pathology: impingement syndrome

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impingement syndrome of the shoulder (subacromial syndrome)

Definition of

The term impingement of the shoulder is not used uniformly; it is usually used to describe a painful restriction of flexibility of the shoulder joint, usually due to degeneration, rupture or muscular imbalance with injury to the supraspinatus tendon, which becomes trapped. A more precise distinction must be made between two forms of impingement:

Internal Impingement

Internal joint impingement is a collision within the shoulder . It can be posterosuperior (PSI) or anteriorsuperior (ASI).

PSI (Posterosuperiores Internal Impintment)

PSI GIRD is usually the result of overhead activities, whether sporting or manual, and this usually results in (glenohumeral internal rotational deficit ) . Typical sports that cause this are volleyball, baseball, tennis, and overhead throwing and hitting sports in general. The sometimes complex damage is also referred to by the collective term athlete’s shoulder or thrower’s shoulder (see also here). Painful restriction of movement with loss of strength can then occur. become trapped The insertion tendons of the supraspinatus and infraspinatus between the greater tubercle and the posterosuperior glenoid rim and damage both the labrum and the tendons. The triggering situation is a wide lateral abduction with simultaneous wide frontal abduction and further exorotation .
The cause of the tendency to PSI is a congenital or acquired hyperlaxity of the capsular ligament apparatus, especially the inferior glenohumeral ligament , which allows the humeral head to slide too far anteriorly , especially when the greater tubercle abuts the posterosuperior edge of the glenoid ; This mainly occurs during overhead swing movements. An emerging mostly GIRD worsens the situation. Another aggravating factor is scapuladyskinesia or fatigue of the trunkoscapular muscles during training or competition. For possible damage, see thrower’s shoulder. Jobe categorises the damage according to the symptoms:

  • Feeling of stiffness, pain towards the end of the outstroke when throwing
  • Constant posterior shoulder pain
ASI (Anterior Superior Internal Impingement)

The ASI is an abutment of the lesser tubercle on the anterosuperior glenoid rim . It is usually triggered by wide endorotation during frontal abduction with transverse adduction ; swimmers are often affected. There is often a medial subluxation of the long biceps tendon , a lesion of the attachment tendon of the supraspinatus and a lesion of the rotator interval (RCI, i.e. the area of ​​the capsule tendons between the supraspinatus and subscapularis ). Several causes are possible: a pulley lesion , in which the ASI pinches the medially subluxated long biceps tendon , secondly, a partial rupture of the subscapularis tendon , which reinforces the former pathomechanism, and thirdly, overuse in frontal adduction , transverse adduction and endorotation , in which the pully complex the superior edge of the subscapularis tendon and the anterosuperior glenoid rim repeatedly rubs . For an ASI, Speed’s test , O’Brien test , Hawkings sign are positive, instability tests are negative.

External Impingement

External joint impingement is an impact outside the shoulder . A distinction must be made between

primary

due to structural changes in the subacromial space:
1. “Outlet impingement ” bony narrowing from the cranial side : e.g. bone changes after fractures
2. “Non-outlet impingement ” soft tissue changes: bursitis subacromial or calcareous tendinosis

secondary

based on instability with a tendency to subluxation . Due to functional disorders in humerus centering and guidance, such as rotator cuff dysfunction . It is unclear whether (extrinsic theory) pressure damage to the supraspinatus through repeated impact or (intrinsic theory) through degenerative processes in the supraspinatus tendon leads to its disruption and inadequate guidance. It is assumed that both pathomechanisms complement each other.

Idiopathic shape abnormalities of the acromion, including an excessively long acromion, favor the development of impingement. In addition to subacromial impingement, subcoracoid impingement is also possible.

ICD M75.4

Cause

  1. (see definition)

Predisposing

– Behavior

  1. Prolonged incorrect loading: habitual lifting of the humeral head
  2. inner PSI impingement: overhead activities, professions such as painting and sports such as volleyball, handball, swimming, javelin throwing
  3. Internal ASI impingement: sports with adduction in endorotation such as swimming
  4. Smoking

– Musculoskeletal system

  1. Weakness of the lateral abductors and exorotators
  2. Limescale deposits

Diagnosis

Tests and signs:

  1. Neer sign
  2. Jobe sign: (Full Can and Empty Can variant) Irritation of the supraspinatus tendon
  3. Painful Arc Test
  4. Hawkins test
  5. drop arm sign
  6. shoulder relocation test

Reduction of pain in the painful arc by pulling the arm down externally ( caudally) indicates that it is mainly bursitis. Pressure of the humeral head in the direction of the acromion then increases the pain. If the pain increases when pulling caudally or remains the same, the suprapinatus tendon is the cause.

Symptoms

  1. Often begins with acute, bright pain when working overhead
  2. Painful restriction of movement „painful arc“: pain between approx. 70° and 130° abduction, which worsens with endorotation
  3. Rotation of the upper arm painfully restricted
  4. possibly also pain at rest and night pain
  5. Later: restricted flexibility due to adhesions and muscular dystrophy, which leads to further progression and instability

Therapy

  1. Initial immobilization if necessary. Then promote flexibility
  2. Heat or cold therapy, iontophoresis
  3. Corticosteroid infiltrations if necessary (not in the tendons). Risk of infection, CAVE for diabetics!
  4. Shock wave therapy for calcification
  5. Proprioceptive neuromuscular fascilitation (PNF)
  6. PT
  7. Specific stretching and strengthening training
  8. Posture training for the spine
  9. Elimination of existing scapular dyskinesia, strengthening of the muscles that move the shoulder blade, elimination of imbalances and flexibility restrictions
  10. conservative in about 80% of cases. There are no predictors for success.
  11. Avoiding painful movement
  12. Surgery: subacromial decompression, but in a review one year post-op does not prove superior to physiotherapeutic measures.
  13. Strengthening primarily of the exorotators of the shoulder joint and the muscles that depress the humeral head(infraspinatus and subscapularis)
  14. With PSI: stretching of the posterior capsule, capsulotomy if necessary

DD

  1. Calcified shoulder
  2. Frozen Shoulder

Asana practice and movement therapy

The literature and online media recommend a striking number of exercises to stabilize the muscular functions of the shoulder joint: Strengthening postures for frontal adduction, straight and retroverted support exercises with and without arm bends (backward dips, lifting from support on a chair), strengthening the exorotators in various ways (dumbbells, cable pull, theraband, lying, sitting, standing), Strengthening the endorotators, biceps curls, side raises up to 90°, rowing, 45° rowing, rowing with endorotated arms, push-ups, exorotated frontal abduction at sternal level (pushing away), retroversions, stretching the pectoralis, pronated-endorotated side raises. It is also recommended to train the retractors, protractors, elevators and depressors of the scapula.

Many authors consider impingement to often have multifactorial causes. Therefore, all plausible or diagnosed causes should be addressed. Hyperkyphosis of the thoracic spine and a tendency to protraction of the shoulder blades, for example, must be counteracted. If there are muscular causes in the form of shortening, as is often seen in the pectoralis major, for example, this must be reduced by stretching and reducing tone, i.e. also by working in long sarcomere lengths as in the bar position. Other end rotators of the shoulder joint, including the subscapularis, latissimus dorsi and teres major, also tend to shorten and should be treated. Any existing scapular dyskinesia must be eliminated. All exercises and postures should be performed in such a way that the well-known impingement pain does not occur; enduring pain in no way leads to any improvement, rather the opposite.

Asanas