Differential Diagnosis of Shoulder Impingement

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Differential Diagnosis of Shoulder Impingement

• Charlie Cotterill
• Junior Physiotherapist
• Feb 2006

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AIMS
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Anatomy

• Subacromial joint.
• Subacromial space 9-10mm
• Force couple to counteract downward pull of
  deltoid Thompson et al (1996)
• Jarjavay (1867)
• Neer (1972), anatomical variations in build,
  strain and repetitive microtrauma.
• Degeneration of the rotator cuff, oedema,
  bleeding, fibrosis and calcification ? ruptures,
  osteophyte formation, and spur formation.

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Aetiology

• Primary/Secondary
• Intrinsic/Extrinsic

Bigliani Classification (1991)
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Aetiology

• Aetiology of SIS is multifactoral (Lewis et al
  2001).
• Mechanical/Anatomical
• Primary mechanical impingement (Neer 1972, 1983)
• Acromial bone spurs (Neer 1972)
• Os acromiale (Neer 1972, 1983)
• Corocoacromial ligament (soslosky et al 1994)
• Postereosuperior glenoid impingement (Jobe 1997,
  Riand et al 1998)
• Rotator cuff
• RC overuse (Jobe and Jobe 1983, Meister and
  Andrews 1993, Frost et al 1999)
• Degenerative tendinopathy (Ozaki et al 1988)
• Instability/hypermobility
• Secondary tensile disease (Meister and Andrews
  1993)
• Secondary compressive impingement (Warner et al
  1990)

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Aetiology

• Restrictive processes
• Restricted glenhumeral capsule (Harryman et al
  1990, Matsen and Arntz 1990)
• Posture
• Ayub 1991, Bowling et al 1986, Calliet 1991,
  Solem-Bertoft et al 1993)
• Functional scapular instability
• Kibler 1991, 1998, 2002, 2003, Warner et al 1992,
  Lukasiewicz 1999, Ludewig and Cook 2000,
  Wandsworth, Bullock Saxton 1997)
• Lateral Kibler slide test

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Scapula
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Differential Diagnosis?

• Labrum tear Cervical/Thoracic spine RA
  Bursitis
• Polymyalgia Rheumatica Rotator cuff tear
• Biceps tendon rupture/tendinopathy Calcific
  tendinitis
• Adhesive capsulitis AC arthritis
  Glenohumeral arthritis
• Septic arthritis Gout Lyme disease Long
  thoracic nerve injury
• Visceral PE, pleuritis, pericarditis, angina,
  MI, cholecystitis, pancreatitis, adnexitis.
• Lupus erythematosus Spondylo-arthropathy AVN
  
• Cervical radiculopathy Tumor/Malignancy
  Thoracic outlet Brachial plexus neuropathy
  Trigger points Post CVA Glenohumeral instability
  Humeral subluxation

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Evidence

• Evidence suggests that the condition is not
  self-limiting.
• Systematic review of manual and physical therapy
  treatment in SIS by Desmeules et al. revealed
  only 7 RCTs Limited evidence to support the
  efficacy of physical therapy in SIS
• Lack of uniformity in defining, evaluating, and
  treating SIS.
• Supervised exercises appear to be preferable to
  arthroscopic surgery for patients with persistent
  shoulder impingement syndrome. Brox et al (1993)
• A review of 8 RCTs evaluated the efficacy of
  corticosteroid injection in the rx of rotator
  cuff tendonitis (Koester et al). 2 of the 8
  trials showed clinically relevant improvements in
  pain and range of motion in the injection groups
  as compared with placebo.
• Two systematic reviews found ultrasound to be
  ineffective in the management of pain in the
  shoulder (Green and Heijden

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Scapula Rehab
Living within a window
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CONCLUSION
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REFERENCES

• Neer CS. Impingement lesions. Clin Orthop Rel
  Res. 198317370 77.
• Neer, C. S. II. Anterior acromioplasty for the
  chronic impingement syndrome in the shoulder. J.
  Bone Joint Surg. 54A4150, 1972 22.
• Neer, C. S. II and R. P. Welsh. The shoulder in
  sports. Orthop. Clin. North Am. 8583591, 1977.
• Hawkins RJ, Brock RM, Abrams JS, Hobeika P.
  Acromioplasty for impingement with an intact
  Rotator cuff. J Bone Joint Surg Br. 1988
  70795797.
• Michael C. Koester, MD, Michael S. George, MD,
  John E. Kuhn, MD Shoulder impingement syndromeThe
  American Journal of Medicine (2005) 118, 452455
• Brox JI et al Arthroscopic surgery compared with
  supervised exercises in patients with rotator
  cuff disease (stage II impingement syndrome) BMJ
  1993 Oct 9 307899-903.
• Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman
  JD, Efficacy of injections of corticosteroids for
  subacromial impingement syndrome. J Bone Joint
  Surg Am. 1996 Nov78(11)1685-9. 
• Downing DS, Weinstein A. Ultrasound therapy of
  subacromial bursitis. A double blind trial. Phys
  Ther1986661949.
• Nykanen M. Pulsed ultrasound treatment of the
  shoulder. A randomised, double blind, placebo
  controlled trial. Scand J Rehabil
  Med1995271058.
• Hasson S, Mundorf R, Barnes W, Williams J, Fujii
  M. Effect of pulsed ultrasound versus placebo on
  muscle soreness perception and muscular
  performance. Scand J Rehabil Med199022199205.
• Green S, Buchbinder R, Glazier R, Forbes A.
  Systematic review of randomised controlled trials
  of interventions for painful shoulder selection
  criteria, outcome assessment and efficacy. Br Med
  J199831635460.

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REFERENCES

• Kibler, W. Ben MD a Uhl, Tim L. PhD, ATC, PT b
  Maddux, Jackson W. Q. MD c Brooks, Paul V. MD a
  Zeller, Brian MS, ATC d McMullen, John MS, ATC
  2002. a Qualitative clinical evaluation of
  scapular dysfunction A reliability study.
  Journal of Shoulder Elbow Surgery.
  11(6)550-556,
• W. Ben Kibler, MD and John McMullen, ATC , 2003
  Scapular Dyskinesis and Its Relation to Shoulder
  Pain, J Am Acad Orthop Surg, Vol 11, No 2,,
  142-151.
• Lewis. J, Green. A, Dekel. S, The Aetiology of
  subacromial impingement syndrome, Physiotherapy
  Sept 2001, vol 87, No 9, pg 453-468.
• McKenna et al (2004) Inter-tester reliability of
  scapular pposition in junior elite swimmers,
  Physical therapy in sport 5, 146-155.
• Van der Heijden GJMG, van der Windt DAWM, de
  Winter AF. Physiotherapy for patients with
  shoulder disorders a systematic review of
  randomised controlled clinical trials. Br Med
  J19973152530.
• C. A. Speed, Rheumatology 2001 40 1331-1336,
  Therapeutic ultrasound in soft tissue lesions
• P Frost and JH Andersen, shoulder impingement
  syndrome in relation to Shoulder intensive
  workOccup. Environ. Med. 199956494-498