subacromial impingement syndrome

7/26/2019 Subacromial Impingement Syndrome

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CLINICALREVIEW

AuthorRudy Dressendorfer, BScPT, PhD

Cinahl Information Systems, Glendale, CA

ReviewersDiane Matlick, PT


Amy Lombara, PT, DPT

Rehabilitation Operations Council

Glendale Adventist Medical Center,

Glendale, CA

EditorSharon Richman, MSPT


June 26, 2015

Published by Cinahl Information Systems, a division of EBSCO Information Services . Copyright2015, Cinahl Information Systems. All rreserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, oany information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for ador information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthprofessional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Subacromial Impingement Syndrome

Indexing Metadata/Description

Title/condition:Subacromial Impingement Syndrome

Synonyms:Shoulder impingement syndrome, shoulder; rotator cuff impingement;

subacromial pain syndrome; supraspinatus impingement; impingement syndrome,shoulder; subacromial impingement

Anatomical location/body part affected:Shoulder/subacromial bursa, rotator cuff

tendons, scapula

Areas of specialty:Orthopedic rehabilitation, sports rehabilitation, home health

Description

Subacromial impingement syndrome (SIS) is characterized byshoulder pain and altere

glenohumeral kinematics on elevation of the involved arm, especially in overhead

activities such as reaching, lifting, and throwingthat require abduction and internal

rotation(1)

SIS is the most common painful disorder of the shoulder, accounting for 44% to 65%

all cases of shoulder pain in primary care(1)

SIS is associated with several musculoskeletal shoulder conditions, including

subacromial bursitis, rotator cuff tendinosis, partial tears of the rotator cuff tendons, an

calcific tendinitis of the biceps long head tendon. SIS involves, therefore,a spectrum o

etiological factors(1,2)

Physical therapy, corticosteroid injection, and surgeryare effective treatment

approachesfor reducing pain and disability in patients with SIS. However, high-quality

comparative research evidence is lacking to determine which of these approachesis be

for restoring shoulder function in the progressive stages of SIS(1,2)

ICD-9 codes

726.1 rotator cuff syndrome of shoulder and allied disorders

726.10 disorders of bursae and tendons in shoulder region (unspecified) 726.11 calcifying tendonitis of shoulder

719.41 pain in joint, shoulder region

ICD-10 codes

M75 shoulder lesions

M75.1 rotator cuff syndrome

M75.3 calcific tendonitis of shoulder

M75.4 impingement syndrome of shoulder

M75.5 bursitis of shoulder

(ICD codes are provided for the readers reference, not for billing purposes)

G-Codes

Carrying, Moving & Handling Objects G-code set

G8984, Carrying, moving & handling objects functional limitation, current status, at

therapy episode outset and at reporting intervals

G8985, Carrying, moving & handling objects functional limitation, projected goal

status, at therapy episode outset, at reporting intervals, and at discharge or to end

reporting


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G8986, Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end

reporting

Self Care G-code set

G8987, Self care functional limitation, current status, at therapy episode outset and at reporting intervals

G8988, Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, andat

discharge or to end reporting

G8989, Self care functional limitation, discharge status, at discharge from therapy or to end reporting

Other PT/OT Primary G-code set

G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at

reporting intervals

G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at

reporting intervals, and at discharge or to end reporting

G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to e

reporting

Other PT/OT Subsequent G-code set

G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at

reporting intervals

G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset

at reporting intervals, and at discharge or to end reporting

G8995, Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or t

end reporting .

G-code Modifier Impairment Limitation Restriction

CH 0 percent impaired, limited or restricted

CI At least 1 percent but less than 20 percent impaired, limited or restricted

CJ At least 20 percent but less than 40 percent impaired, limited or restricted

CK At least 40 percent but less than 60 percent impaired, limited or restricted

CL At least 60 percent but less than 80 percent impaired, limited or restricted

CM At least 80 percent but less than 100 percent impaired, limited or restricted

CN 100 percent impaired, limited or restricted

Source: http://www.cms.gov

.

Reimbursement:No specific issues or information regarding reimbursement have been identified

Presentation/signs and symptoms

The patient is often a past or present throwing athlete or uses/has usedthe involved arm in overhead occupational work(2)

Shoulder pain is usually unilateral. The dominant upper extremity is most often affected(1)

Shoulder pain may interfere with or impair activities of daily living (ADLs), sports, or occupational work

Pain is localized in the superior-lateral aspect of shoulder and upper arm, and seldom below elbow

Pain increases when elevating arm in abduction and inward rotation

Tenderness at point of shoulder, often at night when sleeping on affected shoulder or with arm above affected shoulder(1)

Altered shoulder mobility (usually with scapular dyskinesis) and reduced range of motion (ROM) that may interfere with

ADLs and sports(2)

Possible edema, erythema, and warmth at point of shoulder (or at arthroscopic portal sites in surgical cases)(1)

Patient may also complain of neck pain and/or upper back pain


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Postoperative patients typically present to physical therapy for shoulder rehabilitation(3)

Causes, Pathogenesis, & Risk Factors

Causes

The etiology of SIS remains debated, but appears multifactorial(1)

Shoulder pain is likely caused by impingement or compression of various soft tissues (e.g., supraspinatus tendon/muscle

long head of the biceps tendon, coracoacromial ligament, or subacromial bursa) between the humeral greater tuberosity a

the coracoacromial arch/postero-superior glenoid(1)

Primary impingement: Increased subacromial loading due to compression between the greater tuberosity of the humerusand the acromial arch is associated with variant anatomy of the scapula such as a curved or hooked acromion(1)

Secondary impingement: Results from rotator cuff overuse; microtrauma (friction and abrasion) to shoulder rotator tendo

(most often supraspinatus) and/or subacromial bursa(1)

Functional: work-related factors such as handling loads overhead or repetitive overhead throwing that produce

- Muscle strength imbalance with excessive superior translation of the humerus and irritation of the rotator cuff tendons

- Space-occupying hypertrophy of the supraspinatus tendon(1,2)

Biomechanical changes

- Scapular dyskinesis (i.e., abnormal scapular movement) may place excessive traction on rotator cuff (especially

supraspinatus muscle). However, whethervariantposition and movement of the scapula are causative factors remains

unclear(42,46)

- Glenohumeral joint hyperlaxity

Direct trauma (e.g., fall or other blunt force)to point of shoulder

Pathogenesis

The subacromial space ranges from 1.0 to 1.5 cm and is surrounded by the head of humerus inferiorly, the anterior edge

and inferior surface of the anterior one third of acromion, as well as by the coracoacromial ligament and acromioclavicul

joint superiorly(1)

The impingement ROM is commonly described as a painful arc between 70 and 120 abduction when elevating arm in

the scapular plane(4,5)

Neer classified SIS in 3 progressive stages(6)

Stage 1: low-grade inflammation with edema and hemorrhage of the subacromial bursa and/or rotator cuff. This stage iusually found in patients under 25 years of age

Stage 2: subacromial bursal fibrosis; rotator cuff tendinitis (typically found in patients 25 to 45 years of age)

Stage 3: chronic acromial bone spurring; tendon tearing or rupture requiring surgery (typically found in patients more

than 45 years of age)

Visual scapular dyskinesis, characterized byreduced scapular external rotation and increased upper trapezius muscle

activity, is commonly seen in patients with SIS.(46)However, biomechanical changes in shoulder forces (assessed by

functional torque ratios and torque curve analysis) that may contribute to SIS in overhead throwing athletes remain

unclear.(7)Variations in scapular position that appear abnormal may not contribute to SIS, according to an 2014

systematic review of studies that used 2-dimensional radiological measurements, 360 inclinometers, or 3-dimensional

motion and tracking devices to assess patients with or without SIS(42)

Risk factors High-velocity overhead movements of the upper extremity, as in throwing sports(8)

Occupations that involve repetitive or sustained elevated shoulder postures (e.g., painting, welding, carpentry)(9)

Competitive swim training, especially front-crawl and butterfly strokes, and its association with hyperlaxity(10)

Scapular dyskinesis(11,47)

Poor posture

Hooked acromion(1)

No clear risk associated specifically with age or gender


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Overall Contraindications/Precautions

Any of the followingwarrants referring the patient back to physician

Suspected fracture

Suspected rotator cuff tear

Catching and pseudo-locking: this presentation is atypical, suggestive of loose bodies in subacromial space

Radicular pain below the elbow

Recalcitrant/persistent pain after 2 to 3 months of conservative treatment and activity modification(4,5)

Patients who present after trauma to the involved shoulder are at high risk for developing glenohumeral adhesive capsuliti

Modify or restrict painful ADLs that may exacerbate condition, especially overhead activities See specific Contraindications/precautions under Assessment/Plan of Care

Examination

History

History of present illness/injury

Mechanism of injury:Was the onset of SIS sudden or gradual? Is there a history of repetitive overhead activities, such

throwing sports or work-related (e.g., painting, lifting)? Is the patients dominant arm affected? How have the symptom

progressed since onset?

Course of treatment

- Medical management:A conservative treatment plan (pain management, exercise therapy, activity modification, pati

education, and monitoring) typically precedes surgical intervention. Document nonoperative interventions used anddates of treatment

- Surgical management:Arthroscopic subacromial decompression (ASD) may improve function in patients with

recalcitrant SIS after an initial trial of conservative treatment.(47)Document date of surgery for SIS and procedure used

(e.g., ASD, acromioplasty), if applicable. A proposed randomized controlled trial (RCT) in Denmark may provide a

model for postoperative shoulder rehabilitation to reduce disability in patients with SIS(48,49)

- Medications for current illness/injury:Determine what medications clinician has prescribed, if any; are they being

taken as prescribed and are they effective? Nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter

pain relievers are commonly used. Moderate evidence supports a trial of immediate-release ibuprofen or 2 sessions of

corticosteroid injection for treatment of patients with SIS, based on a 2013 systematic review.(43)Authors of a trial in

Turkey found that local steroid injection (2 times with an interval of 10 days, n=45) was associated with reduced pain

at rest and during shoulder activity as compared to sham treatment(n=45). They also separately found no significantdifference between the steroid treatment and low-level lasertreatment (n=45)(50)

- Diagnostic tests completed:Plain radiographs are generally not necessary in mild acute cases; however, imaging

studies are often conducted in recalcitrant cases to evaluate for calcific deposits, sclerosis, cyst-like changes, tendon

tears, and subacromial spurring.(1,4,5)Magnetic resonance imaging (MRI) may be used if thickening of the supraspina

tendon is suspected(1,2)

- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative

therapies (e.g., acupuncture) and whether or not they help

- Previous therapy:Document whether patient received occupational or physical therapy for this or related

musculoskeletal conditions and what specific treatments were helpful or not helpful

Aggravating/easing factors(and length of time each item is performed before the symptoms come on or are eased):Aggravating factors may include overhead activities, throwing, and position during sleep

Body chart: Use body chart to document location and nature of symptoms. Pain is localized in the superior-lateral aspe

of shoulder, seldom below elbow

Nature of symptoms:Document nature of symptoms (e.g., constant vs. intermittent, sharp, dull, aching, burning,

numbness, tingling), 24-hour pain patterns and frequency

- Are symptoms getting better, worse, or staying the same?

- Is there associated neck pain or upper back pain?

- Pain in the shoulder may radiate into upper arm (C5 dermatome)

Rating of symptoms:Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, an

at the moment (specifically address if pain is present nowand how much)


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Pattern of symptoms:Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,

night); also document changes in symptoms due to weather or other external variables. Night pain is typical

Sleep disturbance:Document number of wakings/night, if any

Other symptoms:Document other symptoms patient may be experiencing that could be indicative of a need to refer to

physician (e.g., dizziness, sudden onset of upper extremity swelling, arm pain)

Barriers to learning

- Are there any barriers to learning? Yes__ No__

- If Yes, describe ________________________

Medical history

Past medical history

- Previous history of same/similar diagnosis:Any prior trauma to shoulder? Previous treatments to the affected

shoulder? Are there other musculoskeletal problems (such as arthritis in the elderly)?

- Comorbid diagnoses:Ask patient about any other medical conditions being treated, including diabetes, cancer,

cardiovascular disease, pulmonary disease, complications of pregnancy, psychiatric disorders, orthopedic disorders,

obesity, thyroid disorders,etc.

- Medications previously prescribed:Obtain a comprehensive list of medications prescribed and/or being taken

(including over-the-counter drugs)

- Other symptoms:Ask patient about other symptoms he or she may be experiencing

Social/occupational history

Patients goals:Document the patient specific and general goals for therapy

Vocation/avocation and associated repetitive behaviors, if any:Does the patient participate in recreational orcompetitive sports? Does shoulder pain restrict recreational or occupational activities?

Functional limitations/assistance with ADLs/adaptive equipment:Any difficulty with daily activities (e.g., putting o

coat, combing hair)?

Living environment:Stairs, number of floors in home, with whom patient lives, caregivers, etc. Identify if there are

barriers to independence in the home; any modifications necessary?

Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be

appropriate to patient medical condition, functional status, and setting)

Anthropometric characteristics:Document patients height, weight, and body mass index (BMI)

Assistive and adaptive devices:Assess need for and proper use of ambulatory assistive devices, especially in cases with

increased fall risk

Balance:Assess static and dynamic balance in standing, as indicated by patient history (e.g., if shoulder trauma wassustained in a fall). Use Berg Balance Scale for objective measure in elderly patients, as indicated

Cardiorespiratory function and endurance:Evaluate and monitor if cardiorespiratory conditioning is part of the

treatment plan

Circulation:Assess distal radial and ulnar pulses

Functional mobility:Assess ability in transfers, standing, walking, stairs, carrying, etc. Use FIM, as indicated

Cranial/peripheral nerve integrity:Cervical screen for radicular pain. Assess motor and sensory function in radial nerv

Ergonomics/body mechanics:Assess for scapular dyskinesis, i.e., changes associated with this syndrome: altered timin

and magnitude of acromial upward rotation, excessive anterior tilting of the glenoid (due to pectoralis tightness), and los

of maximal rotator cuff activation;(2)assess shoulder and general body mechanics in simulated lifting and loading work

tasks

Functional mobility(including transfers, etc.): Does impairment in affected arm affect mobility? Gait/locomotion:Evaluate as indicated. Usually not applicable

Joint integrity and mobility:Assess glenohumeral joint for hyperlaxity (instability), hypomobility, and passive translat

movements. Athletes at risk (e.g., throwers, swimmers) for shoulder impingement syndrome typically have glenohumera

joint instability(2,5)

Muscle strength:Assess strength at shoulder and scapulothoracic joints in all directions using manual muscle testing

(MMT), especially for possible weakness (< 5/5) in isometric forward flexion, internal and external rotation, as well as

scaption and abduction. Expect strength deficits in the impingement position due to pain avoidance. Assess for serratus

anterior and lower trapezius muscle weakness(12)

Observation/inspection/palpation(including skin assessment)

Examine shoulder for edema, warmth, scars, or deformity; atrophy around shoulder suggests chronic impairment


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Expect tenderness at greater tuberosity and biceps tendon (long head); tenderness and crepitus often also at

acromioclavicular joint

Observe scapulohumeral rhythm

Posture:Assess overall posture in standing. Observe for deviations in head, neck, shoulder girdle, and shoulder posture

Range of motion:ROM may be limitedbypain. High-levelbaseball pitchers typically have increased active and passive

ROM in shoulder external rotation.(13)Assess for dyskinetic scapulohumeral rhythm, especially in athletes at risk (e.g.,

throwers(8)and swimmers)(10)

Reflex testing:Assess upper extremity reflexes

Self-care/activities of daily living(objective testing): Assess for functional ROM in external rotation/abduction (thumb C7) and internal rotation/adduction (thumb to L5)

Sensation:Scan C5 dermatome. Assess for proprioception deficits in affected shoulder

Special tests specific to diagnosis: A wide variety of physical tests can be used in SIS cases

Neers test (Neers impingement sign): Patient in seated position with examiner supporting scapula, patient forward fle

shoulder with elbow straight and forearm pronated against examiners resistance; positive sign (reproduces pain and

patient grimaces) suggests inflammation or injury to structures in subacromial space(1)

Hawkins (Hawkins-Kennedy) test: Patient in a seated position with 90 forward shoulder flexion and 90 elbow flexion

patient internal rotates shoulder against examiners resistance; positive if reproduces pain. In a 2008 systematic review,

meta-analysis revealed moderate sensitivity (79%) for both Neers and Hawkins tests but poor specificity (53% and 59

respectively), indicating high false-positive rates(14)

Drop arm sign: In a sitting or standing position, the patient fully elevates the extended arm in scaption and then slowlyreverses the motion in the same arc. Test is positive if the arm drops suddenly or the patient has severe pain(1)

A 2012 systematic review found that the Hawkins-Kennedy test and Neers sign were found more useful for ruling out

SIS, whereas the drop arm sign was more useful for ruling in SIS(15)

Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure

Insufficient evidence was foundin an 2013 Cochrane review of 33 studies (4002 shoulders in 3,852 patients) to determi

which testfor SIS is most accurate(44)

Assessment/Plan of Care

Contraindications/precautions

Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patients physician. The treatmesummary below is meant to serve as a guide, not to replace orders from aphysician or a clinics specific protocols

Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regards

modalities. Rehabilitation professionals should always use their professional judgment when using modalities

Avoid ultrasound over growth plates in pediatric/adolescent patients

Cryotherapycontraindications(16)

Raynauds syndrome

Medical instability

Cryoglobulinemia

Cold urticaria

Paroxysmal cold hemoglobinuria

Avoid applying cold over superficial nerves, areas of diminished sensation or poor circulation, or with slow-healingwounds

Cryotherapyprecautions(16)

Use caution with patients who are hypertensive as cold can cause a transient increase in blood pressure; discontinue

treatment if there is an elevation in blood pressure

Use caution with patients who are hypersensitive to cold

Avoid aggressive treatment with cold modalities over an acute wound

Use of cryotherapy with patients who have an aversion to cold may be counterproductive if being used to promote mus

relaxation and decrease in pain

Superficial heatcontraindications(16)

Decreased circulation


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Decreased sensation

Acute/subacute traumatic and inflammatory conditions

Skin infections

Impaired cognition or language barrier

Malignant tumors

Tendency for hemorrhage or edema

Heat rubs

Whirlpoolcontraindications(16)

Severe epilepsyCertain dermatologic conditions

Surface infections

Uncontrolled bowels

Acute rheumatoid arthritis

Venous ulcers

Tissues devitalized by x-ray therapy

Peripheral vascular disease

Decreased thermal sensation

Respiratory dysfunctions

Cardiac dysfunctions

Active bleedingMalignancies

Previously existing fever

Acute inflammatory conditions

Whirlpoolprecautions (* only relevant if entire body is immersed)(16)

Impaired sensation

Confusion or impaired cognition

Recent skin grafts

Certain medications

Alcohol consumption*

Decreased strength/ROM/endurance/balance*

Urinary incontinence*Fear of water*

Respiratory problems

Pregnancy*

Multiple sclerosis*

Poor thermal regulation*

Seasickness

Edema, when warm/hot water immersion

Electrotherapycontraindications/precautions (in some cases, when approved by the treating physician, electrotherapy

may be used under some of the circumstances listed below when benefits outweigh the perceived risk)(16)

Stimulation through or across the chest

Cardiac pacemakersImplanted stimulators

Over carotid sinuses

Uncontrolled hypertension/hypotension

Peripheral vascular disease

Thrombophlebitis

Pregnancy

Over pharyngeal area

Diminished sensation

Acute inflammation

Seizure history


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Confused patients

Immature patients

Obesity

Osteoporosis

Cancer

Used in close proximity to diathermy treatment

Therapeutic ultrasound: Evidence is lacking to support the use of therapeutic ultrasound for management of patients w

SIS(17)

Diagnosis/need for treatment:SIS/shoulder pain, weakness, and pain-restricted ROM; reduced functional capacity forADLs, work, and/or sport

Rule out

Acromioclavicular joint arthritis

Internal impingement (dead arm syndrome)

Labral tear

Glenohumeral joint dislocation

Thoracic outlet syndrome

Cardiac event

Coracoid impingement

Bicipital tendonitis

Primary rotator cuff tendinitis (pain on isometric strength testing outside impingement position)

Rotator cuff tear

Cervical (C5-6) radiculopathy

Glenohumeral joint arthritis

Adhesive capsulitis (passive and active ROM equally restricted)

Suprascapular nerve entrapment(17)

Prognosis

Most patients with uncomplicated SIS return to their regular activitiesin 8 to 12 weeks after either conservative

management or postoperative care(2,3,18)

The average time until return to full work duty after arthroscopic subacromial decompression for SIS was 11.1 weeks in

retrospective study (N=166) in Belgium. Patients performing manual labor typically had a longer period of sick leave (12

weeks) than other employees (8 weeks)(18)

Long-term outcomes appear to be similar for surgical and physical therapy management of SIS, based on a 2008 Cochran

review and a 2009 systematic review(19,20)

Results of a 2011 systematic review of 5 RCTs indicate that as an initial approach to patients with SIS, surgery does not

improve prognosis more than conservative management(3)

Referral to other disciplines:Orthopedic surgeon for suspected fracture, rotator cuff tear, pseudo-locking, and recalcitrant

cases.(4,5)Occupational therapist (OT) for disability in ADLs

Treatment summary

Manual therapy

Manual therapy does not appear more effective than other conservative interventions in the treatment of patients with S

based on a 2009 systematic review of 3 RCTs(21)

Authors of a 2004 systematic review of 12 trials found that therapeutic exercise and joint mobilizations each effectively

restored function in patients with SIS, whereas ultrasound was of no benefit.(22)This review supports similar findings i

2003 Cochrane review of 26 trials(23)

In a 2010 case study, manual therapy techniques, including thrust and nonthrust spinal mobilization and soft tissue

mobilization of the posterior and inferior glenohumeral joint, were successful at reducing patients pain and improving

functional outcomes. Manual techniques were coupled with stretching and strengthening exercises

Manual therapy coupled with therapeutic exercise may be more effective than therapeutic exercise alone in the treatmen

of patients with SIS, based on an RCT (N=52) in the U.S.(24)


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- Participants were randomized to Group 1, which received therapeutic exercise (6 sessions over 3 weeks) only, or

Group 2, which received a similar course of therapeutic exercise coupled with manual therapy. Results (between-grou

comparisons) indicate Group 2 had significantly greater pain reduction and improvement in shoulder function

- According to a 2014 systematic review, no further high-quality studies have investigated whether combining manual

therapy with exercise therapy improves desired outcomes for patients with SIS more than exercise therapy alone(51)

Modalities

Laser therapy

- Low-level laser therapy (LLLT) in combination with a home exercise program may not offer any considerable

therapeutic advantage over a home program alone for patients with SIS, based on an RCT (N=44) in Turkey(25)

- Participants were randomized to Group 1, which received gallium-arsenide laser therapy and a 12-week home exerc

program,or Group 2, which received an 12-week home exercise program similar to group 1

- Results (between-group comparisons) at

- 2 weeks from baseline

- showed no significant differences in mean changes in night pain and Shoulder Pain and Disability Index (SPADI)

scores or in

- University of California, Los Angeles (UCLA) shoulder scale scores between the groups.

- At 12 weeks from baseline,

- Group 1 had a significantly greater reduction in night pain, but the

- UCLA shoulder scale scores and SPADI scores did not differ significantly between groups

- Authors of a RCT (N=60) in Turkey found that LLLT was not more effective than placebo LLLT for the treatment ofSIS(26)

- High-intensity laser therapy (HILT) may be more effective than ultrasound therapy in the short-termtreatment of patie

with SIS, based on an RCT (N=70) in Italy(27)

- Participants were randomized to 1 of 2 groups

- Group 1 received HILT in 10 sessions over 2 weeks

- Group 2 received therapeutic ultrasound in 10 sessions over 2 weeks

- Results (between-group comparisons; immediately after 2-week intervention period)

- Group 1 reported a significantly greater reduction in pain (VAS scores) compared to group 2

- Group 1 had significantly greater improvement in Constant-Murley Scale (CMS) scores for pain, function, strength

and ROM

- Group 1 had significantly greater improvement in Simple Shoulder Test scores for pain and functionPulsed electromagnetic field (PEMF) therapy

- PEMF in addition to standard conservative therapy does not appear to offer additional therapeutic benefit for patients

with SIS, based on a double-blind RCT (N=46) in Turkey(28)

Evidence is lacking to support the use of ultrasound therapy for treatment of SIS(17,20,22)

There is insufficient evidence to support phonophoresis, iontophoresis,(29)or extracorporeal shockwave therapy for

management of SIS(30)

Therapeutic exercise

A comprehensive physical-therapy-based program for shoulder rehabilitation may include four phases(2)

- The initial phase: protection, icing for pain and edema, and activity modification

- Early rehabilitation: manual therapy that includes joint and soft tissue mobilization to address shoulder joint stiffness,muscle shortening, and scapular dyskinesis. Pendulum exercise, active assisted ROM,postural re-education

- Late rehabilitation: restoration of active ROM and glenohumeral motion, after which resistance and proprioception

retraining exercises are introduced

- The functional phase: specific exercises (see below) for high-functioning patients to further build strength and

endurance and scapulohumeral coordination exercises aimed at restoring fitness for work and sports

A 2010 systematic review of 8 RCTs found moderate evidence that exercise may effectively reduce shoulder pain and

improve function in patients with SIS (31)

Similarly, a 2014 systematic review of 10 RCTs reported moderate evidence that a program of exercise therapy is

effective for reducing pain and disability in patients with SIS over the short term(51)


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Findings of a 2010 systematic review, a 2011 review of electromyographic (EMG) studies, and an RCT (N=40) in Turk

support the use of specific shoulder exercises for reducing pain and/or improving function in patients with SIS(32,33,34)

- Stretching exercises should target the upper trapezius muscle and posterior glenohumeral capsule

- Strengthening exercises should target the rotator cuff muscles through the full/painless ROM and scapular stabilizers,

including the serratus anterior

Authors of an RCT (N=102) in Sweden found that a specific regimen of strengthening eccentric exercises for the rotato

cuff and concentric/eccentric exercises for the scapula stabilizers in combination with manual mobilization effectively

reduced pain and improved shoulder function in patients with persistent SIS(35,45)

- 95% of participants had SIS for over 6 months and failed earlier conservative treatment- Participants were randomized to 1 of 2 groups

- Specific exercise group received 5 to 6 individualized and guided treatment sessions combined with manual

mobilization over 12 weeks

- Control group 5 to 6 nonspecific exercises for the neck and shoulder over 12 weeks

- Both groups performed home exercises twice a day for the 12 weeks

- The following significant differences on follow-up favored the specific exercise group:

- Higher CMS assessment score (24 points vs. 9 points)

- Reported successful outcome (69% vs. 24%)

- Fewer chose to undergo surgery (20% vs. 63%)

Scapular stabilization exercises

- The following shoulder exercises may target specific periscapular muscles to elicit their highest maximum voluntaryisometric contraction recruitment, based on a review of 22 EMG studies(35)

- Resisted prone shoulder extension with elbow in full extension (targets middle trapezius)

- Resisted prone horizontal abduction at 90 with full external rotation (targets middle trapezius)

- Isometric low row patient stands (with shoulder and elbow in neutral position) and applies pressure with palm

of hands facing posteriorly on immovable surface (such as a doorway), while attempting to retract and depress the

scapula (targets low trapezius and serratus anterior)

- Inferior glide patient sits with arm abducted to 90, wrist neutral position, elbow extended, and applies pressure wi

fist clenched on a full supportive surface, while attempting to retract and depress the scapula (targets low trapezius a

serratus anterior)

- Push-up plus patient lies prone with hands shoulder-width apart (in push-up position) and chest on/near the floor;

then extends elbows as in standard push-up; then continues to rise up by protracting the scapula (targets serratus

anterior)

- Dynamic hug resisted horizontal flexion with both shoulders at a constant 60 of humeral elevation while hands

follow an imaginary arc until maximum protraction is attained (targets serratus anterior)

Authors of a 2012 systematic review and meta-analysis (1,162 participants withSIS) found moderate evidence that

therapeutic exercise (scapular stabilization, rotator cuff strengthening, and exercises through range to 90 abduction)

decreased pain at 6 to 12 weeks follow-up and improved patient-reported function beyond 12 weeks(40,41)

Authors of a 2014 systematic review found evidence was lacking to conclude that exercise therapy for repositioning the

scapula to an idealized normal posture improved shoulder symptoms and function patients with SIS(42)

A home exercise program may be effective in reducing pain and increasing function for individuals (working in the

construction industry) with SIS, based on an RCT (N=67 male construction workers) in the United States(9)

- Participants were randomized to 1 of 2 groups- Intervention group received a home exercise program (stretching and strengthening) for 8 weeks

- Control group did not receive an intervention

- Results show the intervention group had significantly greater improvements in Shoulder Rating Questionnaire (SRQ

score, shoulder satisfaction score, pain, and patient-reporteddisability

A standard upper extremity progressive concentric resistance exercise program may reduce pain and increase function i

individuals with SIS compared to no intervention, based on an RCT (N=60) in Brazil(36)

- Participants were randomized to Group 1, which received progressive resistance exercise training 2 times per week fo

months, or to Group 2, which received no intervention and remained on a waiting list

- Results showed significantly greater improvements in the intervention group for pain (VAS), shoulder function (DASH

Outcome Measure), and quality of life (Health Survey Short-Form 36)


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Evidence is lacking to support the use of eccentric-loadingexercise therapy in the treatment of patients with SIS(52)

A high-dose exercise regimen may be more effective than a low-dose regimen for patients with persistent SIS due

supraspinatus tendon impingement, based on an RCT (N=61) in Norway(37)

- Participants were randomized to Group 1, which received high-dose exercise therapy (HDET, 11 supervised resistan

and mobility exercises 3 sets of 30 for each exercise plus ergometer cycling for about 40 minutes [spread out throug

treatment session] at 70% to 80% of estimated maximum heart rate [HR]) 3 times per week for 3 months), or to Group

2, which received low-dose exercise therapy (6 of the HDET groups exercises 2 sets of 10 for each exercise plus

cycling for about 10 minutes at 70-80% of maximum HR) 3 times per week for 3 months

- The HDET group had significantly greater improvements for pain (VAS), ROM, SRQ, patient satisfaction withoutcome, and strength in shoulder abduction and external rotation. Neither group showed a significant change in the

thickness of the impinged tendon on MRI

.

Problem Goal Intervention Expected Progression Home Program

Pain and tenderness

_

_

Joint and soft tissue

swelling

Relief of pain and

tenderness

_

_

Resolve edema

Physical agents and

mechanical modalities

_

Cryotherapy for pain

and edema

N/A Recommend a home

program for pain/

edema management

as indicated and

appropriate for each

unique patientPoor posture Normal posture Functional training

_

Functional

strengthening and

scapular stabilization

exercises for upper

extremity movements

in daily activities

_

_

Patient education_

For correct postural

alignment at rest and

during activity

Progress as indicated Implement a home

program to address

faulty posture as

indicated

Restricted shoulder and

scapulothoracic joint

mobility

Improve shoulder and

scapulothoracic joint

mobility

Manual therapy

_

Focus on resolving

posterior and inferior

shoulder capsule

hypomobility, and neck

and shoulder muscle

tightness

_

_

Physical agents and

mechanical modalities

_

Dry or moist heat to

relax muscles prior to

manual therapy

Progress as indicated Home exercise

program

_

May provide illustrate

unassisted stretches

(for deltoids, internal

and external rotators,

scapular elevators and

rotators) and rotator-

cuff strengthening

exercises


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Scapular dyskinesis Normalize scapular

kinematics

Functional training

_

Exercises to retrain

abnormal scapular

kinematics(35)


program to address

scapular dyskinesis as

indicated

Shoulder and shoulder

girdle muscle weakness

_

_Proprioception deficits

Improve strength at and

around the shoulder

_

_Normal proprioception

and kinesthesis

Therapeutic exercises

_

Focus on stretching the

anterior and posteriorshoulder muscles(2)

and strengthening the

rotator cuff, shoulder

adductors, and scapular

stabilizers

_

_

Resistance tubing

exercises appear

effective for activating

targeted shoulder

muscles used in

overhead activities,

such as throwing(38,39)

_

_

Posture awareness

exercises, as indicated


program to address

shoulder weakness as

indicated

Reduced shoulder

function for work

or sports; risk

of disability; no

independent self-care

program

Restore functional

strength and

performance for work

or sports

_

_

Return to work or sport;

independent self-care

program

Functional training

_

Isokinetic and

plyometric exercises to

regain work or sports

fitness


program to assist in

regaining the capacity

to return to work as

indicated

.

Desired Outcomes/Outcome Measures

Desired outcomes

Relief of pain and tenderness

Resolved edema Improved shoulder and scapulothoracic joint mobility and kinematics

Improved shoulder and scapulothoracic strength

Normal proprioception/kinesthesis

Restored functional strength and performance for work or sports

Independent self-care program

Outcome measures

VAS

Goniometry

MMT

Reassessment of posture, proprioception, and kinematics, as indicated


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Shoulder function (e.g., CMS, SRQ, Western Ontario Rotator Cuff Index, DASH Outcome Measure, Global Rating of

Change Scale)

Indicators of patient satisfaction (e.g., ADLs, return to work or sport)

Maintenance or Prevention

Continue therapeutic exercises to maintain shoulder fitness for work or sport, to promote normal kinematics, and to preven

recurrence

Patient Education

Shoulderdoc.co.uk Web site, Subacromial Impingement, http://www.shoulderdoc.co.uk

Coding MatrixReferences are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentationsother such materials

CP Conference proceedings, abstracts, presentation

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