1. SUBACROMIAL IMPINGEMENT SYNDROME
ESSENTIALS OF DIAGNOSIS
Shoulder pain with overhead motion.
Night pain with sleeping on shoulder.
Numbness and pain radiation below the elbow are usually due to cervical spine disease.
The shoulder is a ball and socket joint. The socket is very shallow, however, which enables this joint to have the most motion of any joint. The shoulder, therefore, relies heavily on the surrounding muscles and ligaments to provide stability. The subacromial impingement syndrome describes a collection of diagnoses that cause mechanical inflammation in the subacromial space. Causes of impingement syndrome can be related to muscle strength imbalances, poor scapula control, rotator cuff tears, subacromial bursitis, and bone spurs.
With any shoulder problem, it is important to establish the patient’s hand dominance, occupation, and recreational activities because shoulder injuries may present differently depending on the demands placed on the shoulder joint. For example, baseball pitchers with impingement syndrome may complain of pain while throwing. Alternatively, older adults with even full-thickness rotator cuff tears may not complain of any pain because the demands on the joint are low.
Subacromial impingement syndrome classically presents with one or more of the following: pain with overhead activities, nocturnal pain with sleeping on the shoulder, or pain on internal rotation (eg, putting on a jacket or bra). On inspection, there may be appreciable atrophy in the supraspinatus or infraspinatus fossa. The patient with impingement syndrome can have mild scapula winging or “dyskinesis.” The patient often has a rolled-forward shoulder posture or head-forward posture. On palpation, the patient can have tenderness over the anterolateral shoulder at the edge of the greater tuberosity. The patient may lack full active range of motion (Table 41–1) but should have preserved passive range of motion. Impingement symptoms can be elicited with the Neer and Hawkins impingement signs (Table 41–1).
Table 41–1.Shoulder examination. |Favorite Table|Download (.pdf) Table 41–1. Shoulder examination.
|Table 41–1. Shoulder examination. |
|Maneuver ||Description |
|Inspection ||Check the patient’s posture and “SEADS” (swelling, erythema, atrophy, deformity, surgical scars). |
|Palpation ||Include important landmarks: acromioclavicular (AC) joint, long head of biceps tendon, coracoid, and greater tuberosity (supraspinatus insertion). |
|Range of motion testing ||Check range of motion actively (patient performs) and passively (clinician performs). |
|Move the arm forward as high as possible in the sagittal plane. |
|Check with the patient’s elbow touching their body so that external rotation occurs predominantly at the glenohumeral joint. |
|The patient is asked to reach the thumbs as high as possible behind the spine on each side. The clinician can record the highest spinous process that the individual can reach on each side (iliac crest = L4, inferior angle of scapula = ...|