Diagnosis: Shoulder Impingement

The term impingement syndrome is used to refer to a full range of rotator cuff abnormalities. There are two kinds of shoulder impingement; external impingement, which consists of primary and secondary, and internal impingement.

Primary external impingement involves changes to the subacromial space due to the shape of the acromion. It can occur in the older population when thickening of the coracoacromial arch or osteophyte formation of the acromioclavicular joint is present. Secondary external impingement involves instability of the shoulder due to inadequate muscular stabilisation. Internal impingement occurs mainly in overhead sportspeople who do a lot of throwing where the rotator cuff impinges against the glenoid.

How shoulder impingement presents

Depending on the type of impingement occurring, patients with external impingement will typically present with anterior and/or lateral shoulder pain with overhead activity, or posterior and/or anterior shoulder pain with abduction/external rotation with internal impingement.

How shoulder impingement is diagnosed

There are a number of physiotherapy assessment tests that can be helpful in ruling in or out impingement syndrome. These include empty can/full can test, Hawkins-Kennedy test, Speeds test and Neer’s test. X-ray imaging may also be used to see changes.

Causes of shoulder impingement

There are many potential causes for getting or being pre-disposed to impingement and they relate to the structure and function of the shoulder. These include:

• Too much or too little mobility or movement in the shoulder capsule. Increased laxity (movement) can lead to impingement, as the humeral head is moving too much. Whereas too little movement caused by posterior tightness of the capsule can move the humeral head upwards, causing impingement.
• Abnormal scapula (shoulder blade) position causing glenohumeral dysfunction.
• Postural changes such as scoliosis or a rounded shoulder posture. These can effect the position of the scapula.
• Inflammation or thickening of the bursa of the shoulder complex. Also thickening of the rotator cuff tendon can be a factor.
• An inefficient rotator cuff. If it is not stabilizing the humeral head as much as it normally should, the humerus will again move and can cause impingement against the coracoacromial arch.
• Changes in coracoacromial arch structure itself can also be a factor in the presence of impingement syndrome.

Treatment of shoulder impingement

Non-operative rehabilitation for shoulder impingement typically involves four phases.

Firstly, the acute phase focuses on pain and inflammation relief, returning to normal range of motion, re-establishing muscular balance, posture improvement and withholding from aggravating activities. This phase may involve range of motion exercises, joint mobilisations, strengthening exercises, postural exercises, patient education and guidance for progression of these.

The second phase, the intermediate phase again focuses on the points of the first phase but progresses each to further enhance function and strength. It aims to achieve pain-free range of motion, normalise muscular strength and movements of the shoulder complex, continue reduced inflammation and pain and further 
increase activities with involved arm.

Phase three, the advanced strengthening phase, focuses on flexibility and stretching, and strengthening exercises. It aims to improve muscular strength and endurance, sustain flexibility and range of motion, continue postural correction
 and begin a graduated increase in functional activity level.

Lastly, the return to activity phase, aims to achieve unrestricted, symptom free activity, where the patient begins to integrate an interval sports program for their activity, such as throwing or tennis. It also continues with the exercise plan as per the previous phases, involving flexibility exercises and isotonic exercises, to maintain the strength of the rotator cuff and overall function of the shoulder.

There are also surgical options for impingement when non-operative treatment is not warranted or effective.

Sandi Davis
Student Physiotherapist

References

Brukner, P. (2014). Impingement. In Brukner and Khan’s Clinical Sports Medicine (4^th ed., pp 353-356) Australia, Mcgraw-Hill Education (Australia) Pty Ltd.

Escamilla, R. F., Hooks, T. R., & Wilk, K. E. (2014). Optimal management of shoulder impingement syndrome. Open access journal of sports medicine, 5, 13.

Papadonikolakis, A., McKenna, M., Warme, W., Martin, B. I., & Matsen, F. A. (2011). Published evidence relevant to the diagnosis of impingement syndrome of the shoulder. The Journal of Bone & Joint Surgery, 93(19), 1827-1832. doi:10.2106/JBJS.J.01748

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