Pathophysiology
Not entirely clear |
Thought to be syndrome that begins as overuse injury with tendinopathy of supraspinatus (undersurface near bicep) |
Age at presentation
Primary (External) |
>35 |
Secondary (External) |
<35 |
Internal (Glenoid) |
<35 |
Epidemiology
Repetitive overhead activities (handball, volleyball, swimming, carpenters, painters, hairdressers) |
Risk factors: heavy loads, infection, smoking, and fluoroquinolone antibiotics. |
Types
Primary (External) |
Narrowing of subacromial space. Abnormal acromion anatomy (hooked class III acromion) or swelling of soft tissues |
Secondary (External) |
Normal anatomy at rest and onset of impingement during shoulder motion, secondary to RC weakness (uncontrolled cranial translation of humeral head), or weak traps and SA muscles (limiting ER and rise of scapula w abd). |
Internal (Glenoid) |
Impingement of the articular surface of the RC against the glenoid labrum. |
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Complications
Altered biomechanics and atrophy |
Rotator cuff/bicipital tendonitis or tear |
Adhesive capsulitis |
Prognosis
~2 years w physio, NSAIDs, corticosteroid injections and other conservative interventions |
Clinical Presentation
Pain lifting arm or lying on affected side |
Functional restrictions, specifically overhead |
Pain during night |
Weakness and stiffness secondary to pain |
Subjective Markers
Onset is usually gradual or insidious, typically developing over weeks to months |
Patients unable to describe direct trauma or inciting event |
Pain described as being located over the lateral acromion, frequently with radiation to the lateral mid-humerus |
Inquire about overhead and repetitive activities |
Relief may be noted with rest, anti-inflammatory meds, and ice, but symptoms often recur upon return to activity |
Describe "Dead Arm": weakness after throwing, slipping of shoulder |
Popping, clicking, catching, sliding |
Creech and Silver, 2021 |
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Objective Assessment
Observation |
Observe neck and shoulder height. Muscular asymmetry. |
Palpation |
Tenderness when palpating over coracoid process |
AROM/PROM |
Loss w abd. and ER. Scapular dyskinesis seen with forward elevation. GIRD loss of IR & loss of total rotational motion. May have increased laxity. |
Strength |
Weakness with abduction and ER. |
Functional |
Throwing, reaching overhead |
Rehab
Equal effectiveness of physiotherapy led sessions and surgery in long term (Kromer, 2009) |
Conservative, NSAIDs, subacromial cortisol injections, treatment of choice for first 3-6 months |
Focus on rotator cuff strengthening (supraspinatus and infraspinatus), trap and SA strengthening |
Retraining exercises to minimize scapular dyskinesia |
Correct strength imbalances |
Hyperthermia (short-term relief) moderate evidence |
Special Tests (Positive Sign Combined)
Neer's |
Hawkins-Kennedy |
Empty Can (Jobe's) |
Painful Arc (btwn 70-120 degree) |
Negative sulcus sign, anterior apprehension, and relocation: shoulder instability |
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