Dr. P.

Ratan khuman (PT)

M.P.T., (Ortho & Sports)
 Anatomy of shoulder
Left
Anterior
Shoulder

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 2

 Scapula

Anterior View Posterior View

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 3

 rotator cuff Muscles

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 4

 Muscle Force Couple
• Two forces of equal magnitude, but in opposite
direction, that produce rotation an axis.

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 5

 Muscles of
Shoulder
Girdle

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 6

 introduction
• The term “Impingement Syndrome” was popularized
by Charles Neer in 1972
• Neer defined impingement as pathologically
compression of rotator cuff against the anterior
structure of coracoacromial arch, anterior 1/3 of the
acromion, coraco-acromial ligament & AC joint.
• Progression of syndrome is define by a narrowing of
the sub-acromial outlet by spur formation in
coracoacromial ligament & undersurface.

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 7

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 8
 Definition:
• Shoulder impingement:
– It is compression & mechanical abrasion of supraspinatus as they
pass beneath the coracoacromial arch during elevation of the arm.
• Rotator Cuff Tendinitis:
– It encompasses impingement & result from acute rotator cuff
overload, intrinsic rotator cuff degeneration, or chronic overuse.
• Rotator cuff syndrome:
– It is the term used to describe the process whereby tendinitis &
impingement are ongoing simultaneously.
• Painful arc syndrome:
– Pain in the shoulder and upper arm during the midrange of
glenohumeral abduction, with freedom from pain at extremes of
the range due to supraspinatus damage
7/27/2013 Ratan Khuman (MPT Ortho & Sports) 9
• Impingement causes Mechanical irritation of cuff
tendons - resulting in haemorrhage and swelling
(commonly known as tendonitis of rotator cuff)
– The supraspinatus muscle is usually involved.
• This also affect the bursa – resulting in bursitis.
• Shoulder complex is susceptible to impingement
injuries from overhead sports –
– Such as baseball, tennis, swimming, volleyball etc.
• Impingement with rotator-cuff tendonitis is one of
most common shoulder injuries seen in athletes.

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 10

 Signs and Symptoms
• Pain & tenderness in the gleno-humeral area
• Pain or weakness with active abd in midrange
• Limited internal rotation compared to normal side
• Confirmation with special tests (Hawkins
impingement test)
• Tenderness to palpation in the sub-acromial area

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 11

 ETIOLOGY OF IMPINGEMENT

External Internal (Glenoid)

Repetitive
Primary Secondary Trauma

Outlet Instability Instability

Obstruction

Rotator Cuff Rotator Cuff Rotator Cuff

Dysfunction Dysfunction Dysfunction

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 12

 Factor development of
External impingement
• Anatomical abnormalities
– e.g. beaked/ # acronion, osteophyte
• Poor scapular control
• Anterior instability
• Postural changes in upper quadrant
– Forward head & rounded shoulder posture

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 13

 Types of acromions

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 14

 Factor development of
internal impingement
• Overuse – repetitive trauma
• Loose joint
• Instability
• Muscle imbalance
• Superior labrum injury

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 15

 stage of
shoulder impingement
syndrome (Sis)

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 16

 Stage-I:
edema & inflammation
• Age – younger than 25 years (but may occur at
any age)
• Reversible lesion
• Tenderness over greater tuberosity of humerus
• Tenderness over anterior ridge of acromion
• Painful arch 600 – 1200
• (+) ve Neer impingement test
• ROM may restricted with sub-acromial
inflammation

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 17

 Stage-II:
fibrosis & tendinitis
• Age – 25 – 40 years
• Not reversible by modification of activities
• Stage-I signs + the following –
– Soft tissue crepitus
– Catching sensation at lowering arm (approx 1000)
– Limitation of active & passive ROM

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 18

 Stage-III:
bone spur & tendon rupture
• Age > 40 years
• Not reversible
• Stage I + II signs + following –
– Limited ROM more prominently
– Atrophy of infra-spinatus
– Weakness of abductor & external rotator
– Bicep tendon involvement
– AC joint tenderness

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 19

 Common test
• For impingement –
– Neer impingement test
– Hawkins impingement test
– Crossover impingement test
• Rotator cuff test –
– Intraspinatus – external rotation
– Supraspinatus – empty can position & resistance
– Subscapularis – hand behind back (Lift off)
– Drop arm – for full thickness rotator cuff

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 20

Common test for impingement

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 21

 Treatment goal
• To relieve pain & swelling
• To decrease inflammation
• To retard muscle atrophy & strengthen cuff
muscle
• To maintain & improve ROM
• To increase neuromuscular control
• To increase strength, endurance & power
• Unrestricted symptom free activities
• To modified activity & prevent
7/27/2013 Ratan Khuman (MPT Ortho & Sports) 22
 Treatment approaches

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 23

 Functional modification
• Complete restriction of painful movt
• Analysis of aggravating exercises & motion
will help in modification of training programs
• A logical approach to restriction of activity &
gradually return
• Activity from painful column should not
reintroduce until pain free

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 24

 Pharmacological approach

• Oral anti-inflammatory medication

• Subacromial steroid in early inflammation stage
• Medication combine with therapeutic
modalities like – LASER, TENS, US etc

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 25

 Cryotherapy
• Over the tenderness in early inflammation stage
• Duration – 10 – 15 min
• Greater effect along with medication

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 26

 Electrotherapy
• TENS is useful in controlling muscular pain
• US therapy with 0.8 w/cm2, 3MHz, 6 min – to
restore inflammation
• Other modalities like LASER, IFT & heat
therapy are also effective in pain control

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 27

 Bio feed back
• It may be appropriate if there is excessive
laxity of humeral head
• Helpful in athlete unable to gain control of the
rotator cuff musculature

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 28

 Manual therapy approach
• Maitland’s concept –
– Mobilization for GH & ST joint
– Grade –
• I & II in early stage
• As symptoms response, can shift to even grade III & IV
– Glide –
• AP & inferior in scapular plane
• Combine glide as per requirement
– Oscillation – Usually 10 oscillation, 3 set is used.

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 29

 Manual therapy approach
• Cyriax’s concept
– Transvers friction massage is useful
– Better effect when combine with other modalities
& medications
• Mulligan’s concept
– Movement with mobilization (MWM) is effective

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 30

 Therapeutic exercise
• ROM exercise –
– Penduler exercises with light weight (1kg or Less)
– Active assisted ROM exercises in pain free range
• E.g. Rope & Pulley – flexion
– Anterior & posterior capsular stretching
– Stretching of upper trapezius, pectorals, biceps etc.
– Towel exercise
– Codman's exercises

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 31

 Stretching exercises
Internal
Rotator

Posterior
Complex
Pectoralis

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 32

 Therapeutic exercise
• Strengthening exercise –
– Isometric exercises –
• External & internal rotators
• Biceps
• Deltoid (all 3 fibers)
– Scapulo-thoracic stability exercise –
• Important for primary & secondary impingement
• OKC & CKC scapular stabilizing exercises
– Arm aerometry for endurance exercise

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 33

• Strengthening exercise –
– Plyometric shoulder strengthening using therabend
– Isokinetic exercise for
• Supraspinatus, prone extension & horizontal abduction

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 34

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 35
 Strengthening exercises

Adductor
Strengthening

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 36

 Deltoid
Strengthening

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 37

 Extensor
Strengthening

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 38

 Medial Rotator
Strengthening

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 39

 Lateral Rotator
Strengthening

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 40

 taping
• Taping for scapular abnormal movt or dyskinesia
• Taping + strengthening

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 41

 Mechanical correction
taping

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 42

 Kinesio-taping for
impingement
1 2 4

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 43

 Surgery
• Arthroscopic subacromial decompression
• Capsulorrhaphy

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 44

 Preventive measures
• Perform warm-up exercises & flexibility training
• Exercise the whole kinetic chain, including
strength training.
• Avoid abuse (pain-causing situations).

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 45

 Preventing Re-injury
• Perform warming-up before & cooling-down after
training, for no less than 15 minutes.
• Include stretching ex for the posterior shoulder.
• Perform preventative strengthening exercises for
the shoulder twice a week.
• Ensure you take adequate rest & avoid playing
too many games in too short period.
• Fatigue plays an important role in occurrence of
this kind of injury.

7/27/2013 Ratan Khuman (MPT Ortho & Sports) 46