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Subacromial Impingement Syndrome

Research has shown that subacromial impingement syndrome of the shoulder joint is the most likely cause of shoulder pain. In some literature it has been shown to be the most common of all shoulder pain complaints (Van der Windt et al, 1995). Although the initial condition causes pain, if left untreated this may progress to a loss of function and disability (Michener et al, 2003).

Patient presentation

  • Pain around the anterior aspect of the glenohumeral (GH) joint
  • Pain with active abduction and flexion of the arm.
  • Tenderness on palpation of the soft tissues around the shoulder with associated inflammation.
  • Insidious onset secondary to repetitive movements or post-trauma.
  • Structures involved

The acromioclavicular joint, connects the clavicle to the scapula. Situated under this structure are both the subacromial bursa and the supraspinatus tendon. All of which can be affected by subacromial impingement. Other structures might include the thoracic and cervical spine due to their functional association with the shoulder complex as well as the remaining rotator cuff muscles: infraspinatus, teres minor, subscapularis. 

Etiology
There are numerous reported causes of subacromial impingement syndrome, including:

  • Inflammation of the supraspinatus tendon
  • Inflammation of the subacromial bursa
  • Poor scapula stabilisation
  • Weak or dysfunctional rotator cuff muscles
  • Instability of the GH joint
  • Forward head carriage


Pathophysiology
The two main causes of this condition are degeneration and/or inflammation of the supraspinatus tendon and/or subacromial bursa. An increase in pressure on the supraspinatus tendon as it passes through the subacromial space can cause irritation and inflammation (Seitz et al, 2011). Anatomic anomalies at the acromion process are thought to increase the probability of joint impingement (Bang and Deyle, 2000).

Secondary impingement may arise due to weakness and instability of the GH joint. The combination of weakness around the GH joint and deficient recruitment of the scapula stabilising muscles results in the humeral head shifting anteriorly and superiorly.  This leads to further compression of the soft tissues within the subacromial space (Bang and Deyle, 2000).

Diagnosis
Diagnosis is achieved through both a thorough case history and physical examination. During the examination, a comparison of the affected shoulder with the unaffected shoulder is fundamental, involving both observation and palpation of the affected structures. Active and passive movements of the GH joint to identify range of motion limitations give a good indication of instability around the shoulder joint. Special tests are required to refine the diagnosis and give a clear indication of the structures involved. More specifically, orthopaedic testing for suspected subacromial impingement should include; Hawkins-Kennedy test, Paxinos test, Scapular assistance test and O'Briens test (Brukner and Khan, 2006).

Treatment
Early stages of subacromial impingement can be helped by cryotherapy and physical therapy, which should include soft tissue massage and joint mobilisation. Joint mobilisations may be directed at the GH joint, cervical and thoracic spines. Research by Bang and Deyle (2000) showed that people suffering with subacromial impingement syndrome had a greater improvement in pain, functionality and strength when combining physical therapy and supervised shoulder exercises, compared to people receiving supervised exercises alone.

Once acute pain reduction has been established, muscle rehabilitation is extremely important for the recovery and maintenance of shoulder health. A study has shown that retraining of the muscles of the shoulder can help to reduce pain and increase range of movement, thus aiding functionality further (Ginn et al, 1997). The focus of the strengthening exercises should be on the rotator cuff and stabilising muscles of the scapula (Michener et al 2000).

Postural advice and training is also beneficial to help improve the mechanics of the GH joint. Using postural taping to correct faulty posture has positive effects on forward head carriage and aids the patient to achieve a greater range of GH motion before pain initiates (Lewis et al, 2005).

The use of corticosteroid injections can be effective in reducing the inflammation around the structures causing the impingement. This then gives the therapist and patient a window of opportunity to rehabilitate the shoulder without pain restricting progress (Brukner and Khan, 2005). At the Blackberry Clinic, fluoroscopic guidance can be used to gain optimum accuracy and therapeutic effect. We have several doctors and therapists who are able to deliver these injections should this be necessary.

The Blackberry Clinic is proud to be able to offer a wide variety of treatments to suit different patient's needs and to enhance their recovery.

Contributing Authors:
Louise Barrett, BSc Osteopathic Medicine
Shelley Doole DC MChiro

References
Bang M.D., Deyle G.D., 2000. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. The Journal of Orthopaedic and Sports Physical Therapy, 30(3):126-137.

Brukner P. & Khan K. (2006). Clinical Sports Medicine. 3rd Ed. Australia : Mc Graw-Hill .

Ginn K.A., Herbert R. D., Khouw W . &  Lee R., 1997. A Randomized, Controlled Clinical Trial of a Treatment for Shoulder Pain. Physical Therapy 77(8):802-809.

Lewis J.S., Wright C., Green A., 2005. Subacromial Impingement Syndrome: The Effect of Changing Posture on Shoulder Range of Movement. Journal of Orthopaedic Sports Physical Therapy 35(2).

Michener L., McClure P.W., Karduna A.R., 2003. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clinical Biomechanics 18:369–379.

Michener L.A., Walsworth M.K., Burnet E.N., 2000.  Effectiveness of Rehabilitation for Patients with Subacromial Impingement Syndrome: A Systematic Review. Journal of Hand therapy, 2004;17:152–164.

Seitz A.L., McClure P.W., Finucane S., Douglas-Boardman N., Michener L.A., 2010.  Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? Clinical Biomechanics 26(1):1-12.

Van der Windt D.A., Koes B.W., De Jong B.A., Bouter L.M.,1995. Shoulder disorders in general practice: incidence, patient characteristics, and management. Annals of Rheumatic Disease 54:959–64.