Impingement syndrome

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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 patients 25-40yr
    • Occurs if patients 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 with daily activities and night pain
  • Stage 3

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

Impingement Tests

  • Maneuver of Neer
    • Prevent scapular rotation with one hand while raising patient's straightened arm in full forward flexion to overhead
    • Positive sign is pain in the arc between 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

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Management

  • Relative rest and activity modification
    • Avoid the aggravating activity and minimize all overhead activities
  • NSAIDs and opioids as needed for pain
  • Cryotherapy
    • Apply ice to affected shoulder for 10-15min TID-QID
  • Range of motion exercises
    • Pendulum swings
      • Patient bends slightly at waist with arm hanging freely in front of body
      • Arms should be swung in gentle arcs of motion both clockwise and counter-clockwise
      • Swing to level of pain tolerance x 5-10min TID-QID
    • Walk fingers up wall
      • Stand sideways an arm's length from wall and walk fingers up wall to level of pain tolerance TID-QID

Disposition

  • Refer to primary care provider within 2 weeks

References