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Shoulder Impingement Syndrome WSCC Clinics Conservative Care Pathways Adopted: 07/98 To be reviewed: 10/99 Reformatted: 02/07 SHOULDER IMPINGEMENT SYNDROME Subacromial Impingement Syndrome Primary Author: Laura L. Baffes, BS, DC, CCSP Co-Author: Lisa Revell, BS, DC Background and Evaluation Sections Contributing Author: Ronald LeFebvre, DC The WSCC Care Pathways provide a standardized context for clinical decision making as well as a menu of possible interventions. These pathways are not intended to replace the clinical judgment of the individual physician. The needs of the individual patient may make it necessary to deviate from the recommendations contained in any given pathway. Limitations WSCC pathways are intended for use within our clinic system. They may be useful as a seed for regional guidelines or guidelines with wider application, but caution must be exercised. The following limitations would have to be addressed. 1) The literature searches employed would need to be more exhaustive; 2) inclusion criteria for published studies would need to be more stringent; 3) a wider pool of subject-matter experts must be tapped; 4) the participants of the consensus panel would need to be drawn from a broader cross-section of the profession and perhaps other health care providers as well. Although individual procedures and decision-making points within the Care Pathways have established validity or reliability, the pathways as a whole are untested. Copyright © 1998 Western States Chiropractic College. Do not reprint without permission. ICD-9 Codes 718.81 Shoulder instability, excludes dislocation 719.61 Shoulder joint crepitus 726.0 Tendinitis or adhesive capsulitis of the shoulder 726.1 Supraspinatus syndrome 726.10 Bursitis in shoulder, unspecified 726.12 Biceps tenosynovitis Sprains, strains, tears or ruptures: 840.3 Infraspinatus muscle or tendon 840.4 Rotator cuff or capsule 840.5 Subscapularis muscle 840.6 Supraspinatus muscle or tendon 840.8 Other unspecified sites of the shoulder or upper arm TABLE OF CONTENTS BACKGROUND .................................................................................................................. 5 Pathophysiology and Natural History ............................................................................... 5 Predisposing Factors to Shoulder Impingement .............................................................. 6 Epidemiology ................................................................................................................... 6 EVALUATION ..................................................................................................................... 7 Physical Examination Summary ....................................................................................... 8 Evaluation Strategy ..........................................................................................................8 Key Ancillary Studies ..................................................................................................... 14 Prognostic Considerations ............................................................................................. 15 Outcome Measures ........................................................................................................16 MANAGEMENT: STRATEGY ........................................................................................... 17 Acute Inflammatory Phase ............................................................................................. 18 Rehabilitation: Phase 1 .................................................................................................. 24 Rehabilitation: Phase 2 .................................................................................................. 31 Rehabilitation: Phase 3 .................................................................................................. 35 Rehabilitation: Phase 4 .................................................................................................. 37 MANAGEMENT: SPECIFIC THERAPEUTIC INTERVENTIONS ..................................... 39 Manual Therapy: Joint Manipulation and Mobilization ................................................... 39 Manual Therapy: Soft Tissue ......................................................................................... 41 Physical Therapy Modalities .......................................................................................... 47 Rehabilitation—Active Care ........................................................................................... 50 Other Aspects of Care ................................................................................................... 57 Summary of Operational End Points .............................................................................. 60 Pharmaceutical Therapeutics ......................................................................................... 61 AUTHORS AND CONTRIBUTORS .................................................................................. 63 APPENDIX ........................................................................................................................ 64 REFERENCES .................................................................................................................. 85 To the reader… While the subject of this WSCC Care Pathway is shoulder impingement, the reader should bear in mind that some of the evaluation procedures and much of the rehabilitation and treatment pertain to other shoulder conditions. You will see in the MANAGEMENT STRATEGY section of this document a series of sidebars in the left-hand column. These sidebars are a summary or overview of the office procedures and home care for the entire phase of treatment—not just those treatment goals discussed in the accompanying text. You will notice on that we have chosen to adhere to a strict and limited definition of the terms “efficacy” and “effectiveness.” The term efficacy pertains to those studies whose outcome can be replicated only in a tightly controlled experimental setting but have yet to be borne out in a “real life” setting. Effectiveness, on the other hand, refers to studies whose results have been shown to have broad applicability in clinical practice but have not been subjected to examination in a more tightly controlled experimental setting. BACKGROUND Shoulder impingement syndrome can be defined as the encroachment of the acromion, coracoacromial ligament, coracoid process, and/or acromioclavicular joint on the structures that pass beneath them as the glenohumeral joint is moved, particularly in flexion and rotation. Pathophysiology and Natural NEER’S STAGES OF IMPINGEMENT History Stage 1 is characterized by edema and tendinitis and is more typical in The clinical presentation in shoulder patients under 25 years old. impingement most often results from accumulative and potentially Stage 2 is characterized by chronic degenerative1,2,12 pathology that has 4 inflammation, thickening and fibrosis progressed over months to years. of the impinged tendon due to repeated insults. This further Involvement is usually limited to the 3 decreases the size of the supraspinatus tendon and bursa, and suprahumeral space. Stage 2 is sometimes to the long head of the biceps. more typical in patients between 25 Less commonly, however, the infraspinatus 7,11 and 40 years old and patients who and subscapularis tendons may also be have had a history of episodes of affected. shoulder pain. The condition often begins with minimal Stage 3 is characterized by tendon shoulder pain during activity, no weakness, degeneration, rupture, and arthritis. and full glenohumeral range of motion. Patients with this stage of impingement are usually over 40 The symptoms may progress over years to years old and have a prolonged those of marked tendinitis with significant 4 history of shoulder problems. Often, pain and decreased range of motion. at this stage, there will be Tendon degeneration and bony changes in radiographic evidence and a high the coracoacromial arch may begin to likelihood of partial or full thickness occur. Repeated precipitous periods of rotator cuff tears. shoulder pain at increasing frequency and severity are often seen. Eventually, pain Stage 1 and 2 are usually responsive to with subsequent weakness may develop. conservative management. Stage 3 is Also, tears of the rotator cuff frequently more resistant and a multidisciplinary occur. In severe cases, shoulder approach may be necessary. impingement may result in what is termed “frozen shoulder.”4 BACKGROUND SHOULDER IMPINGEMENT SYNDROME Page 5 of 87 Predisposing Factors to Epidemiology Shoulder Impingement Shoulder pain ranks third in frequency I. Structural factors such as an for conditions seen in general medical practice, behind headache and abnormally shaped acromion, 15 acromioclavicular (AC) degeneration,3 backache. altered vascularity of the supraspinatus or long head of the biceps tendons,4 biceps In a Swedish study of middle-aged tendon degeneration,5 and a decrease in adults, 14% reported shoulder pain within the previous month lasting more the subacromial outlet size due to 14 inflammation or fibrosis. than 24 hours. The incidence of sick leave for shoulder pain within the such as previous year was 3% for the same II. Functional factors 14 glenohumeral (GH) instability,5,6 imbalance population. between the shoulder’s internal rotators/adductors and external The incidence of shoulder impingement rotators/abductors,7 dysfunction of the as a cause of shoulder pain is unknown.
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