Shoulder External Impingement
Normal Anatomy
• The shoulder has a lot
of soft tissue within a
small amount of space
• Also a very mobile joint
with lots of movement
• These 2 components
increase the changes of
‘pinching’ during
movement
Shoulder Impingement
• “ These disparate findings are believed to be at least in part
due to the fact that mechanical impingement is probably a
physical condition rather than a clearly identifiable
diagnostic entity.”
(Kibler et al., 2013)
• “It is increasingly advocated that this diagnosis is no more
specific than a diagnosis of anterior or posterior shoulder
pain, and no more effective in directing treatment”
(Kibler et al., 2013; Schellingerhout et al., 2008)
Shoulder Impingement
External (Bursal Sided)
Impingement
• Classic ‘Subacromial
Impingement’ between
humeral head and acromion
or coracoacromial ligament
Internal (Articular) Impingement
• Pinching of the rotator cuff
between humeral head and
posterior superior glenoid
Shoulder Impingement
External Impingement
• Impingement of rotator
cuff underneath acromion
OR coracoaromial
arch/ligament
• Impingement is NORMAL
due to the small space
available
• Pathology occurs due to
–
–
–
–
Overuse
Trauma
Alignment or Anatomy
Soft Tissue Imbalances
Impingement Stages
• Stage 1
– < 25 years old
– Acute
inflammation
and oedema
and
haemorrhage
in the rotator
cuff
– Reversible and
Non operative
(Neer, 1983)
• Stage 2
– 25 -40 years
– Progression from
acute oedema and
haemorrhage to
fibrosis and
tendinitis of the
rotator cuff
– Usually responds
to conservative
management
• Stage 3
– 40+ years
– Mechanical
disruption of
tendons (tear)
– Osteophytes
under acromion
– Thickening of
coracoacromial
arch
– More likely to
require surgery
Impingement Causes
Primary
Secondary
•
• Secondary to another syndrome
which causes humeral head
migration
– Rotator Cuff weakness
– Glenohumeral instability
– Scapular Dyskinesia
– Posterior Capsule tightness
– Neurological paralysis
Result of a direct compression of
the rotator cuff tendons between
humeral head and overlying
anterior third of the
acromion/coracoacromial arch/
ligament
– Change in anatomy of
acromion
– Acromioclavicular arthrosis
– Coracoacromial ligament
hypertrophy
– Subacromial bursa thickening
or fibrosis
– Trauma
– Repeated Overhead activity
(Chang, 2004)
Subacromial Vs Coracoacromial
• Impingement of the rotator
cuff tendon can occur
against anterior aspect of
the acromion OR the
coracoacromial arch
• Coracoacromial
impingement has more pain
into horizontal adduction
• There is very subtle
differences in presentation
which will affect
management
External Impingement- Assessment
• Subjective History
– History of instability
– History of impingement
– Job or sport that requires
repeated overhead activity
• Subjective Symptoms
– Insidious Onset
– Pain anteriorly, superiorly
and laterally in shoulder
– Pain in positions of flexion
and internal rotation
(Sometimes horizontal
adduction)
External Impingement- Assessment
• Objective
– Painful arc
– Pain resisted lateral
rotation
– Hawkins Kennedy
– Neer’s
• Global Assessment
– Cervical
– Scapula
– Thoracic
Management
• Remember impingement is NORMAL and only
pathological due to the following
– Overuse
– Trauma
– Alignment or Anatomy
– Soft Tissue Imbalances
• Treatment is used to modify the above
• Anatomy cannot be changed, therefore
surgery required
Management
Soft Tissue Imbalances
Management- Soft Tissue Imbalances
• Rotator Cuff pull humeral head into glenoid
• Should pull centrally
• Muscle Imbalance can change the position of
the humeral head within the glenoid
• Main imbalances
– Big V Small (Deltoid V Rotator Cuff)
– Posterior V Anterior (Subscapularis V Posterior
Cuff)
Deltoid V Rotator Cuff
• Deltoid pulls humeral
head superior
• If rotator cuff are
dysfunctional the net
force of deltoid is
increased
• Humeral head migrates
superiorly during
elevation
• Causing impingement
Deltoid V Rotator Cuff
• Pain free range exists
because as elevation
continues the pull of
the deltoid changes
• Less superior pull is
produced as elevation
increases
• Pain at very end of
range simply due to
space available
Posterior Cuff V Subscapularis
• If subscapularis is
dominant the humeral
head will migrate
anteriorly
• Increasing risk of
humeral head impinging
against coracoacromial
arch and acromion
Posterior Cuff
• It therefore stands to
reason that
rehabilitation of the
posterior cuff will be
beneficial
• But what exercises are
most effective for the
posterior cuff?
Rationale For Exercises
• A review paper in 2009 by
Mike Reinold looked
various EMG studies of
shoulder muscles
• Concluded the 3 best
exercises for posterior
cuff were
– Side Lying ER
– Prone ER at 90° Abduction
– ER with Towel (30°
Abduction)
(Reinold et al., 2009)
Management- Soft Tissue Imbalances
• Posterior capsule
tightness can alter
shoulder
arthrokinematics
• Tightness in the Posterior
Capsule and Posterior
Band of the inferior
capsule reduce superior
head migration
(Muraki et al., 2010; Tyler et
al., 2000)
Management- Soft Tissue Imbalances
• Manual Therapy to soft
tissue can improve pain,
range of movement,
function and strength
• Joint mobs, Soft tissue
release, etc etc
(Bang & Deyle, 2000;
Senbursa et al., 2007; Teys
et al., 2008)
Management- Soft Tissue Imbalances
• HEP
– Horizontal adduction
– Sleeper Stretch (Is this
similar to Hawkins
Kennedy?)
Management
Alignment
Management- Alignment
• Any deviation of the
scapula will affect
shoulder kinematics
• Points of impingement
are coracoacromial
ligament, or acromion
• Both parts of scapula
Management- Alignment
• Read the following paper
for an in depth look at the
biomechanics associated
with shoulder
impingement syndrome
Ludewig PM, Braman JP.
Shoulder impingement:
biomechanical
considerations in
rehabilitation. Man Ther
2011; 16(1): 33-9.
Management- Alignment
• Restricted thoracic
extension with
elevation
• Increased thoracic
kyphosis (try elevated
the arms while sitting
slumped)
(Seitz et al., 2011)
(Bullock et al., 2005)
• Scapula Dyskinesis
– Reduced scapular
upward rotation
– Increased internal
rotation (Medial Border
Winging)
– Increased anterior tilt
(Cools et al., 2003)
Management- Alignment
• Increase thoracic extension
and rotation
• Thoracic mobilisation and
manipulation
(Boyles et al., 2009)
• Increase scapular upward
rotation, posterior tilt and
external rotation
• Serratus anterior and Lower
Trapezius Rehab
• (Cools et al., 2003; Ludewig
& Cook, 2000; Ludewig &
Reynolds, 2009; Ellenbecker
& Cools, 2010; Roy et al.,
2009; Hung et al., 2010;
Cools et al., 2013; Dickens
et al., 2005)
Rationale For Exercises
• Serratus Anterior
–
–
–
–
Push up Plus
Dynamic Hug
Serratus Punch 120°
Wall Slides
• Lower Trapezius
– Prone Full Can
– Prone ER at 90° Abduction
– Bilateral ER (Shoulder W’s)
(Reinold et al., 2009)
Subacromial V Coracoacromial
Subacromial
• Avoid Flexion
Coracoacromial
• Avoid Horizontal Adduction
Management
• Mobility BEFORE Stability
– Stability
• Posterior Rotator Cuff
• Serratus Anterior
• Lower Trapezius
– Mobility
• Soft tissue release/MET
–
–
–
–
–
Pec Minor
Upper Trapezius
Subscapularis
Rhomboids
Levator Scapulae
• Joint Mobs
– Posterior and Inferior
Capsule
– Scapular Upward
Rotation
• Stability Principles
1.
2.
3.
4.
5.
Motor Control
Isolated Strengthening
Endurance
Neuromuscular Control
Functional/ Sport Specific
References
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Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy
for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000; 30(3): 126-37.
Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust
manipulation on patients with shoulder impingement syndrome. Man Ther 2009; 14(4): 375-80.
Bullock MP, Foster NE, Wright CC. Shoulder impingement: the effect of sitting posture on shoulder
pain and range of motion. Man Ther 2005; 10(1): 28-37.
Chang WK. Shoulder impingement syndrome. Phys Med Rehabil Clin N Am 2004; 15(2): 493-510.
Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular
dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med 2013.
Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment
patterns: trapezius muscle latency with and without impingement symptoms. Am J Sports Med
2003; 31(4): 542-9.
Dickens VA, Williams JL, Bhamra MS. Role of physiotherapy in the treatment of subacromial
impingement syndrome: a prospective study. Physiotherapy 2005; 91(3): 159-64.
References
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Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries:
an evidence-based review. Br J Sports Med 2010; 44(5): 319-27.
Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the management of musculoskeletal
disorders of the shoulder: a systematic review. Man Ther 2009; 14(5): 463-74.
Hung CJ, Jan MH, Lin YF, Wang TQ, Lin JJ. Scapular kinematics and impairment features for
classifying patients with subacromial impingement syndrome. Man Ther 2010; 15(6): 547-51.
Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of
scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'scapular summit'.
Br J Sports Med 2013; 47(14): 877-85.
Lewis JS, Green AS, Dekel S. The Aetiology of Subacromial Impingement Syndrome. Physiotherapy
2001; 87(9): 458-69.
Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation.
Man Ther 2011; 16(1): 33-9.
Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people
with symptoms of shoulder impingement. Phys Ther 2000; 80(3): 276-91.
Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint
pathologies. J Orthop Sports Phys Ther 2009; 39(2): 90-104.
Muraki T, Yamamoto N, Zhao KD, et al. Effect of posteroinferior capsule tightness on contact
pressure and area beneath the coracoacromial arch during pitching motion. Am J Sports Med 2010;
38(3): 600-7.
References
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Neer CS, 2nd. Impingement lesions. Clin Orthop Relat Res 1983; (173): 70-7.
Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for
glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther 2009; 39(2): 105-17.
Roy JS, Moffet H, Hebert LJ, Lirette R. Effect of motor control and strengthening exercises on shoulder function in
persons with impingement syndrome: a single-subject study design. Man Ther 2009; 14(2): 180-8.
Schellingerhout JM, Verhagen AP, Thomas S, Koes BW. Lack of uniformity in diagnostic labeling of shoulder pain:
time for a different approach. Man Ther 2008; 13(6): 478-83.
Seitz AL, McClure PW, Finucane S, Boardman ND, 3rd, Michener LA. Mechanisms of rotator cuff tendinopathy:
intrinsic, extrinsic, or both? Clin Biomech (Bristol, Avon) 2011; 26(1): 1-12.
Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy
for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports
Traumatol Arthrosc 2007; 15(7): 915-21.
Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan's mobilization with movement technique on range of
movement and pressure pain threshold in pain-limited shoulders. Man Ther 2008; 13(1): 37-42.
Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantification of posterior capsule tightness and motion loss in patients
with shoulder impingement. Am J Sports Med 2000; 28(5): 668-73.
Wassinger CA, Sole G, Osborne H. The role of experimentally-induced subacromial pain on shoulder strength and
throwing accuracy. Man Ther 2012; 17(5): 411-5.