Shoulder+Impingement+Diagnosis

=__Shoulder Impingement__=

Also known as: Swimmer’s shoulder, Pitcher’s shoulder, Tennis shoulder, Tendinitis [rotator cuff], Shoulder overuse syndrome A ball and socket joint, the shoulder consists of the humerus and scapula. The rotator cuff muscles maintain the stability and integrity of the humeral head laying flush with the glenoid fossa of the scapula. Tendons of the rotator cuff muscles pass through the subacromial space to attach to the humeral tubercles. When these tendons become inflamed they fray/tear due to their compression between the bones. This can be caused by…
 * Maintain a prolonged shoulder position
 * Computer work (typing)
 * Hairstyling
 * Sleeping on the same shoulder repeatedly
 * Overhead sports motions
 * Throwing
 * Swimming
 * Tennis
 * Lifting
 * Overhead labor
 * Painting
 * Poor scapular coordination
 * Poor posture
 * Foreward shoulders
 * Acromion Structure (Toivonen et al.)
 * Type 1 (Flat)
 * Angled 0 - 12 degrees
 * Type 2 (Curved)
 * Angled 13 - 27 degrees
 * Type 3 (Hooked)
 * Angled >27 degrees
 * 89% had rotator cuff tears on radiographs

Two Types of Impingement
__Primary:__ Also known as External Subacromial Impingement due to the fact that the source of the pathology is outside the glenohumeral joint and is isolated to the subacromial space. This is most common in the 50+ age range and those who work in the industrial professions. __Secondary:__ Here the pathology occurs because there is a lack in stabilization of the humeral head over the glenoid fossa. Anterior translation of the humeral head occurs because of weak RTC musculature.

Signs/Symptoms
Pain may begin with only the mechanism of injury such as overhead throwing or lowering from a prolonged position often seen with styling hair. Later, the pain may occur even during rest or while sleeping. Weakness or a reduction in ROM may be present as well. Pain is mostly likely seen at the anterior portion of the shoulder and may radiate down the humerus. Discomfort should stop prior to reaching the elbow. If pain crosses the elbow joint it may be an indication of a pinched nerve with or without tendinous involvement.

Epidemiology
There are no national records of the prevalence of shoulder impingement. However, a study by Y.P.C. Lo, et al. concluded that roughly 44% of overhead athletes reported with shoulder problems; the chief complaint being pain followed by weakness and crepitus.

=__Tests __=

Crossover Adduction Test
__ Technique: __ Patient is standing or seated. The scapula should be stabilized and elevation prevented. The therapist moves the patient into horizontal adduction and applies overpressure at end range. __ Positive response: __ Anterior shoulder pain à subscapularis, supraspinatus, and long head of biceps involved Superior shoulder pain à acromioclavicular joint involvement Posterior pain àinfraspinatus, teres minor, and posterior capsule involvement __ Sensitivity & Specificity: __ __ Demonstration Videos: __ [] []
 *  Sens: .23
 *  Spec: .82
 *  Most sensitive diagnostic tests were found to be Hawkins test (92.1%), Neer test (88.7%) and __horizontal adduction test__ (82.0%) (Calis et al).

media type="youtube" key="CR5HxHpBqWk" height="315" width="420" 

Drop Arm Test
__ Technique: __ Patient is standing or seated. The therapist passively moves the arm into 90 degrees of shoulder flexion. The patient is instructed to slowly lower the arm towards the floor. __ Positive Response: __ Patient is unable to perform eccentric lowering in a controlled, smooth manner towards the floor. __ Sensitivity & Specificity: __
 * Positive for impingement or cuff pathology – used to rule in both impingement and rotator cuff pathology, but doesn’t differ between them. Other tests are needed to confirm diagnosis.
 * Subacromial impingement syndrome **(JBJS AM. 2005;87:1446-1455)**
 * Found that if had postive Painful Arc, __Drop Arm Sign__, ER Lag Sign:
 * 95% post test prob, +LR: 10.56 impingement
 * 91% post test prob, +LR: 15.57 RCT
 * “The **__drop arm test __** and lift-off test have higher pooled specificities (range, .92-.97) than sensitivities (range, .21-.42), indicating that they are more useful for ruling in SIS (subacromial impingement syndrome) if the test is positive” (Algunaee, Galvin, & Fahey 2012).
 * Highest specificity were **__drop arm test__** (97.2%), Yergason test (86.1%) and painful arc test (80.5%) consecutively (Calis et al).

Hawkins-Kennedy Test
__ Technique: __ __Positive Response:__ __Sensitivity and Specificity: __
 * This test is performed with the patient sitting and the examiner flexes the shoulder to 90 degrees and then horizontally adducts and internally rotates the arm.
 * A positive test is pain in this position.
 * Sens: 0.80
 * Spec: 0.43
 * These results show that this test is fair at ruling in shoulder impingement.

Speed’s Test
__ Technique: __ __Positive Response:__ __Sensitivity and Specificity:__
 * The patient’s arm is raised to 90 degrees of flexion and then they resist the examiner trying to force them into extension. This is done both with the forearm pronated and supinated.
 * A positive test is pain upon resistance
 * This test can indicate a biceps tendon pathology which can be a result of shoulder impingement or can be an injury of its own
 * Sens: 0.31
 * Spec: 0.61

Internal Rotation Resistance Strength Test (IRRST)
__Technique:__ __Positive Response:__ __Sensitivity and Specificity:__
 * This test is performed by having the patient sitting, shoulder abducted to 90 degrees, elbow bent to 90 degrees, and in 45 degrees external rotation. The examiner then applies resistance to both internal and external rotation, testing the strength of each one.
 * Also, this is the same as supraspinatus and infraspinatus manual muscle testing. If the subacromial space is narrowed, these muscles will possibly be entrapped and thus there will be weaker internal rotation.
 * A positive test is weakness of internal rotation. Usually, internal rotation is stronger than external rotation. Positive test indicates the problem is probably intra-articular at root.
 * Sens: 0.88
 * Spec: 0.96


 * Hegedus et al., in //Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests//, states that the IRRST is the special test with the highest specificity to rule in an intra-articular pathology that could be causing the shoulder impingement.

Neer's Test
__Technique__ __ Alternative Technique __ __ Positive Response __ __ Method __ __Sensitivity and Specificity__
 * The patient is seated or standing. The clinician stabilizes the patient's scapula. The patient's arm is internally rotated and the clinician passively moves it into flexion. Over pressure is applied if needed.
 * The same position as before, except the clinician passively elevates the medially rotated arm in the scapular plane
 * Pain in this position
 * Internal rotation of the arm in full flexion with pain indicates subacromial impingement
 * External rotation of the arm in full flexion with pain indicates AC joint involvement
 * Compression of the supraspinatus tendon in the subacromial space
 * Sensitivity= .79
 * Specificity= .53

Painful Arc
__Technique__ __ Positive Response __ __ Method __ __Sensitivity and Specificity__
 * Patient stands with arm externally rotated. Patient actively elevates arm in plane of abduction (thumb pointing up)
 * Pain from 45-160 degrees is indicative of glenohumeral involvement
 * Pain from 170-180 degrees is indicative of AC joint involvement
 * Compression of the supraspinatus tendon in the subacromial space
 * Sensitivity= .75
 * Specificity= .67
 * The evidence shows varying results in regards to sensitivity and specificity. The reported numbers are the results of a study by Michener, L. A. et al

**Empty/Full Can** __Empty Can __ __Full Can __
 * (+) full & empty can=RTC pathology is cause for impingement (3)
 * (+) empty can, - full can=should impingement but likely not related to RTC (3)
 * Assessment for supraspinatus injury/pathology and muscle strength
 * “may serve as a confirmatory test for impingement” (1)
 * <span style="font-family: 'Arial Black',Gadget,sans-serif; font-size: 15px;">Technique:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Pt shoulder elevated to 90 degrees in scapular plane, arm IR
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">PT applies resistance thru pt’s forearm
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**(****+)**=weakness or pain in supraspinatus
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">More likely to elicit pain therefore less likely to be + for weakness vs full can (1)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Compresses LH biceps
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Sens=.40
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Specificity=.90
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Technique:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Same but arm ER
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Not pinching as much on long head biceps, but still get LH biceps activation
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Sensitivity= .86
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Specificity= .57
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Videos
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">[]

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 15px;">Instability
__<span style="font-family: Arial,Helvetica,sans-serif; font-size: 15px;">Sulcus sign __ __<span style="font-family: 'Times New Roman',serif; font-size: 15px;">Apprehension Tests __ __<span style="font-family: 'Times New Roman',serif; font-size: 15px;">Relocation Test __ __<span style="font-family: 'Times New Roman',serif; font-size: 15px;">Anterior Drawer __ __<span style="font-family: 'Times New Roman',serif; font-size: 15px;">Load & Shift __ __<span style="font-family: 'Times New Roman',serif; font-size: 15px;">Videos __
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 15px;">Excessive humeral head translation can result in internal or external impingement
 * <span style="font-family: 'Times New Roman',serif;">Scale: 0=normal; 3=max laxity
 * <span style="font-family: 'Times New Roman',serif;">Sens=.72
 * <span style="font-family: 'Times New Roman',serif;">Spec=.96
 * <span style="font-family: 'Times New Roman',serif;">(+)=Higher accuracy for positive sign of apprehension (85%) vs. pain (49%) (3)
 * <span style="font-family: 'Times New Roman',serif;">Sens=.81
 * <span style="font-family: 'Times New Roman',serif;">Spec= .92
 * <span style="font-family: 'Times New Roman',serif;">(+)=Higher accuracy for positive sign of apprehension (85%) vs. pain (49%) (3)
 * <span style="font-family: 'Times New Roman',serif;">Sens=.53
 * <span style="font-family: 'Times New Roman',serif;">Spec=.85
 * <span style="font-family: 'Times New Roman',serif;">(+)=subluxation or dislocation of GH joint
 * <span style="font-family: 'Times New Roman',serif;">Trace=<5mm
 * <span style="font-family: 'Times New Roman',serif;">I=5-10 mm
 * <span style="font-family: 'Times New Roman',serif;">II=10-15 mm (humeral head subluxes but spontaneously reduces)
 * <span style="font-family: 'Times New Roman',serif;">III=>15 mm (humeral head dislocates but remains dislocated when stress is removed)
 * []
 * []
 * []

MRI
__Sensitivity and Specificity__
 * Evidence for the use of MRI as a diagnostic tool specifically for shoulder impingement was not found
 * Evidence for the use of MRI as a diagnostic tool to identify rotator cuff tears, which can be involved with shoulder impingement, had varying evidence
 * For partial thickness tears
 * Sensitivity= .44
 * Specificity= .90
 * For full thickness tears
 * Sensitivity= .89
 * Specificity= .93
 * The homogeneity was questioned in this systematic review, so the evidence is not completely clear