Shoulder impingement syndrome (SIS)

‘Impingement syndrome of the shoulder refers to the symptoms of pain and dysfunction resulting from any pathology which either decreases the volume of the subacromial space or increases the size of its contents’. (Bigliani, 1991).

The vulnerable soft tissues are, from superficial to deep, the subacromial bursa, the rotator cuff tendons and the tendon of long head of biceps.

Pain is described as intermittent and localised over shoulder/deltoid and may radiate into arm. It is sharp, catching (chronic ache after use), and aggravated by overhead activities and internal rotation (IR). 
A painful arc can be described and patients often complain of night pain (lying on the affected side).

Possible mechanisms underlying SIS 

• bony anatomical and pathological factors
• shoulder instability: Rotator Cuff (RC) weakness and capsuloligamentous laxity
• impaired scapulohumeral rhythm and scapular instability
• posterior capsular tightness – Glenohumeral Internal Rotation Deficiency (GIRD)
• poor posture
• soft tissue changes (inflammation and thickening of the subacromial bursa or RC

Rotator Cuff Tears

There is a high prevalence of asymptomatic rotator cuff tears in the general population. The rotator cuff wears with age and becomes weak (tendinopathy) and prone to rupture. Rotator cuff tears usually occur through obvious trauma although can be caused by minimal (or no) trauma in the elderly population (degenerative cuffs). Incidence of rotator cuff tears increases with age. They can present with pain on movement, night pain and restricted active range of motion (AROM).

Full thickness and massive rotator cuff tears

A Full Thickness Tear (FTT) is a tear that extends through the full thickness of the tendon.
A massive tear is defined as a tear larger than 5 cm and/or involving 2 or more tendons.
Also used: small <1cm, moderate 1-3cm, large 3-5cm, massive >5cm.

They can present with the inability to actively elevate, shoulder hitch manoeuvre and satisfactory passive range of motion (PROM).

Impingement Tests:

Hawkins-Kennedy (Video link) (Link correct as of 18/03/2024)

Passive internal rotation with the shoulder in 90° of flexion. The test is positive if patient’s pain is reported (NB. In presence of capsular restriction false positive test likely).

Midrange Painful Arc
Patient’s pain is reproduced through 60-120° of range of motion of abduction/scaption. May also present with pain at end of range (EOR) elevation and IR

Assessment of GIRD (Glenohumeral Internal Rotation Deficit, posterior capsule)
Glenohumeral IR is measured in supine, 90° shoulder abduction, scapula stabilised. A positive test is difference of > 20°, in comparison to the opposite side.

Rotator Cuff Integrity Tests:

Pay most attention to weakness (pain can be indicative of inhibition due to muscle/tendon dysfunction).

Full Can Test (supraspinatus) (Video link) (Link correct as of 18/03/2024)

Both shoulders in 90° of scaption with maximum external rotation (ER), manual resistance against further elevation. A positive test is a sign of weakness.

Resisted ER at 45deg IR (infraspinatus)
Manual resist ER. A positive test is a sign of weakness.

Belly Press Test (subscapularis) (Video link) (Link correct as of 18/03/2024)

Patient presses hand into belly without movement of the elbow. A positive test is significant reduction in strength and dropping the elbow by extending rather than internally rotating the shoulder.

Lift-off Test/Gerbes (subscapularis) (Video link) (Link correct as of 18/03/2024)

Hand on the lower back and patient asked to actively lift their hand away from their back. A positive test is the inability to lift the hand off.

Drop Arm test (Video link) (Link correct as of 18/03/2024)

Passively abduct the arm to 90° and ask the patient to hold that position. Next have the patient slowly lower the arm. A positive test is the inability to hold and lower the arm in a controlled way.

Inability to actively elevate:

ERLS (External Rotation Lag Sign)
The shoulder is passively placed in 20° scaption and submaximal ER. Patient is asked to hold that position. A positive test is when the patient is unable to hold that position.

Other Tests:
Long Head of Biceps – Speeds Test (Video link) (Link correct as of 18/03/2024)

Patient in standing with arm fully supinated, elbow in extension. The examiner resists shoulder flexion between 0-60°. Pain over bicipital groove is a positive test. This can be confirmed by re-testing with supination of the forearm with no pain.

Long Head of Biceps – Yergason’s Test (Video link) (Link correct as of 18/03/2024)

Elbow flexed to 90°, forearm in pronation. The examiner resists supination and ER. Pain over bicipital groove is a positive test.

Plain radiographs are of limited value and generally not required.

In most cases X-ray will not reveal any bony abnormalities, but it can reveal the presence of calcific deposits, show cystic changes of the greater tuberosity, sclerotic changes beneath acromion, osteophytes from the acromion and ACJ degenerative changes and narrowing subacromial space.

Ultrasound and MRI can be used to visualise the rotator cuff tendons.

Overview

• Optimise pain management
• Rest/NSAIDs
• Consider CSI if pain problematic
• Consider CSP guidelines

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Treatment

Pharmacology - The potential benefits of a course of NSAIDs (7-21 days) outweigh the risks.

CSI - The use of CSI is beneficial in the short term management of impingement and it is suggested it should be used to facilitate rehabilitation.

Rehabilitation

• Relative rest and avoidance of aggravating activities are beneficial in the early management (but absolute rest should be avoided).
• Cold packs may help to reduce the pain and inflammation (but should not be used prior to exercise).
• An attempt to correct posture is appropriate.
• Passive mobilisations should be considered as a treatment modality.
• A programme of exercises to restore range, strength and scapulohumeral rhythm is beneficial (as long as pain free).
• Scapula stability is paramount when performing strengthening exercises.
• Stretching may be introduced at an early stage.
• The use of TI3's for supersvision of exercises and stretching should be considered.
• Anterior deltoid rehabilitation is recommended for patients with massive rotator cuff tears.

Insufficient Evidence

• Heat therapy is not recommended, and should not be used.
• No evidence that acupuncture is of any benefit.
• Ultrasound is not recommended, and should not be used.
• Not enough evidence regarding TENS, laser and deep transverse frictions to make any recommendations.

Literature and systematic reviews (Kuhn 2009, Cochrane review 2008) have demonstrated that the most effective/ evidence based way of treating Rotator Cuff Tendinopathy and Partial tears is through the provision of exercises. It is important that there are many pathological conditions that contribute to Rotator Cuff overload, and selective isolated rotator cuff exercises are frequently not successful in relieving the clinical symptoms. Therefore rehabilitation should focus on restoring ROM and improving strength, control and scapulohumeral rhythm.

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other

Escalation within MSK Physiotherapy

The use of CSI is beneficial in the short term management of impingement and it should be considered to facilitate rehabilitation.

Escalation outwith MSK Physiotherapy

There is no formal guidance concerning when onwards referral is appropriate. If the patient is not progressing as expected escalation should be discussed with a senior member of staff.

If pain is not controlled by appropriate medication and having a significant impact on sleep, function and quality of life, and if pain is limiting physiotherapy treatment onwards referral should be considered.
Onwards referral should also be considered if underlying structural pathology is suspected.

A large proportion of patients with SIS can be expected to respond to conservative measures and conservative measures should be given an adequate opportunity to succeed before surgery is contemplated (up to 6 months) (Parker and Seitz, 1997; Cavallo and Speer, 1998).

NHS GGC Physiotherapy Service - shoulder https://www.nhsggc.scot/hospitals-services/services-a-to-z/musculoskeletal-msk-physiotherapy/msk-self-help-and-information-shoulder/

NHS Inform may provide useful information, especially for those presenting to physiotherapy within the time frames of natural recovery.
https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/shoulder-problems
(link correct as of 18/03/2024).

Patient education in terms of times frames and prognosis is paramount.  Consider use of local/national publications to support this.