SHOULDER

IMPINGEMENT

SYNDROME Rumy Petkov

ANATOMY OF THE SHOULDER

SCAPULA

ROTATOR CUFF MUSCLES

ABOUT THE ATHLETE

19 year old female

Freshman starter

Outside hitter

Has never had previous shoulder injuries

PHYSICAL EXAMINATION Mechanism: Insidious. Reports sharp ache pain. Reports trouble

with ADL’s such as taking off sports bra. Ranks pain 3/10 after px. No pain during practice

No pervious history

No pain with palpation

AROM: Full ROM but pain at 90 degrees of flexion, 95degrees of abduction and worst pain with horizontal adduction

Special Tests: Empty can (+), Neers (+), Hawkins Kennedy (+), Speeds(+), Apprehension (-), Clunk (-),

MMT: Supraspinatus (4/5 with pain), Internal/External (5/5), Pecminor/major (5/5), Biceps (5/5 with pain)

Diagnosis: Supraspinatus impingement

EPIDEMIOLOGY

NCAA injury surveillance system

Ligament sprains and muscle strains are the most common types of injury in

NCAA women’s volleyball.

More than 51 percent of the injuries occur to the lower extremity

Upper extremity, primarily the shoulder region, is at risk of overuse injuries

because of the amount of overhead motion required in the sport.

Accounts for 21.3% of injuries

CLINICALLY RELEVANT QUESTION

Among athletes with shoulder impingement, does treatment with

laser therapy result in significant improvements in symptoms and

reductions in complications, as compared to other treatment?

What will we be looking at:

Laser therapy vs. Corticosteroid

Ultrasound vs. Laser therapy

Kinesio taping

Exercises with Laser therapy

STUDY LOOKING AT LASER THERAPY

AND CORTICOSTEROID INJECTION

LOW-LEVEL LASER AND LOCAL CORTICOSTEROID INJECTION IN THE

TREATMENT OF SUBACROMIAL IMPINGEMENT SYNDROME: A

CONTROLLED CLINICAL TRIAL

PEDRO SCALE: 5/11

135 patients with subacromial impingement syndrome

Three groups

Group 1: Corticosteroid

Ground II: Sham Laser treatment

Group III: Laser therapy treatment

Patients were evaluated four times during the study period: pre-

treatment, post-treatment and three and six months after the first

visit

The outcome measurements of our study were pain during

activity and pain at rest

RESULTS

STUDY LOOKING AT ULTRASOUND AND

LASER THERAPY

SHORT-TERM EFFECTS OF HIGH-INTENSITY LASER THERAPY VERSUS

ULTRASOUND

THERAPY IN THE TREATMENT OF PEOPLE WITH SUBACROMIAL IMPINGEMENT

SYNDROME: A RANDOMIZED CLINICAL TRIAL

PEDRO SCALE: 10/11

70 total patients with SAIS

Total of 10 treatments for a total of 2 consecutive weeks

Randomly assigned to 2 groups

a group of 35 participants received HILT

a group of 35 participants received US therapy

RESULTS

STUDY LOOKING AT LASER THERAPY

COMBINED WITH REHABILITATION

EXERCISES

THE EFFECTIVENESS OF LOW-LEVEL LASER THERAPY ON

SHOULDER FUNCTION IN SUBACROMIAL IMPINGEMENT SYNDROME

PEDRO: 7/11

67 total patients randomly assigned

Two groups:

received laser

received placebo laser

Both groups were assigned progressive rehabilitation exercises

Assess before and after 3 weeks

RESULTS

ROM

RESULTS

WHY I USED LASER THERAPY

According to evidence:

Quicker reduction of pain

Improved ROM

Improved overall functionally

Evidence proved little to no value in treating patients with

ultrasound for shoulder pain

Future studies: Need evidence for standard parameters of laser

therapy

STUDIES LOOKING AT KINESIOTAPING

FOR SHOULDER IMPINGEMENT

CLINICAL EFFECTIVENESS OF KINESIOLOGICAL TAPING ON PAIN AND

PAIN FREE SHOULDER RANGE OF MOTION IN PATIENTS WITH SHOULDER

IMPINGEMENT SYNDROME: A RANDOMIZED, DOUBLE BLINDED, PLACEBO

CONTROLLED TRIAL

PEDRO SCALE: 11/11

Methods and Subjects:

A randomized, double blinded, placebo controlled study was conducted

in order to assess the effectiveness of KT in patients with SIS.

Thirty patients

Control Trial received placebo KT with no tension

Experimental trial received a standardized therapeutic KT

RESULTS AND OUTCOMES

KINESIO-TAPING FOR IMPINGEMENT

12/5 /2014RATAN KHUMAN (MPT ORTHO & SPORTS) 22

1 2

3

4

EXERCISES PRESCRIBED BASED ON

EVIDENCE

ROM EXERCISES

Glenohumeral Progression

Condmans Pendulum

Active Assistive motion with cane or contralateral arm

Active motion as comfort dictates

Active motion without elevating scapula

Postural Progression

Shrugs

Shoulder retraction

FLEXIBILITY EXERCISES

Door Corner stretch

Posterior shoulder stretch (cross arm)

Lateral neck stretch

STRENGTHENING EXERCISES

Theraband exercise:

External rotation (humerus adducted to the body)

Internal rotation (humerus adducted to the body)

Rows (seated or standing)

Low trapezius rows

Chair press

Scaption

Press-up (subscapula)

Upright row

MANAGEMENT AND OUTCOMES

The patient continued to start and play ever game of the season

Limit hitting/serving

No overhead lifting activities

Patient satisfaction increased at the end of the season

None complaint athlete

MANAGEMENT AND OUTCOMES

Patient developed other complications along the way:

Reported tingling and numbing sensation down all her fingertips

Positive Adson’s and Allen's test

Thoracic Outlet syndrome

DOCTOR APPOINTMENT

MRI diagnosis

Right shoulder pain

Os Acromial

Subscapular nerve impingement

Infraspanatus atrophy

R Shoulder impingement

EMG Testing

DISCUSSION

To answer my clinical question

According to the literature laser therapy is an effective treatment for shoulder

impingement but the combination of rehab exercises and laser therapy

provides no beneficial effect.

WHAT WORKED

Graston most effective treatment

Provided therapeutic effect to upper traps, lats, and posterior capsule of

shoulder

Joint Mobs another effective treatment

Began with Grade 1 to II oscillations to alleviate joint pain

Started Grade III to stretch posterior capsule

Active Release Therapy

WHAT DIDN’T WORK

Rehab exercises

Patient was not consistent and was difficult to motivate

Educate patient

Laser therapy

Patient was not consistent with coming in for treatments

Alternative method for patient because she was not coming in for exercises

Stretching before practices or games

Patient did not like to be stretched-believed it made her “shoulder to lose”

WHAT COULD I CHANGE

Rest the patient for a couple of weeks

Begin conservative rehab program within those weeks

Evaluate progression with Patient Reported Outcomes such as

the the DASH questionnair, Shoulder Pain and Disability Index

Eccentric Exercises

ECCENTRIC TRAINING IN CHRONIC PAINFUL IMPINGEMENT SYNDROME OF

THE SHOULDER: RESULTS OF A PILOT STUDY

PEDRO SCALE: 4/11

9 patients: All patients had tried different treatment regimens like

rest,

cortisone injections, NSAID, and different types of shoulder

rehabilitation exercises.

The patients estimated the amount of pain in the shoulder during

horizontal shoulder activity on a 100-mm long visual analogue

scale (VAS) before treatment, and 12 weeks and 52 weeks after

treatment

RESULTS

REFERENCES

Kelle B, Kozanoglu E. Low-level laser and local corticosteroid injection in the treatment of subacromial impingement syndrome: a controlled clinical trial. Clin Rehabil. 2014;28(8):762-771.

Santamato A, Solfrizzi V, Panza F, et al. Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of people with subacromial impingement syndrome: a randomized clinical trial. Phys Ther. 2009;89(7):643-52.

Yeldan I, Cetin E, Ozdincler AR. The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome. Disabil Rehabil. 2009;31(11):935-40.

Shakeri H, Keshavarz R, Arab AM, Ebrahimi I. CLINICAL EFFECTIVENESS OF KINESIOLOGICAL TAPING ON PAIN AND PAIN‐FREE SHOULDER RANGE OF MOTION IN PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME: A RANDOMIZED, DOUBLE BLINDED, PLACEBO‐CONTROLLED TRIAL. International Journal of Sports Physical Therapy2013;8(6):800-810.

REFERENCES CONTINUED

Jonsson P, Wahlström P, Ohberg L, Alfredson H. Eccentric

training in chronic painful impingement syndrome of the shoulder:

results of a pilot study. Knee Surg Sports Traumatol Arthrosc.

2006;14(1):76-81.

Kuhn JE. Exercise in the treatment of rotator cuff impingement: a

systematic review and a synthesized evidence-based

rehabilitation protocol. J Shoulder Elbow Surg. 2009;18(1):138–

160.

Borstad JD, Ludewig PM. Comparison of three stretches for the

pectoralis minor muscle. J Shoulder Elbow Surg. 2006;15(3):324–

330.

http://datalyscenter.org/programs/ncaa-injury-surveillance-

program/. Accessed November 30, 2014.

QUESTIONS