1. SHOULDER IMPINGEMENT
SYNDROME
Ili Diyana Binti Nor Azni

2. ANATOMY OF THE SHOULDER

3. SHOULDER IMPINGEMENT
SYNDROME
Definition : Occurs when the rotator cuff tendons,
long head of the biceps tendon, glenohumeral
joint capsule, and/or subacromial bursa become
impinged between the humeral head and anterior
acromion.

4. MECHANISM OF INJURY
 Shoulder instability- rotator cuff weakness
A radiographic study of normal subjects has
shown that the humeral head migrates
proximally when the cuff is fatigued (Chop et al
2010)

5.  Bony anatomical pathological factors
Type 3 hooked shaped acromion

6.  Capsular Tightness
 A correlation has been shown between impingement
and posterior capsular tightness (Tyler et al, 2000)
 Impaired scapulohumeral rhythm and scapular
instability
 Scapula motion is impaired with people with
shoulder impingement. This is linked to decreased
serratus anterior activity and scapular instability
(Ludewig and Cook, 2000)

7.  Capsulo-ligamentous laxity
 Consequent minor subluxation of glenohumeral joint,
underlie impingement in the younger population.
 Postural Factors
 The potential link between posture and impingement
may be illustrated by elevation of the arm in a
coronal plane while slouching. It causes a painful arc,
presumably by depressing the point of the acromion
and lowering the acromial arch.( Lin et al., 2010)

8. CLINICAL PRESENTATION
 Pain
Pain is typically localised to the anterolateral acromion
and frequently radiates to the lateral mid-humerus
Patients usually complain of pain at night, exacerbated
by lying on the involved shoulder, or sleeping with the
arm overhead.
Normal daily activities such as combing hair or
reaching up into a cupboard become painful, and a
general loss of strength may be noted.
Painful arch syndrome
Quality of pain (eg, sharp, dull, radiation, throbbing,
burning, constant)

9.  Painful clicking sound
 Apprehension of dislocation on overhead
movement
 Feeling of heaviness of hand.

10. DR MX.
1.Conservative
 Rest and avoid overhead
activities
 Anti-inflammatory drugs
http://www.shouldersurgeon.com/shoulder_impingement/
2. Surgical
- A small incision is made
- Shave off a tiny portion of
the acromion process
- Allowing a pain free
movement in the shoulder
joint

11. PT MANAGEMENT
 Modalities
 Manual therapy
 Stretching
 Mobilizing exercise
 Strethening exercise

12. STRETCHES
Codman’s
Pendulum
Swings
Triceps Stretch
Horizontal
Adduction
Stretch
Internal
Rotation
Stretch
http://www.athleticadvisor.com/images/Acrobat/Impingement.pdf

13. STRETCHES CONT..
External
Rotation
Standing
Adduction
Stretch
http://www.athleticadvisor.com/images/Acrobat/Impingement.pdf
Chest and Biceps
Stretch

14. EXERCISES TO STRENGTHEN SITS
MUSCLES
Bent over
rows
http://www.athleticadvisor.com/images/Acrobat/Impingement.pdf
Seated Dips
Active
Flexion

15. CASE STUDY-
 Demographic Data
 Name : Mr. H.
 Age : 67
 Gender : Male
 Race : Malay
 Doctor’s Diagnosis : Sh. Pain secondary to old injury
 Date of PT assessment : 25/3/2014
 Pt.’s Problems
 c/o inability to fully lift up his Lt sh. and on overhead
movement
 Claim had difficulty removing shirt and inability lift
heavy (>5kg objects)

16.  Pain Assessment
Area : ant. aspect of Lt. sh.
Nature : throbbing, catching pain
Agg. : Lift hand >90deg, remove off shirt, carry heavy
objects >5kg, do exercise (VAS : 5/10)
Ease : Rest, hand in normal position (VAS : 0/10)
24 hrs: Depend on activity, more pain at night if
sleep on Lt. sd. but not disturbing sleep
Irritability : non-irritable (pain will subside
immediately after agg. factor removed )
Severity : not severe

17. AREA OF PAIN

18.  Special Question
General health : Good
Other health condition : HPT and DM since past 2 yrs
Medication : HPT and DM medication
X-ray : Nil
Dominant hand : Lt. hand
 Current Hx.
Pt referred to physio HKK after receiving physio
treatment at KK Cheras for 3/52
 Past Hx. : Pt had Lt sh. pain since past 6/12 after
knitting fruit. The pain gradually increase and
pt referred dr. on Jan 2014 as the pain
became unbearable. Pt then referred to do
physio at KK Cheras

19.  Past Hx. : Pt had h/o Lt ant sh. dislocation
10 yrs ago
 Social Hx. :
Occ: Retired estate manager
Dominant hand : Lt hand

20. OBJECTIVE ASSESSMENT
 Observation
General :
Pt medium sized Malay man came into dept.
with normal gait.
Posture : - Slightly kyphotic
- ears slightly anterior than
shoulder
- Lt. Sh. and scapula lower than
Rt.
- No winging of scapula
- Pelvic same level
- Kn. same level

21. Local :
No swelling at shoulder region
No redness at shoulder region
Palpation
 Muscle spasm noted on Lt upper trapezius
 Pain on palpation over biceps long head,
supraspinatus and subscapularis tendon.

22.  ROM
Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-100° 0-110°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM

23.  UL Muscle strength
 30 secs biceps curl
Reading Lt Rt
1st
23 25
2nd
22 24
3rd
21 24
Average 22 24

24. CLEARING TEST
 Scapula physiological movement –
 Neck - AFROM
movemen
t
Lt. Rt
Active Passive Active Passive
Elevation normal normal normal normal
Depression normal normal normal normal
Protractio
n
normal normal normal normal
Retraction normal normal normal normal

25. SPECIAL TEST
 Neer’s test: +ve indicate impingement
 Hawkin Kennedy : +ve indicate impingement
 Speed test : +ve indicate bicipital tendinitis
 Empty can test: +ve indicate supraspinatus
tendinitis
 Anterior drawer test : -ve
 Posterior drawer test : -ve

26. FUNCTIONAL ACTIVITY
 DASH Diasability Symptom score
Score: 42.5% - moderate disability

27. ANALYSIS
 Impairment
 Pain at Lt anterior and lateral sd. of Lt. sh d/t
subacromial inflammation
 Reduced ROM of Lt. glenohumeral jt. d/t pain
 Recduced Lt Sh. Muscle power d/t reduced mobility
 Muscle spasm of upper trapezius d/t protective
mechanism of muscle

28.  Functional limitation
 Difficulty to remove off shirt
 Difficulty on reaching high objects (overhead
movement)
 Unable to carry heavy objects (>5kg)
 Participation rx
 Restricted sports and recreational activity with
friends and family members

29. SHORT TERM GOAL
 To reduce pain in 1/7
 To improve ROM in 1/52
 To increase muscle power in 2/52
 To reduce upper trap muscle spasm in 1/7

30. LONG TERM GOAL
 To maximize functional activity of daily living
 To prevent secondary complication

31. PLAN OF TX
 Pain mx.
 Mobilizing exe
 Strengthening exe
 Stretching
 MFR
 HEP
 Pt. edu

32. INTERVENTION U/S at biceps long head, supraspinatus , and subscapularis
tendon; 1MHz, 0.8 W/cm X 5min
 MFR at upper trap muscle X 10 min
 Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;
rep 10 X every movt.
 Std.; put hands on hips, lean back, hold 15 sec.;
rep 5X
 Std.; pull sh. Up and back; hold 15s; rep 5X
 Sitt.;horizontal add. Lt sh.;hold and push Lt
elbow backward using Rt. Arm; hold 5s; rep 5X
 Sitt.; ext rot sh. With 1kg dumbell ;rep 10X
 Sitt.; int rot sh. With 1kg dumbell ;rep 10X
 Hot pack at Lt Sh.; X 20min
 Educate pt. to do exe as taught at home 3X/ day

33.  Evaluation : Pt able to do exercise with minimal
pain.
 Review : To reasess ROM and painscale on next
visit

34. 2ND
VISIT ON 26TH
MAR 2014
 Subjective Ax: Pt. claim VAS still same
 Objective Ax:
 Observation
General :
 Pt medium sized Malay man came into dept. with
normal gait.
Local :
No swelling at shoulder region
No redness at shoulder region
 Palpation
 Muscle spasm noted on Lt upper trapezius
 Pain on palpation over biceps long head, supraspinatus
and subscapularis tendon.

35. Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-100° 0-110°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM

36.  Analysis : no significant improvement
 Plan :
 Pain mx.
 Mobilizing exe
 Stretching
 Strengthening exe
 MFR
 HEP
 Pt. edu

37. INTERVENTION
 Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ;
10X; 6 cycle
 MFR at upper trap muscle X 10 min
 Std. in front of mirror; stick exercise for flex.; ext.;
abd.;add.; rep 10 X every movt.
 Sitt.;horizontal add. Lt sh.;hold and push Lt elbow
backward using Rt. Arm; hold 5s; rep 5X
 Std.;place hand at sh. Level on room corner; lean fwd;
hold 15 s; rep 5X
 Sitt.; ext rot sh. Using theraband;rep 10X
 Sitt.; int rot sh. Using theraband;rep 10X
 Hot pack at Lt Sh.; X 20min
 Educate pt. to do exe as taught at home 3X/ day

38.  Evaluation : Pt able to do exercise with minimal
pain.
 Review : To reasess ROM and painscale on next
visit

39. 3RD
VISIT ON 31ST
MAR 2014
 Subjective Ax: Pt. claim VAS still same
 Objective Ax:
 Observation
 General :
 Pt medium sized Malay man came into dept. with
normal gait.
Local :
No swelling at shoulder region
No redness at shoulder region
 Palpation
 Muscle spasm noted on Lt upper trapezius
 Pain on palpation over biceps long head, supraspinatus
and subscapularis tendon.

40. Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-120° 0-125°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM

41.  Analysis :Sh. flex ROM improved by 10 °
 Plan :
 Pain mx.
 Mobilizing exe
 Stretching
 Strengthening exe
 MFR
 HEP
 Pt. edu

42. INTERVENTION
 Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ; 10X; 6
cycle
 MFR at upper trap muscle X 10 min
 Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;
rep 10 X every movt.
 Sitt.;neck stretching; hold 5s; rep 5X
 Std.;place hand at sh. Level on wall; wall push up; hold 10 s;
rep 10X
 Std.; bend elbows at sh. Level using elastic cord; hold 10s; rep
10 X
 Sitt.; ext rot sh. Using theraband;rep 10X
 Sitt.; int rot sh. Using theraband;rep 10X
 SWD at Lt Sh.; X 20min
 Educate pt. to do exe as taught at home 3X/ day

43.  Evaluation : Pt able to do exercise with minimal
pain.
 Review : To reasess ROM and painscale on next
visit

44. 4TH
VISIT ON 3 APR 2014
 Subjective Ax: Pt. claim VAS still same
 Objective Ax:
 Observation
General :
Pt medium sized Malay man came into dept.
with normal gait.
Local :
No swelling at shoulder region
No redness at shoulder region
 Palpation
Muscle spasm noted on Lt upper trapezius
Pain on palpation over biceps long head,
supraspinatus and subscapularis tendon.

45. Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-140° 0-145°
FROM
Ext FROM FROM
Abd 0-90° 0-95°
Int. Rot. 0-15° 0-15°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM

46.  Analysis : no significant improvement
 Plan :
Pain mx.
Mobilizing exe
Stretching
Strengthening exe
MFR
HEP
Pt. edu

47. INTERVENTION
 Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ;
10X; 6 cycle
 MFR at upper trap muscle X 10 min
 Std. in front of mirror; stick exercise for flex.; ext.;
abd.;add.; rep 10 X every movt.
 Sitt.;horizontal add. Lt sh.;hold and push Lt elbow
backward using Rt. Arm; hold 5s; rep 5X
 Std.;place hand at sh. Level on room corner; lean fwd;
hold 15 s; rep 5X
 Sitt.; ext rot sh. Using theraband;rep 10X
 Sitt.; int rot sh. Using theraband;rep 10X
 Hot pack at Lt Sh.; X 20min
 Educate pt. to do exe as taught at home 3X/ day

48.  Evaluation : Pt able to do exercise with minimal
pain.
 Review : To reasess ROM and painscale on next
visit

49. 5TH
VISIT ON 7TH
APR 2014
 Subjective Ax: Pt. claim VAS still same
 Objective Ax:
 Observation
 General :
 Pt medium sized Malay man came into dept. with
normal gait.
Local :
No swelling at shoulder region
No redness at shoulder region
 Palpation
 No spasm noted on Lt upper trapezius
 Pain on palpation over biceps long head tendon.

50. Joint Motion Left Right
Active Passive Active Passive
Sh. Flex. 0-150° 0-155°
FROM
Ext FROM FROM
Abd 0-100° 0-105°
Int. Rot. 0-20° 0-20°
Ext. Rot. 0-45° 0-45°
Elb. Flex. FROM FROM
Ext. FROM FROM

51.  Analysis : Increased Sh. ROM and reduced VAS
to 4/10 on agg condition.
 Plan :
 Pain mx.
 Mobilizing exe
 Stretching
 Strengthening exe
 HEP
 Pt. edu

52. INTERVENTION
 Jt Mob oscillatory grade 1 ; AP, PA and inferior glide ; 10X; 6
cycle
 MFR at upper trap muscle X 10 min
 Std. in front of mirror; stick exercise for flex.; ext.; abd.;add.;
rep 10 X every movt.
 Sitt.;neck stretching; hold 5s; rep 5X
 Std.;place hand at sh. Level on wall; wall push up; hold 10 s;
rep 10X
 Std.; keep elb. Straight and pull elastic band posteriorly; hold
10s; rep 10X
 Sitt.; ext rot sh. Using theraband;rep 10X
 Sitt.; int rot sh. Using theraband;rep 10X
 SWD at Lt Sh.; X 20min
 Educate pt. to do exe as taught at home 3X/ day

53.  Evaluation : Pt able to do exercise with minimal
pain.
 Review : To reasess ROM and painscale on next
visit

54. CONCLUSION
 Manual technique and exercise is beneficial in order
to reducing pain and improving function on patient
with shoulder impingement syndrome
 Review on articles found that ultrasound is either
not give a significant benefit or giving no benefit at
all for impingement cases.
 Grade 1 oscillatory joint mobilization technique can
be used in order to relieve pain in impingement
syndrome only but not necessary to improve
mobility and function when combined with
modalities, stretching strengthening exercise and
patient education.

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