Impingement syndrome

       IMPINGEMENT  SYNDROME 

It  is also  called  as supraspinatus Tendinitis or painful  arc  syndrome.

                  "Impingement  syndrome  is  a clinical  syndrome  occurs  due  to narrowing  of  the subacromion  space  which  cause  impingement  of  tendons  of rotator  cuff muscles  under the  subacromion  bursa causing  pain and  restriction of movements."

-The subacromion  space  is a space between  humeral head and  coracoacromial  arch .Average value  is 10 mm. When  this space  decrease  due  to any cause it  causes  impingement of rotator  cuff  tendons. 

The  muscles  of rotator  cuff  includes  supraspinatus  ,Infraspinatus, subscapularis and  Teres  minor muscles. 

ETIOLOGY:-

1)Occurs  due  to  chronic  and repetitive  compression  of rotator  cuff tendons. 

2) It most commonly  occurs  in  overhead  athletes as in swimmers, ballers, weight lifter etc.

3)It can also be caused by an injury to shoulder  joint .

4) It may occurs due  fracture  of greater  tuberocity.

5) It may also occurs due  to calcification  of supraspinatus  Tendons.

PATHOGENESIS:-

-Chronic repetitive  overhead activities. 

-Narrowing  of  subacromion  space. 

-Cause  compression  of rotator cuff  tendons  .

-Cause  Rotator cuff dysfunction. 

-As a result  appearance  of  symptoms  like pain  and  restriction  of  movements. 

STAGES OF IMPINGEMENT  SYNDROME :-

1) STAGE -1:- Inflammation  .

2)STAGE-2:-Tendinitis and Fibrosis. 

3) STAGE -3:-Bone spure  and tendon rupture. 

CLINICAL  PRESENTATION :-

1) Shoulder  pain.

2)Tenderness  below  Acromion and greater tuberocity  .

3)Pain and weaknesses  with  active  Abduction  in midrange  (60°-120°).

4)Pain during active resisted internal rotation  .

5) Tenderness  over subacromion  area.

SPECIAL  TESTS  :-

1) Neer impingement  test:-

-Patient  stands or sits comfortably. 

-Clinician  passively  flexes the arm  to end  range  and   applies  overpressure.

2)Howkin's test:--The  athlete stands or sits with arm  and  elbow  each flexed to 90°and arm internally  rotated. 

- The  clinician   applies  overpressure  to internal  rotation  produces symptoms  of  anterior  shoulder  pain.

-Produce symptoms  indicates  positive  test  for  impingement  syndrome. 

INVESTIGATION  :-

1) X-Ray

2)USG 

3)MRI

TREATMENT :-

1)Conservative treatment :-

-NSAIDS 

-Local injection of  hydrocortisone. 

-Local injection  of  steroids. 

2)Surgical  treatment :-

-In case of failure  of  conservative management for  3 months.

-The  following  surgeries  are performed :-

1) Excision  of  adhesion. 

2)Manipulation  of  shoulder  .

3)Excision  of calcium  deposits.

4)Repair  of incomplete  tear .

5) Acromioplasty. 

6)Acromioctomy.

7)Direct suture for complete  tear  .

8)Flaps , grafts  may also be  used. 

PHYSIOTHERAPY  MANAGEMENT :-

GOALS  :-

1) Pain  relief  .

2 )Prevent  the  condition  from further  worsening. 

3 )Muscle strengthening .

4)Functional  improvement. 

TREATMENT :-

1) Thermotherapy :-TENS  ,US ,SWD.

2)Passive  mobilization :-Relaxed  full range passive mobilisation. 

3)Pendular  exercises. 

4)Shoulder  ladder  exercises. 

5)Gradual  resisted  exercises. 

Physiotherapy management  after  surgery:'

1) shoulder  immobilisation for 3 weeks.

2) Active  elbow  , wrist  and  hand  movement  should  be  encouraged after surgery.

3)Isometric  exercises  for  deltoid  after 10 to 15 days.

                                    PENDULAR  EXERCISES 

pathomechanics of elbow joint