Anterior Shoulder Impingement
Shoulder impingement syndrome is a common issue of the shoulder, and is caused when the supraspinatus tendon becomes painfully entrapped between the tip of your shoulder blade (the acromion process) and humerus while raising and internally rotating the arm. Repetitive impingement is thought to precipitate a cascade of shoulder dysfunction including rotator cuff tendonopathy, degeneration of associated joints and eventually, rotator cuff rupture. Research suggests that 95% of chronic rotator cuff tears are due to impingement (7).
Symptoms of Anterior Impingement Syndrome
The onset of SAIS is often related to a period of overuse. Initially, symptoms may be limited to a sharp pain during overhead activity or while reaching behind the back to fasten a bra or close a zipper. As the condition progresses, the patient may develop a constant ache that is present at rest. Nighttime pain is common, often disrupting sleep. Sleeping on the affected side may exacerbate symptoms. The discomfort is often located over the anterior shoulder and lateral deltoid areas.
What causes impingement?
Impingement results from repetitive injury, and its development is partially related to the amount of “room” in the subacromial space. AC joint degeneration, osteophytes, and thickened coracoacromial ligament can decrease this space. Perhaps the greatest threat to subacromial space comes from having misshapen acromion. A “Beaked” (type III) acromion is more common in males and is present in 75% of patients with a rotator cuff tear. (8) Researchers believe that the changes to the acromion may be the result of longstanding impingement (23,24). Scapular dyskinesis is present in up to 100% of impingement cases. (9)
Risk factors for Impingement Syndrome
“Upper crossed syndrome” and scapular dyskinesis are significant predisposing factors for impingement. Upper crossed syndrome is a functional pattern that involves tight upper traps, tight pectorals, weak deep neck flexors, and weak lower traps. Scapular dyskinesia is simply the improper movement of the shoulder blade as the arm moves.
Who is affected the most?
Impingement Syndrome is the most common disorder of the shoulder and accounts for 44-65% of all shoulder complaints seen by physicians (2). Rotator cuff problems are common in younger and middle-aged populations. Those who perform repetitive overhead activity are at greatest risk. This group includes athletes who participate in: swimming, baseball, volleyball, weightlifting, and tennis as well as professions like carpenters, electricians, painters and wallpaper hangers.
Stages of Impingement Syndrome:
Impingement is a continuum of degeneration that can be categorized into three stages.
Stage 1 is common in younger patients and is characterized by acute but reversible pain and swelling.
Stage 2 typically affects patients between the ages of 25-40 who have suffered from impingement for months or years. Stage 2 is characterized by tendonitis and fibrosis of the supraspinatus tendon, biceps tendon and subacromial bursa.
Stage 3 is the culmination of a prolonged irritation that has caused significant tendon degeneration and fibrosis for many years. It typically affects patients over the age of 40 or 50 and is characterized by irreversible mechanical disruption of the rotator cuff tendon. Stage 3 often includes degenerative changes to the biceps tendon and/or rupture.
Is imaging necessary?
Radiographs are typically not necessary until a trial of care is performed. In general, shoulder radiographs are appropriate in cases of trauma, severe pain, prolonged pain or the inability to raise your arm 90 degrees (4). Ultrasound can identify tendon disruptions, but MRI is the imaging of choice for shoulder pathology and is useful to differentiate between findings consistent with SAIS vs. rotator cuff tear. An MRI arthrogram enhances clinical accuracy by detecting tendon tears or labral injury (5). Best treatment options for impingement syndrome:
Successful management of anterior impingement syndrome should initially focus on restoring range of motion while avoiding aggravating movements, i.e., raising arm and internal rotation. Patients should avoid overhead presses, lateral raises, and push-ups. Selective rest may be necessary for some patients.
Best Treatment options:
- Manual therapy
- Isometric and Eccentric Strengthening Exercises
- Specific strengthening should include: scapular retractions, shoulder flexion, isolated supraspinatus, horizontal abduction, prone horizontal abduction, extension, external rotation and reverse shrugs. Home-based exercises are effective tools for managing SAIS. (30,45)
- Active release/myofascial release/IASTM
- Soft tissue manipulation or myofascial release should address associated hypertonic muscles . IASTM may be performed prudently over the supraspinatus tendon and associated adhesions.
- Kinesiology taping
- Kinesiology tape applied across the supraspinatus, deltoid, and teres minor, may promote scapular movement, enhance strength, and speed recovery times with lower disability (13-15) Applying tape over the deltoid and supraspinatus may increase subacromial space (38).
- Spinal manipulation of the cervical and thoracic spine
- Manual manipulation is needed to address restrictions in the cervical, upper thoracic and shoulder areas (6). There is evidence to suggest that cervicothoracic and thoracic spine manipulation may help decrease shoulder pain while improving mobility and function. (19-22,29, 32-36,41) Thoracic manipulation has been shown to significantly increase subacromial space (41).
- Shoulder mobilizations-in particular inferior glide
- Shoulder mobilization has been shown to decrease pain and improve range of motion in impingement patients. (28)
- Home stretching of shoulder capsule and tight muscles
Other Treatment Options:
Ultrasound, anti-inflammatory modalities, and ice may be useful in the earliest stages. However, most passive therapy modalities, including IFC, provide little benefit for chronic impingement patients. (27,40) Low-level laser therapy (LLT) may be useful. (27,37) However, other studies question the utility of LLT for anterior impingement (43).
Poor Treatment Options for Anterior Impingement:
A study of over 300 patients with subacromial shoulder pain, demonstrated that arthroscopic surgery, with or without decompression, delivered no clinically significant advantage when compared to no treatment (39).
At Creekside Chiropractic & Performance Center, we are highly trained to treat shoulder impingement. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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