Latest News - Mount Gravatt | Back In Motion

Shoulder Impingement

Published: July 5, 2021

What is shoulder impingement?


Subacromial impingement syndrome (SIS), often referred to as ‘rotator cuff impingement’ or ‘swimmers’ shoulder’ is a common overuse injury of those who engage in forceful overhead arm movements1. The rotator cuff muscles and/or shoulder bursa are intermittently trapped and compressed under the coracoacromial arch during shoulder elevation movements. When the arm is abducted or rotated, the subacromial space width reduces resulting in compression of the rotator cuff muscles2, commonly the supraspinatus tendon. Although shoulder impingement generally arises from chronic movement repetition, acute traumatic injuries may also contribute to the prevalence of this condition.3 Persisting shoulder impingement can often lead to shoulder bursitis and partial or complete rotator cuff tendon rupture.

 

What is the clinical presentation?

Subjective History

Shoulder impingement typically presents as pain localised to the anterolateral acromion and frequently radiates to the lateral mid-humorous4. Patients usually complain of pain at night, exacerbated by lying on the involved shoulder, or sleeping overhead. Pain also tends to be induced by activities of daily living which involve shoulder elevation at or above 90 degrees, such as combing one’s hair or reaching up into a cupboard5. Symptoms generally develop insidiously over a period of weeks to months, however impingement may arise from trauma.

Physical Examination

The physical examination of shoulder impingement is undertaken with a cluster of special tests. Testing positively on the Hawkins-Kennedy test, Neer’s sign, drop arm test and lift-off test is typical of shoulder impingement, however the diagnostic accuracy of these tests is limited6. The lift-off test provided strong evidence to rule in SIS when the test is positive.6 A thorough neck/shoulder examination should also be completed, with SIS patients often presenting with significantly increased resting thoracic flexion and reduced upper thoracic active range of motion, posterior shoulder range and passive internal rotation range of motion.7

 

Is imaging required for the diagnosis of shoulder impingement?

Diagnosis of SIS is based on the clinical findings, while imaging is used in conjunction to rule out rotator cuff tears or other physiological indicators8. Ultrasounds can be used primarily to detect rotator cuff tears, while MRI and MR arthrography are able to detect additional features which are suggestive of SIS such as bursitis and acromial spurs.8 Imaging plays an important part in identifying the cause of impingement and will hence assist clinicians with treatment planning9.

 

Conservative Vs. Surgical Management

There are several treatment options available for shoulder impingement. From a surgical perspective, this involves different types of open and arthroscopic surgical decompression techniques of the subacromial space. Conservatively, treatment methods include but are not limited to heat, cold, education, exercise prescription, dry needling and shockwave therapy. There is moderate evidence to suggest that surgical treatment is not more effective than active exercises in reducing pain intensity caused by shoulder impingement10. A recent systematic review synthesised evidence to infer that physiotherapy intervention programs, particularly those with an exercise component, should be used as the first treatment approach for patients with shoulder impingement11. The surgical option lacked clinically important benefits over physiotherapy from both a pain and functional standpoint.

 

What can physiotherapy do for shoulder impingement?

A physiotherapist will assess the patient’s experienced shoulder pain through subjective assessment, impingement-specific tests, shoulder range of motion and strength. From a treatment perspective, high-quality trials indicate statistically significant benefits with regards to shoulder pain and function through the completion of multiple types of exercise such as rotator cuff strengthening through range and scapular stability exercises12 13. Manual therapy may also be used to address extrinsic factors of the thoracic spine or posterior shoulder tightness, helping to reduce SIS related symptoms.14 Taping with either Kinesio or standard tape has also been proven effective at reducing pain levels15. Additionally, physiotherapists will provide continuous patient education regarding posture, activity modifications and self-management16.

 

Clinical bottom line

Patients presenting with ongoing shoulder pain during overhead activities and reduced shoulder range of motion should be assessed by a physiotherapist for shoulder impingement. A physiotherapist-guided treatment program consisting of patient-specific exercises, manual therapy, education and taping can help to reduce pain and improve function. Conservative management should be used as a first treatment approach for this condition.

 

References

  1. Kent, M. (2007). The Oxford Dictionary of Sports Science & Medicine (3 ed.). Oxford University Press: Oxford, UK.
  2. Graichen, H., Bonel, H., Stammberger, T., Englmeier, K. H., Reiser, M., & Eckstein, F. (1999). Subacromial space width changes during abduction and rotation- a 3-D MR imaging study. Surgical and Radiologic Anatomy, 21(1), 59-64. doi:10.1007/bf01635055
  3. Khan, Y., Nagy, M. T., Malal, J., & Waseem, M. (2013). The painful shoulder: shoulder impingement syndrome. The Open Orthopaedics Journal, 7(1), 347-351. doi:10.2174/1874325001307010347
  4. Koester, M. C., George, M. S., & Kuhn, J. E. (2005). Shoulder impingement syndrome. The American Journal of Medicine, 118(5), 452-455. doi:10.1016/j.amjmed.2005.01.040
  5. Harrison, A. K., & Flatow, E. L. (2011). Subacromial impingement syndrome. Journal of the American Academy of Orthopaedic Surgeons, 19(11), 701-704. Retrieved from https://pdfs.semanticscholar.org/4fa8/4b78e53b6ec2fedeb6fbaa1d34314a9c335d.pdf
  6. Alqunaee, M., Galvin, R., & Fahey, T. (2012). Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 93(2), 229-236. doi:10.1016/j.apmr.2011.08.035
  7. Land, H., Gordon, S., & Watt, K. (2017). Clinical assessment of subacromial shoulder impingement – which factors differ from the asymptomatic population? Musculoskeletal Science and Practice, 27(1), 49-56. doi:10.1016/j.msksp.2016.12.003
  8. Pesquer, L., Borghol, S., Meyer, P., Ropars, M., Dallaudiere, B., & Abadie, P. Multimodality imaging of subacromial impingement syndrome. Skeletal Radiology, 47(7), 923-937. doi:10.1007/s00256-018-2875-y
  9. Smith, C. P., Vassiliou, C. E., Pack, J. R., & von Borstel, D. (2018). Shoulder impingement and associated MRI findings. Journal of the American Osteopathic College of Radiology, 7(3), 1-14. Retrieved from https://www.jaocr.org/articles/shoulder-impingement-and-associated-mri-findings
  10. Saltychev, N., Aarimaa, V., Virolainen, P., & Laimi, K. (2014). Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Disability and Rehabilitation, 37(1), 1-8. doi: 10.3109/09638288.2014.907364
  11. Nazari, G., MacDermid, J. C., Bryant, D., & Athwal, G. S. (2019). The effectiveness of surgical vs conservative interventions on pain and function in patients with shoulder impingement syndrome. A systematic review and meta-analysis. Public Library of Science, 14(5). doi: 10.1371/journal.pone.0216961
  12. Hanratty, C. E., McVeigh, J. G., Kerr., D. P., Basford, J. R., Finch, M. B., Pendleton, A., & Sim, J. (2012). The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis. Seminars in Arthritis and Rheumatism, 42(2), 297-316. doi:10.1016/j.semarthrit.2012.03.015
  13. Turgut, E., Duzgun, I., & Baltaci, G, (2017). Effects of scapular stabilization exercise training on scapular kinematics, disability, and pain in subacromial impingement: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 98(10), 1915-1923. doi:10.1016/j.apmr.2017.05.023
  14. Land, H., Gordon, S., & Watt, K. (2019). Effect of manual physiotherapy in homogeneous individuals with subacromial shoulder impingement: a randomized controlled trial. Physiotherapy Research International, 24(2). doi:10.1002/pri.1768
  15. Kocyigit, F., Acar, M., Turkmen, M. B., Kose, T., Guldane, N., & Kuyucu, E. (2016). Kinesio taping or just taping in shoulder subacromial impingement syndrome? A randomized, double-blind, placebo-controlled trial. An International Journal of Physical Therapy, 32(7), 501-508. doi:10.1080/09593985.2016.1219434
  16. Hanratty, C. E., Kerr, D. P., Wilson, I. M., McCracken, M., & Sim, J. (2016). Physical therapists’ perceptions and use of exercise in the management of subacromial shoulder impingement syndrome: focus group study. Physical Therapy, 96(9), 1354-1363. doi:10.2522/ptj.20150427
Latest posts
Archive
View all news