SHOULDER

IMPINGEMENT
SYNDROME
Rumy Petkov
ANATOMY OF THE SHOULDER
SCAPULA
ROTATOR CUFF MUSCLES
ABOUT THE ATHLETE
 19 year old female
 Freshman starter
 Outside hitter
 Has never had previous shoulder injuries
 PHYSICAL EXAMINATION
 Mechanism: Insidious. Reports sharp ache pain. Reports trouble
with ADL’s such as taking off sports bra. Ranks pain 3/10 after px.
No pain during practice
 No pervious history
 No pain with palpation
 AROM: Full ROM but pain at 90 degrees of flexion, 95degrees of
abduction and worst pain with horizontal adduction
 Special Tests: Empty can (+), Neers (+), Hawkins Kennedy (+),
Speeds(+), Apprehension (-), Clunk (-),
 MMT: Supraspinatus (4/5 with pain), Internal/External (5/5), Pec
minor/major (5/5), Biceps (5/5 with pain)
 Diagnosis: Supraspinatus impingement
EPIDEMIOLOGY
 NCAA injury surveillance system
 Ligament sprains and muscle strains are the most common types of injury in
NCAA women’s volleyball.
 More than 51 percent of the injuries occur to the lower extremity
 Upper extremity, primarily the shoulder region, is at risk of overuse injuries
because of the amount of overhead motion required in the sport.
 Accounts for 21.3% of injuries
CLINICALLY RELEVANT QUESTION
 Among athletes with shoulder impingement, does treatment with
laser therapy result in significant improvements in symptoms and
reductions in complications, as compared to other treatment?
 What will we be looking at:
 Laser therapy vs. Corticosteroid
 Ultrasound vs. Laser therapy
 Kinesio taping
 Exercises with Laser therapy
STUDY LOOKING AT LASER THERAPY
AND CORTICOSTEROID INJECTION
LOW-LEVEL LASER AND LOCAL CORTICOSTEROID INJECTION IN THE
TREATMENT OF SUBACROMIAL IMPINGEMENT SYNDROME: A
CONTROLLED CLINICAL TRIAL

PEDRO SCALE: 5/11

 135 patients with subacromial impingement syndrome
 Three groups
 Group 1: Corticosteroid
 Ground II: Sham Laser treatment
 Group III: Laser therapy treatment

 Patients were evaluated four times during the study period: pre-
treatment, post-treatment and three and six months after the first
visit
 The outcome measurements of our study were pain during
activity and pain at rest
RESULTS
STUDY LOOKING AT ULTRASOUND AND
LASER THERAPY
SHORT-TERM EFFECTS OF HIGH-INTENSITY LASER THERAPY VERSUS
ULTRASOUND
THERAPY IN THE TREATMENT OF PEOPLE WITH SUBACROMIAL IMPINGEMENT
SYNDROME: A RANDOMIZED CLINICAL TRIAL

PEDRO SCALE: 10/11

 70 total patients with SAIS
 Total of 10 treatments for a total of 2 consecutive weeks
 Randomly assigned to 2 groups
 a group of 35 participants received HILT
 a group of 35 participants received US therapy
RESULTS
STUDY LOOKING AT LASER THERAPY
COMBINED WITH REHABILITATION
EXERCISES
THE EFFECTIVENESS OF LOW-LEVEL LASER THERAPY ON
SHOULDER FUNCTION IN SUBACROMIAL IMPINGEMENT SYNDROME

PEDRO: 7/11

 67 total patients randomly assigned

 Two groups:
 received laser
 received placebo laser
 Both groups were assigned progressive rehabilitation exercises
 Assess before and after 3 weeks
RESULTS

ROM
RESULTS
WHY I USED LASER THERAPY
 According to evidence:
 Quicker reduction of pain
 Improved ROM
 Improved overall functionally

 Evidence proved little to no value in treating patients with

ultrasound for shoulder pain

 Future studies: Need evidence for standard parameters of laser

therapy
STUDIES LOOKING AT KINESIOTAPING
FOR SHOULDER IMPINGEMENT
CLINICAL EFFECTIVENESS OF KINESIOLOGICAL TAPING ON PAIN AND
PAIN FREE SHOULDER RANGE OF MOTION IN PATIENTS WITH SHOULDER
IMPINGEMENT SYNDROME: A RANDOMIZED, DOUBLE BLINDED, PLACEBO
CONTROLLED TRIAL

PEDRO SCALE: 11/11

Methods and Subjects:

 A randomized, double blinded, placebo controlled study was conducted
in order to assess the effectiveness of KT in patients with SIS.
 Thirty patients
 Control Trial received placebo KT with no tension
 Experimental trial received a standardized therapeutic KT
RESULTS AND OUTCOMES
 KINESIO-TAPING FOR IMPINGEMENT

1 2 4

R A T A N K H U MA N ( MP T O R T H O & S P O R T S ) 12/5/2014 22
EXERCISES PRESCRIBED BASED ON
EVIDENCE
ROM EXERCISES
 Glenohumeral Progression
 Condmans Pendulum
 Active Assistive motion with cane or contralateral arm
 Active motion as comfort dictates
 Active motion without elevating scapula

 Postural Progression
 Shrugs
 Shoulder retraction
FLEXIBILITY EXERCISES
 Door Corner stretch
 Posterior shoulder stretch (cross arm)
 Lateral neck stretch
STRENGTHENING EXERCISES
 Theraband exercise:
 External rotation (humerus adducted to the body)
 Internal rotation (humerus adducted to the body)
 Rows (seated or standing)
 Low trapezius rows

 Chair press
 Scaption
 Press-up (subscapula)
 Upright row
MANAGEMENT AND OUTCOMES
 The patient continued to start and play ever game of the season
 Limit hitting/serving
 No overhead lifting activities
 Patient satisfaction increased at the end of the season
 None complaint athlete
MANAGEMENT AND OUTCOMES
 Patient developed other complications along the way:
 Reported tingling and numbing sensation down all her fingertips
 Positive Adson’s and Allen's test

 Thoracic Outlet syndrome

DOCTOR APPOINTMENT
 MRI diagnosis
 Right shoulder pain
 Os Acromial
 Subscapular nerve impingement
 Infraspanatus atrophy

 R Shoulder impingement
 EMG Testing
DISCUSSION
 To answer my clinical question
 According to the literature laser therapy is an effective treatment for shoulder
impingement but the combination of rehab exercises and laser therapy
provides no beneficial effect.
WHAT WORKED
 Graston most effective treatment
 Provided therapeutic effect to upper traps, lats, and posterior capsule of
shoulder
 Joint Mobs another effective treatment
 Began with Grade 1 to II oscillations to alleviate joint pain
 Started Grade III to stretch posterior capsule

 Active Release Therapy

WHAT DIDN’T WORK
 Rehab exercises
 Patient was not consistent and was difficult to motivate
 Educate patient
 Laser therapy
 Patient was not consistent with coming in for treatments
 Alternative method for patient because she was not coming in for
exercises
 Stretching before practices or games
 Patient did not like to be stretched-believed it made her “shoulder
to lose”
WHAT COULD I CHANGE

 Rest the patient for a couple of weeks

 Begin conservative rehab program within those weeks
 Evaluate progression with Patient Reported Outcomes such as
the the DASH questionnair, Shoulder Pain and Disability Index
 Eccentric Exercises
ECCENTRIC TRAINING IN CHRONIC PAINFUL IMPINGEMENT SYNDROME OF
THE SHOULDER: RESULTS OF A PILOT STUDY

PEDRO SCALE: 4/11

 9 patients: All patients had tried different treatment regimens like

rest,
cortisone injections, NSAID, and different types of shoulder
rehabilitation exercises.
 The patients estimated the amount of pain in the shoulder during
horizontal shoulder activity on a 100-mm long visual analogue
scale (VAS) before treatment, and 12 weeks and 52 weeks after
treatment
RESULTS
REFERENCES
 Kelle B, Kozanoglu E. Low-level laser and local corticosteroid injection in the
treatment of subacromial impingement syndrome: a controlled clinical trial.
Clin Rehabil. 2014;28(8):762-771.
 Santamato A, Solfrizzi V, Panza F, et al. Short-term effects of high-intensity
laser therapy versus ultrasound therapy in the treatment of people with
subacromial impingement syndrome: a randomized clinical trial. Phys Ther.
2009;89(7):643-52.
 Yeldan I, Cetin E, Ozdincler AR. The effectiveness of low-level laser therapy
on shoulder function in subacromial impingement syndrome. Disabil Rehabil.
2009;31(11):935-40.
 Shakeri H, Keshavarz R, Arab AM, Ebrahimi I. CLINICAL EFFECTIVENESS
OF KINESIOLOGICAL TAPING ON PAIN AND PAIN‐FREE SHOULDER
RANGE OF MOTION IN PATIENTS WITH SHOULDER IMPINGEMENT
SYNDROME: A RANDOMIZED, DOUBLE BLINDED,
PLACEBO‐CONTROLLED TRIAL. International Journal of Sports Physical
Therapy2013;8(6):800-810.
REFERENCES CONTINUED
 Jonsson P, Wahlström P, Ohberg L, Alfredson H. Eccentric
training in chronic painful impingement syndrome of the shoulder:
results of a pilot study. Knee Surg Sports Traumatol Arthrosc.
2006;14(1):76-81.
 Kuhn JE. Exercise in the treatment of rotator cuff impingement: a
systematic review and a synthesized evidence-based
rehabilitation protocol. J Shoulder Elbow Surg. 2009;18(1):138–
160.
 Borstad JD, Ludewig PM. Comparison of three stretches for the
pectoralis minor muscle. J Shoulder Elbow Surg. 2006;15(3):324–
330.
 http://datalyscenter.org/programs/ncaa-injury-surveillance-
program/. Accessed November 30, 2014.
QUESTIONS