caused by PSGI tends to be activity specific and may be felt posteriorly. SLAP lesion symptoms are vague and inconsistent and therefore have little predictability. Physiotherapist Role Conservative management of SIS, PSGI and SLAP lesions should all follow
similar lines. Physiotherapists should aim to minimise pain and optimise function through reducing subacromial inflammation; managing pain; improving posture; restoring range, strength, stability and scapulohumeral rhythm and identifying when patients should be referred for orthopaedic opinion. Exercise is a large component when treating shoulder impingements. Exercise has been shown to significantly improve recovery function and range of abduction at 1 month compared to controls, in a mixed shoulder group in which 67% of diagnosis were impingement (Ginn et al 1997). Kuhn (2009) carried out a systematic review of literature on exercise in the treatment of rotator cuff impingement. After reviewing the data there was a statistical and significant effect on pain reduction and improving function. From large retrospective studies, a high proportion of patients with SIS can be expected to respond to conservative measures. Morrison (1997) reported satisfactory to excellent outcomes in 413 (67%) of 636 patients with SIS following a 6 week rehabilitation program. Parker and Seitz (1997) reported a 74% positive response to a 6 month rehabilitation program in their review of 50 consecutive patients with impingement syndrome. Kromer et al (2009) critically summarised the effectiveness in patients presenting with shoulder impingement. 16 studies were included and they concluded that physiotherapy led exercises and surgery were equally effective treatments for shoulder impingement syndrome in the long term. Patients should therefore trial a rehabilitation program before seeking an orthopaedic opinion if no change in their condition occurs.
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