Shoulder Impingement S yndrome

1. Shoulder Impingement Syndrome

2. Shoulder Impingement Syndrome • Painful Arc Syndrome • Supraspinatus Syndrome • Swimmer's Shoulder • Thrower's Shoulder

3. Shoulder Impingement Syndrome • is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion.

4. Shoulder Impingement Syndrome • Occurs when one of the rotator cuff tendons (supraspinatus) or bursa (a flat, fluid-filled membrane that prevents the shoulder parts from rubbing together) is pinched between the ‘ball’ part of the upper bone (the humeral head) and the undersurface of the top of the shoulder blade (acromion). • This happens because as we raise our arm, the narrow space between the top of our arm bone (the humeral head) and the top of the shoulder blade naturally compresses. • It is the repetition of such movements that ultimately leads to the condition developing, causing swelling and an excess of fluid in the joint.

6. Shoulder Impingement Syndrome • This can result in pain, weakness and loss of movement at the shoulder.

7. Causes • The rotator cuff muscle tendons pass through a narrow space between the acromion process of the scapula and the head of the humerus. • Anything which causes further narrowing of this space can result in impingement syndrome.

8. Causes - Bony Structures • Subacromial spurs (bony projections from the acromion) • Osteoarthritic spurs on the acromioclavicular joint • Variations in the shape of the acromion.

11. Causes • Thickening or calcification of the coracoacromial ligament

12. Causes • Loss of function of the rotator cuff muscles, due to injury or loss of strength, may cause the humerus to move superiorly

13. Causes • Inflammation and subsequent thickening of the subacromial bursa may also cause impingement.

14. Shoulder Impingement Syndrome • Result of painting, carpentry, construction work or any other jobs that involve overhead work. • take many years before someone begins to notice the symptoms of the condition.

15. Signs and Symptoms • The most common symptoms in impingement syndrome are pain, weakness and a loss of movement at the affected shoulder

16. Signs and Symptoms • The pain is often worsened by shoulder overhead movement and may occur at night, especially if the patient is lying on the affected shoulder.

17. Signs and Symptoms • The onset of the pain may be acute if it is due to an injury • Insidious onset if it is due to a gradual process such as an osteoarthritic spur.

18. Signs and Symptoms • Other symptoms can include a grinding or popping sensation during movement of the shoulder.

19. Signs and Symptoms • The range of motion at the shoulder may be limited by pain. A painful arc of movement may be present during forward elevation of the arm from 60° to 120°.

20. Signs and Symptoms • Passive movement at the shoulder will appear painful when a downwards force is applied at the acromion but the pain will ease once the downwards force is removed.

21. Diagnosis • Impingement syndrome can usually be diagnosed by history and physical exam.

22. Neer test • Stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion.

23. Hawkins test • Elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.

24. Diagnosis - Plain X-ray • Joint pathology and variations in the bones, • Acromioclavicular arthritis • Variations in the acromion • Calcifcation

25. Diagnosis - Arthrography

26. Diagnosis - Ultrasonography

27. Diagnosis • MRI showing subacromial impingement with partial rupture of the supraspinatus tendon.

28. Treatment - Conservative • Rest, • Cessation of painful activity, • Physiotherapy focused at maintaining range of movement and avoid shoulder stiffness. • NSAID's and ice packs may be used for pain relief.

29. TREATMENT • 1 - stop any activity that can/may aggravate symptoms • 2 - medicate with anti-inflammatory medicine • 3 - cold therapy or 'cryotherapy' • 4 - REST!!!! • 5 - gentle stretching exercises • 6 - exercises to STRENGTHEN the rotator cuff • 7 - if all else fails after 6 to 12 months, arthroscopic or open surgery to repair damage and relieve the pressure on the tendons and bursae

33. RTC Exercises - one • Start by lying on your stomach on a table or a bed. • Put your left arm out at shoulder level with your elbow bent to 90° and your hand down. • Keep your elbow bent and slowly raise your left hand • Stop when your hand is level with your shoulder. Lower the hand slowly.

34. RTC Exercises - Two • Lie on your right side with a rolled-up towel under your right armpit. • Stretch your right arm above your head. • Keep your left arm at your side with your elbow bent to 90° and the forearm resting against your chest, palm down. • Roll your left shoulder out, raising the left forearm until it's level with your shoulder. • Lower the arm slowly.

35. Rotator Cuff Exercises - Three • Lie on your right side. Keep your left arm along the upper side of your body. • Bend your right elbow to 90°. • Keep the right forearm resting on the table. • Now roll your right shoulder in, raising your right forearm up to your chest. • Lower the forearm slowly.

36. Rotator Cuff Exercise - Four • In a standing position, start with your right arm halfway between the front and the side of your body, thumb down. • Raise your right arm until almost level (about a 45° angle). (This is like emptying a can.) Don't lift beyond the point of pain. • Slowly lower your arm.

37. Treatment • Therapeutic injections of corticosteroid and local anesthetic may be used for persistent impingement syndrome. • The total number of injections is generally limited to three due to possible side effects from the corticosteroid.

38. Treatment - Surgery • Done arthroscopically or as open surgery.

39. Treatment - Surgery • The impinging structures may be removed in surgery, and the subacromial space may be widened by resection of the distal clavicle and excision of osteophytes on the under-surface of the acromioclavicular join

40. Treatment - Surgery • Also damaged rotator cuff muscles can be surgically repaired.