Impingement syndrome

Background

Shoulder anatomy, anterior.

Shoulder anatomy, posterior.

• 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
  • 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

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:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular joint injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis
• Cervical radiculopathy

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
  • Rucksack paralysis
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Evaluation

• See Shoulder (Tests)

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