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Simon Pratt BSc(Physio), M.Sports Physio, M.Manip. Therapy, Grad. Cert. High. Ed., Grad. Dip(Secondary),

BEc (W.Aust), APA Musculoskeletal and Sports Physiotherapist

Lecturer

Subacromial Impingement Syndrome (SAIS)

Simon Pratt

APA Musculoskeletal and Sports Physiotherapist

The University of Notre Dame

Vario Health Institute

Acknowledgements: James Debenham, The University of Notre Dame

*

Subacromial Impingement Syndrome (SAIS)

Definition:

“a clinical syndrome which

occurs when the

structures within the

subacromial space

become mechanically

sensitised, resulting in

shoulder pain and

disability”

*

http://axonblogg.se/wp-content/uploads/2012/09/shoulder-

pain_78173912_82825803_101521191_139958857.gif

Pathoaetiology

*Primary GH instability may be a

contributing factor

Mechanical Contributing Factors

•Thoracic spine

•STM

•GHJ*

Overuse (acute or chronic)

•Swimming

•Painting

•‘Static’ work

•Throwing

•Racquet sports Supraspinatus tendinopathy

Shoulder pain

Rotator cuff dysfunction (loss of sensorimotor control)

Glenohumeral instability* (proximal humeral migration)

Subacromial bursitis

2

Clinical Features of SAIS

Subjective History

Anterolateral shoulder pain

Pain with overhead activity

History of overuse

(History of spinal disorder(s))

Physical Examination

Painful arc (or limited abduction)*

Thoracic spine kyphosis

independent extension

STM DR, protracted & ant. tilt

GHJ Anteriorly displaced humeral head

IR (posterior capsule)

AP

PA

SST +ve (esp. palpation) *

IST/TM +ve *

SA, UT

Lev Scap, PMi, LD

Impingement tests +ve *

*

Magee, D.J. (2008). Orthopedic Physical Assessment (5th

ed.). Missouri; Saunders Elsevier, p.250.

Clinical Reasoning for SAIS- Diagnosis Clinical Reasoning

Category

Clinical Features Notes

Triage Benign neuromusculoskeletal disorder Full thickness cuff tear

Medical Diagnosis Subacromial (Impingement) Syndrome Swimmers shoulder,

rotator cuff tendinopathy,

subacromial bursitis, etc...

Pain Mechanism Peripheral

Source of Symptoms •(Rotator cuff (SST))

•(Subacromial bursa)

Check the spine

Nature of Dysfunction •(Rotator Cuff Tendinopathy)

•(Subacromial Bursitis)

Local •Tight posterior GH capsule ( IR and AP)

•Lax anterior GH Capsule

• rotator cuff sensorimotor control

This is your secondary

management priority

*

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Clinical Reasoning for SAIS- Diagnosis Clinical Reasoning

Domain

Clinical Features Notes

Remote

•Thoracic spine

• Kyphosis

• Independent extension (performance)

•STM

•DR, Pro, Ant tilt

•Muscles

• SA, UT

• Lev Scap, PMi, LD

This is your primary

management priority

General Poor technique; posture; ergonomics Sport technique,

ergonomics, activity

levels, training

regimens, physical

fitness, work habits

Physiological

•Poor tissue health- Age, comorbidities, general

health (e.g. Diabetes)

•Weight, diet, lifestyle factors

Modifiable vs Non-

Modifiable

Psychosocial

ABCDEFW Diagnosis, Prognosis,

Management

* Clinical Reasoning for SAIS- Management

Impairment

Domain

Specific Impairment Management

Pain N/A Rest (restrict aggravating factors)

Taping

Referral for CSI

Ice???

NSAIDs

Pathology •(Tendon degeneration) Isometric loading

•(Bursitis) Referral for CSI

Local •Tight posterior GH

capsule ( IR and AP)

Mobilise with AP glides

Stretch posterior capsule

•Lax anterior GH

Capsule

• rotator cuff

sensorimotor control

Therapeutic exercise to improve cuff control

*

Clinical Reasoning for SAIS- Management

Impairment

Domain

Specific

Impairment

Management

Remote •Thoracic spine

•Kyphosis

• Independent

extension

(performance)

Mobilise thoracic spine into extension; Tx

manipulation

Therapeutic exercise to improve thoracic

independent extension performance

•STM

•DR, Pro, Ant

tilt

•Muscles

• SA, UT

• Lev Scap,

PMi, LD

Therapeutic exercise to improve performance:

•Serratus anterior

•Upper trapezius

Soft tissue techniques and therapeutic exercise to

improve myofascial mobility:

•Levator scapulae

•Pectoralis minor

•Latissimus dorsi

*

Clinical Reasoning for SAIS- Management

Impairment

Domain

Specific

Impairment

Management

General •Sports technique

•Training regimens

•Physical Fitness

•Activity levels

•Ergonomics, work

habits

Discussion with coaches, patient

Education re: loading

Office review: workstation set-up; work habit diary

Physiological E.g. Diet

•Poor tissue health-

modifiable:

Weight, diet, lifestyle

factors

Refer to dietician

Education re: health eating, portions, and lifestyle

choices: exercise; activity levels; psychosocial issues

(see below)

Psychologist referral may be appropriate

*

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Clinical Reasoning for SAIS- Management Impairment

Domain

Specific

Impairment

Management

Psychosocial Attitude and beliefs

Behaviours

Compensation issues

Diagnostic issues

Emotions

Family issues

Work issues

•Clear and concise diagnosis, prognosis and Mx plan

•Support, understanding and reassurance

•Emphasise a favourable outcome

•Provide clear, non-threatening explanations

•Avoid therapist-sanctioned disability

•Decrease fear

•Emphasise the importance of

activity/work/socialisation

•Educate about the pain experience

•Normal

•Sensitization process

•Reconceptualisation of pain

•Decrease threat value of pain

•Distinguish between pain and disability

•Encourage involvement in rehabilitation

•Identify individual psychological risks

•Explain and correct these

•Encourage helpful behaviours and coping strategies

•Discourage unhelpful behaviours and coping strategies

•Support through the stages of change

•Help with problem solving

•Motivation, praise, reward

•Engage other stake holders in the problem (family, etc)

*

Research

Aim- Identify factors associated with shoulder pain in elite junior cricketers

Methods- 60 players (15-19 years) divided into shoulder pain (SP) and non-shoulder pain (NSP) clinically evaluated

Results 15% SP

SP group had scapular DR

No difference in training levels and ROM

Contrary to expectations, SP group had strength on some variables

Interpretation A downwardly rotated scapula in young cricketers may contribute to SP due to its influence

on subacromial impingement, and also the increased load on the rotator cuff working at the GHJ in throwing

*

Research

Aim- To illustrate a clinical phenomenon and review the underlying mechanisms

Methods- 2 case reports of 1 middle aged woman, 5 month history, shoulder pain following pulling a weed from the ground. Had

posterior, anterior and lateral shoulder pain. Diagnosed as right shoulder impingement lesion

1 AFL footballer, acute presentation (24 hours post injury) with post-traumatic impingement

Interpretation First paper describing the role of the ‘ribs’ in shoulder dysfunction. Treatment involved rib mobilisation,

release to scalenes and levator scapulae, spinal postural re-education and scapula positioning. Both patients responded to Rx.

Author suspects sprain of the second rib spinal articulation in isolation, either acute or chronic, is a cause of shoulder pain commonly misdiagnosed as shoulder impingement syndrome and/or rotator cuff muscle partial tear

Grieve (1988): second rib syndrome: heavy, useless upper limb; reduced ability to grip

Maigne et al. (1991) report the dorsal ramus of the second thoracic nerve continues laterally to the acromion, and provides a cutaneous distribution over the posterolateral shoulder.

*

Research

Nakagawa et al (2012): investigated the role of posterior capsular tightness in throwing shoulder injuries. Found posterior capsule tightness in 82% of throwing athletes who had shoulder injuries,

mainly affecting the anterior labrum (anterior instability) and supraspinatus (subacromial impingment)

Haik, M. N., Alburquerque-Sendín, F., Silva, C. Z., Siqueira-Junior, A. L., Ribeiro, I. L., & Camargo, P. R. (2014). Scapular Kinematics Pre– and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder Impingement Symptoms: A Randomized Controlled Study. Journal of Orthopaedic & Sports Physical Therapy, 44(7), 475-487.

Muth, S., Barbe, M. F., Lauer, R., & McClure, P. W. (2012). The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy. The Journal of orthopaedic and sports physical therapy, 42(12), 1005. doi: 10.2519/jospt.2012.4142

*

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Case Study: SAIS

61 year-old male tennis player

R Shoulder discomfort over past year

R shoulder pain came on in the last 4-5 months

http://www.feeltennis.net/wp-content/uploads/2013/02/serve-back-fence.jpg

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Clinical Reasoning Form

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Clinical Reasoning Form (cont.) Clinical Reasoning Form (cont.)

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Clinical Reasoning Form (cont.)

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Clinical Reasoning Form (cont.) Clinical Reasoning Form (cont.)

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Loading

History

How much?

How to increase?

Warning signs?

http://www.nams.ca/MagiBlog//wp-content/uploads/2010/07/2010.07.02-

cricket-bowler-and-runner.jpg

References

Boyle, J.J.W. (1999): Is the pain and dysfunction of shoulder impingement lesion really second rib syndrome in disguise? Two case reports. Manual Therapy 4 (1), 44-48.

Haik, M. N., Alburquerque-Sendín, F., Silva, C. Z., Siqueira-Junior, A. L., Ribeiro, I. L., & Camargo, P. R. (2014). Scapular Kinematics Pre– and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder Impingement Symptoms: A Randomized Controlled Study. Journal of Orthopaedic & Sports Physical Therapy, 44(7), 475-487.

Green, R.A., Taylor, N.F., Watson, L., & Arden, C. (2013). Altered scapula positions in elite young cricketers with shoulder problems. Journal of Science and Medicine in Sport, 16(1), 22-27.

Muth, S., Barbe, M. F., Lauer, R., & McClure, P. W. (2012). The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy. The Journal of Orthopaedic and Sports Physical Therapy, 42(12), 1005. doi: 10.2519/jospt.2012.4142

Nakagawa, S., Yoneda, M., Mizuno, M., Hayashida, K., Yamada, S., & Sahara, W. (2012). Influence of posterior capsular tightness on throwing shoulder injury. Knee surgery, sports traumatology, arthroscopy, July 21(7), 1598-602. doi: 10.1007/s00167- 012-2107-2. Epub 2012 Jun 23.

The University of Notre Dame Australia Physiotherapy Resources.

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