Shoulder impingement: Biomechanical considerations in rehabilitation

doi:10.1016/j.math.2010.08.004

Manual Therapy

Volume 16, Issue 1, February 2011, Pages 33-39

https://doi.org/10.1016/j.math.2010.08.004 Get rights and content

Abstract

Shoulder impingement is a common condition presumed to contribute to rotator cuff disease. Impingement can occur externally with the coracoacromial arch or internally with the glenoid rim. Normal scapulothoracic motions that occur during arm elevation include upward rotation, posterior tilting, and either internal or external rotation. These scapulothoracic motions and positions are the result of coupled interactions between sternoclavicular and acromioclavicular joints. The sternoclavicular and acromioclavicular joints both contribute to scapulothoracic upward rotation. Posterior tilting is primarily an acromioclavicular joint motion. The sternoclavicular and acromioclavicular joint motions offset one another regarding final scapulothoracic internal/external rotation position. This manuscript discusses these coupled interactions in relation to shoulder muscle function. Two case examples are presented to demonstrate application of understanding these interactions and potential mechanisms of movement abnormalities in targeting treatment interventions for movement based subgroups of impingement patients.

Section snippets

Normal shoulder motion

During normal motion, the scapula will upwardly rotate and posteriorly tilt on the thorax during elevation of the arm in flexion, abduction, scapular plane abduction, or unrestricted overhead reaching (McClure et al., 2001, Braman et al., 2009, Ludewig et al., 2009). Throughout this manuscript, elevation will be used to refer to raising the arm overhead in any of these planes. Scapulothoracic internal or external rotation is less consistent during arm elevation, differing in pattern depending

Effects of trapezius and serratus anterior muscle function

Although somewhat complex to understand, these interrelationships between how SC and AC joints contribute to overall motion of the scapula on the thorax are also important with regard to how they influence muscle function. Based on common clinical presumptions, the upper trapezius is often described as an ST upward rotator. However, as identified by Johnson et al. (1994), its distal attachments are to the clavicle. The line of action of the upper trapezius muscle attached to the distal clavicle

Abnormal shoulder motion in impingement

A recent review article identified scapular motion abnormalities in subjects with impingement or rotator cuff disease (Ludewig and Reynolds, 2009). Briefly, nine of 11 studies reviewed demonstrated a statistically significant scapular movement deviation in at least 1 variable, as compared to healthy control groups (Warner et al., 1992, Lukaseiwicz et al., 1999, Ludewig and Cook, 2000, Graichen et al., 2001, Endo et al., 2001, Hebert et al., 2002, Su et al., 2004, Mell et al., 2005, Lin et al.,

Movement based intervention case examples

Clinical trials demonstrate that therapeutic exercise can reduce pain and improve function in patients with shoulder impingement and rotator cuff disease (Bang and Deyle, 2000, Ludewig and Borstad, 2003, McClure et al., 2004, Michener et al., 2004, Haahr and Andersen, 2006, Senbursa et al., 2007). However, this evidence also suggests that not all patients improve, and that most do not return to healthy levels of function (Ludewig and Borstad, 2003). Exercise protocols vary widely across these

Summary

Acknowledgements

This manuscript was supported in part by NIH grants K01HD042491 and R03ND053399 from the National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institute of Child Health and Human Development or the National Institutes of Health.

References (64)

M.J. Bey et al.
In vivo measurement of subacromial space width during shoulder elevation: technique and preliminary results in patients following unilateral rotator cuff repair
Clinical Biomechanics
(2007)
J.P. Braman et al.
In vivo assessment of scapulohumeral rhythm during unconstrained over head reaching in asymptomatic subjects
Journal of Shoulder and Elbow Surgery
(2009)
J.E. Budoff et al.
Internal impingement in the etiology of rotator cuff tendinosis revisited
Arthroscopy
(2003)
A. Deutsch et al.
Radiologic measurement of superior displacement of the humeral head in impingement syndrome
Journal of Shoulder and Elbow Surgery
(1996)
Z. Dvir et al.
The shoulder complex in elevation of the arm: a mechanism approach
Journal of Biomechanics
(1978)
D.D. Ebaugh et al.
Effects of shoulder muscle fatigue caused by repetitive overhead activities on scapulothoracic and glenohumeral kinematics
Journal of Electromyography and Kinesiology
(2006)
K. Endo et al.
Influence of age on scapulo-thoracic orientation
Clinical Biomechanics
(2004)
G. Edelson et al.
Internal impingement in the shoulder
Journal of Shoulder and Elbow Surgery
(2000)
K. Endo et al.
Radiographic assessment of scapular rotational tilt in chronic shoulder impingement syndrome
Journal of Orthopedic Science
(2001)
H. Graichen et al.
Three-dimensional analysis of shoulder girdle and supraspinatus motion patterns in patients with impingement syndrome
Journal of Orthopaedic Research
(2001)

L.J. Hebert et al.

Scapular behavior in shoulder impingement syndrome

Archives of Physical Medicine and Rehabilitation

(2002)

G. Johnson et al.

Anatomy and actions of the trapezius muscle

Clinical Biomechanics

(1994)

A.R. Karduna et al.

Contact forces in the subacromial space: effects of scapular orientation

Journal of Shoulder and Elbow Surgery

(2005)

M. Kebaetse et al.

Thoracic position effect on shoulder range of motion, strength and three-dimensional scapular kinematics

Archives of Physical Medicine and Rehabilitation

(1999)

J.J. Lin et al.

Functional activity characteristics of individuals with shoulder dysfunctions

Journal of Electromyography and Kinesiology

(2005)

P.W. McClure et al.

Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo

Journal of Shoulder and Elbow Surgery

(2001)

L.A. Michener et al.

Anatomical and biomechanical mechanisms of subacromial impingement syndrome

Clinical Biomechanics

(2003)

L.A. Michener et al.

Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review

Journal of Hand Therapy

(2004)

K.J. Paley et al.

Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff

Arthroscopy

(2000)

N.T. Tsai et al.

Effects of muscle fatigue on 3-dimensional scapular kinematics

Archives of Physical Medicine and Rehabilitation

(2003)

C.H. Wang et al.

Stretching and strengthening exercises: their effect on three-dimensional scapular kinematics

Archives of Physical Medicine and Rehabilitation

(1999)

C.M. Werner et al.

Subacromial pressures in vivo and effects of selective experimental suprascapular nerve block

Journal of Shoulder and Elbow Surgery

(2006)

T. Yanai et al.

In vivo measurements of subacromial impingement: substantial compression develops in abduction with large internal rotation

Clinical Biomechanics

(2006)

J.D. Zuckerman et al.

The influence of coracoacromial arch anatomy on rotator cuff tears

Journal of Shoulder and Elbow Surgery

(1992)

M.D. Bang et al.

Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome

Journal of Orthopaedic and Sports Physical Therapy

(2000)

M.R. Borich et al.

Scapular angular positioning at end range internal rotation in cases of glenohumeral internal rotation deficit

Journal of Orthopaedic and Sports PhysicalTherapy

(2006)

J.D. Borstad et al.

The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals

Journal of Orthopaedic and Sports Physical Therapy

(2005)

A.M. Cools et al.

Trapezius activity and intramuscular balance during isokinetic exercise in overhead athletes with impingement symptoms

Scandinavian Journal of Medicine and Science in Sports

(2007)

A.M. Cools et al.

Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms

American Journal of Sports Medicine

(2003)

A.M. Cools et al.

Evaluation of isokinetic force production and associated muscle activity in the scapular rotators during a protraction-retraction movement in overhead athletes with impingement symptoms

British Journal of Sports Medicine

(2004)

E. Culham et al.

Functional anatomy of the shoulder complex

Journal of Orthopaedic and Sports Physical Therapy

(1993)

D.D. Ebaugh et al.

Scapulothoracic and glenohumeral kinematics following an external rotation fatigue protocol

Journal of Orthopaedic and Sports Physical Therapy

(2006)

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Effectiveness of scapular mobilization in people with subacromial impingement syndrome: A randomized controlled trial
2023, Annals of Physical and Rehabilitation Medicine
Scapular mobilization is a manual therapy technique widely used in the management of musculoskeletal disorders of the shoulder.
To determine the effects of scapular mobilization in addition to an exercise program in people with subacromial impingement syndrome (SIS).
Seventy-two adults with SIS were randomly allocated to 1 of 2 groups. The control group (n=36) participated in a 6-week exercise program, and the intervention group (n = 36) participated in the same exercise program plus passive manual scapular mobilization. Both groups were assessed at baseline and 6 weeks (end of treatment). The primary outcome measure was upper limb function assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Secondary outcome measures were the Constant-Murley questionnaire, pain (visual analog scale [VAS]), and scapular upward rotation.
All participants completed the trial. The between-group difference in DASH was -1.1 points (Cohen d = 0.05; p = 0.911), Constant-Murley 2.1 points (Cohen d = 0.08; p = 0.841), VAS rating of pain at rest -0.1 cm (Cohen d = 0.05; p = 0.684), and VAS rating of pain during movement -0.2 cm (Cohen d = 0.09; p = 0.764); scapular upward rotation at rest (arm by the side) was 0.6° (Cohen d = 0.09; p = 0.237), at 45° shoulder abduction was 0.8° (Cohen d = 0.13; p = 0.096), at 90° was 0.1° (Cohen d = 0.04; p = 0.783), and at 135° was 0.1° (Cohen d = 0.07; p = 0.886). Most differences were in favor of the intervention group; however, the effect sizes were weak and not statistically significant.
In the short-term, the addition of scapular mobilization did not provide significant clinical benefits in terms of function, pain or scapular motion in participants with SIS.
Brazilian registry of clinical trials UTN number U1111-1226-2081. Registered February 25, 2019.
3D measurement of clavicular and scapular orientations: The association with clinical characteristics and responsiveness to scapular repositioning in patients with neck pain
2022, Musculoskeletal Science and Practice
Clavicular and scapular orientations vary between neck pain patients as do clinical features and responses (changes in pain and rotation range) to scapular repositioning. Associations between these factors are unknown.
To identify subgroups of neck pain patients based on three-dimensional (3D) measures of clavicular and scapular orientations and differences between subgroups in clinical characteristics and responses to scapular repositioning.
Cross-sectional study.
Eligible participants were recruited as part of a larger study. The 3D clavicular and scapular orientations were analyzed on the more painful side of the neck using a hierarchical cluster analysis. Clinical characteristics were neck pain location, intensity, duration, disability and presence of headache. Responses to scapular repositioning were classified as “yes and no”.
Fifty-eight participants (29 responsive; 29 non-responsive to scapular repositioning) participated in the study. Analysis identified two distinct subgroups: subgroup1 had greater clavicular retraction and scapular downward rotation (n = 26) and subgroup2 had greater clavicular elevation and scapular internal rotation and anterior tilt (n = 32). Headache and dominant pain in the upper neck were more frequent in subgroup 1 while dominant pain in the lower neck was frequent in subgroup 2 (p < 0.01). Most participants who responded positively to scapular repositioning (88.5%) were in subgroup1 and most non-responsive participants (81.2%) in subgroup2.
The 3D clavicular and scapular orientations identified two subgroups of neck pain patients. Participants with predominantly downward scapular rotation were distinguished by pain in the upper neck, presence of headache and a positive response to scapular repositioning.
Associations between range of motion, strength, tear size, patient-reported outcomes, and glenohumeral kinematics in individuals with symptomatic isolated supraspinatus tears
2022, Journal of Shoulder and Elbow Surgery
Clinical failure associated with nonoperative treatment of rotator cuff tears may be due to inadequate characterization of the individual's functional impairments. Clinically, restricted passive range of motion (ROM) (restrictions imply capsular tightness), limitations in muscle strength, and larger rotator cuff tears are hypothesized to be related to altered glenohumeral kinematics. Understanding these relationships, as well as the relationship between glenohumeral kinematics and patient-reported outcomes (PROs) prior to exercise therapy, may help characterize functional impairments in individuals with rotator cuff tears. The objectives of the study were to describe the baseline presentation of individuals with an isolated supraspinatus tear, including passive ROM, rotator cuff muscle strength, tear size, PROs, and glenohumeral kinematics, and to determine associations among these variables.
One hundred one individuals with symptomatic isolated supraspinatus tears were recruited for the study and underwent assessments of passive glenohumeral ROM, isometric muscle strength, and ultrasonography to assess anterior-posterior tear size. Glenohumeral kinematics during scapular-plane abduction were measured using biplane radiography. Furthermore, PROs including the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Rotator Cuff Index (WORC) score were collected.
Individuals presented with decreased ROM, external rotation weakness compared with the uninvolved side, and pain and disability as measured by the ASES and WORC scores. These findings were not associated with glenohumeral kinematics, with the exception of a weak positive association between glenohumeral contact path lengths and WORC scores (ρ = 0.25, P = .03). Tear size was 11.7 ± 5.7 mm, and maximum anterior translation, superior translation, and contact path length were 3.0% ± 3.8% of glenoid width, 3.5% ± 3.8% of glenoid height, and 38.2% ± 20.7% of glenoid size, respectively.
Individuals with a symptomatic isolated supraspinatus tear presented with decreased ROM, external rotation weakness, and pain and disability as measured by the ASES and WORC scores. However, no abnormal kinematics associated with these limitations were observed. Thus, given that the tear is isolated to the supraspinatus tendon and no capsular restrictions are present, normal function of the glenohumeral joint may be possible during scapular-plane abduction.
Current concepts on management of cuff tear
2022, Journal of Clinical Orthopaedics and Trauma
Among pathologies of the shoulder, rotator cuff tear is the most common. Diagnosis of cuff tear around mid twenties is unusual, but the prevalence increases significantly after the age of forty. The prevalence after the age of 60 is around 20–30%. A well recognised feature of cuff tear is being asymptomatic but, tear progression in asymptomatic is a known consequence. The spectrum of cuff tear ranges from partial, full thickness cuff tear with or without retraction. The mainstay of treatment for partial thickness cuff tear is systematic rehabilitation and for the full thickness cuff tear an initial rehabilitation is an accepted management. Failed rehabilitation for 3 months, acute traumatic tear, younger age, intractable pain, good quality muscle would be the indications for repair of a full thickness cuff tear. Though there are defined indications for surgical intervention in the full thickness rotator cuff tear, differentiating an asymptomatic tear that would not progress or identifying a tear that would become better with rehabilitation is an undeniable challenge for even the most experienced surgeon.
Rehabilitation in cuff tear consists of strengthening the core stabilizers along with rotator cuff and deltoid muscles. In a symptomatic cuff tear that merits surgical intervention the objective is to do an anatomical foot print repair. In scenarios where the cuff is retracted, one has to settle for a medialised repair. As, a repair done in tension is more likely to fail than a tensionless medialised repair. The success rate of all these non anatomical procedures varies from series to series but it approximates around 60–80%.
Augmenting cuff repair to enhance biological healing is a recent advance in rotator cuff repair surgery. The augmentation factors can be growth factors like PRP, scaffolds both auto and allografts. The outcome of these procedures from literature has been variable. As there are no major harmful effects, it can be viewed as another future step in bringing better outcomes to patients having rotator cuff tear surgery.
Despite being the commonest shoulder pathology, the rotator cuff tear still remains as a condition with varied presenting features and a wide variety of management options. The goal of the treatment is to achieve pain free shoulders with good function. Correcting altered scapular kinematics by systematic rehabilitation of the shoulder would be the first choice in all partial thickness cuff tear and also as an initial management of full thickness cuff tears. Failure of rehabilitation would be the step forward for a surgical intervention. While embarking on a surgical procedure, correct patient selection, sound surgical technique, appropriate counselling about expected outcome are the most essential in patient satisfaction.
Pilots After Shoulder Surgery and Rehabilitation in a Dedicated Musculoskeletal Rehabilitation Unit of a Major Airline Returned to Work Earlier When Compared to Standard Rehabilitation by External Providers
2022, Arthroscopy, Sports Medicine, and Rehabilitation
The purpose of this study was to compare the time to return to work (RTW) for pilots who underwent shoulder surgery and underwent rehabilitation within a dedicated musculoskeletal rehabilitation (MSK) unit of a major airline to a group of pilots who had standard rehabilitation and to calculate cost savings.
The database of Emirates Airline was searched for all ICD-10 codes relating to shoulder pathology. Pilots who had shoulder surgery between January 2017 and June 2021 were included. Pilots who had previous shoulder surgery, underwent fracture surgery, joint replacement, revision surgery, or conservative treatment were excluded. The time between suspension and reinstatement of their license was defined as RTW. Cost savings were calculated on the basis of the median salary and rosterable fraction of a commercial airline pilot. RTW compared between a group undergoing rehabilitation in the MSK unit and a group receiving standard rehabilitation by external providers. Group allocation for either attending MSK unit or standard rehabilitation occurred randomly and according to the individual pilots preferences.
The MSK unit treated 36 pilots (36 males/0 females, mean age 45.4 ± 9.4), and 18 pilots (17 males/1 female, mean age 50.3 ± 7.3) were treated by external physical therapist providers. Patients treated by the MSK unit returned to work at a mean of 85.3 ± 32.8 days, and patients treated by external providers returned to work at a mean of 117.9 ± 42.5days (P = .02). The cost savings for pilots treated by the MSK unit were calculated to be $27,948 USD per patient.
The results of this study showed that pilots’ after shoulder surgery RTW times range between 85 to 118 days. Rehabilitation in a dedicated MSK unit reduced the return to flying duties by 39%. Pilots treated by the MSK unit returned to work by a mean of 33 days earlier with cost savings of $27,948 USD per pilot.
The association between gird and overhead throwing biomechanics in cricket
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The development of GIRD is a well-documented adaptation associated with repetitive overhead throwing in numerous sports. In occurrence with total rotational range of motion deficit, GIRD is considered pathological and increases shoulder injury risk. While cricketers demonstrate these deficits in rotational range; the association between GIRD and overhead throwing has yet to be explored. Therefore, the aim of this study was to determine the relationship between GIRD and overhead throwing biomechanics in cricketers. Passive shoulder rotational range of motion was measured in 15 cricketers (elite = 8, amateur = 7). Kinetic and kinematic data were obtained during overhead throws from a stationary and run-up approach. Linear regression was used to determine potential relationships between GIRD and discrete shoulder kinetics for both throwing approaches. One-dimensional statistical parametric mapping regression was conducted to assess relationships between GIRD and throwing kinematics. When throwing overhead from a stationary position, GIRD was associated with reduced hip abduction during the preparatory arc (p = 0.002); superior shoulder (p = 0.003) and elbow compressive (p = 0.009) forces, at cocking. In addition, GIRD was associated with increased posterior shoulder force during arm deceleration for both stationary (p = 0.013) and run-up approaches (p = 0.03) to overhead throwing. Cricketers with GIRD utilise a shorter stride, creating early pelvic rotation and a slow throwing arm with an associated reduction in forces about the shoulder and elbow at cocking, when throwing from a stationary position. Further, overload of the posterior shoulder occurs during arm deceleration, irrespective of throwing approach. These findings highlight potential shoulder injury risk.

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3rd International conference on movement dysfunction 2009Shoulder impingement: Biomechanical considerations in rehabilitation

Abstract

Section snippets

Normal shoulder motion

Effects of trapezius and serratus anterior muscle function

Abnormal shoulder motion in impingement

Movement based intervention case examples

Summary

Acknowledgements

Clinical Biomechanics

Journal of Shoulder and Elbow Surgery

Arthroscopy

Journal of Shoulder and Elbow Surgery

Journal of Biomechanics

Journal of Electromyography and Kinesiology

Clinical Biomechanics

Journal of Shoulder and Elbow Surgery

Journal of Orthopedic Science

Journal of Orthopaedic Research

Archives of Physical Medicine and Rehabilitation

Clinical Biomechanics

Journal of Shoulder and Elbow Surgery

Archives of Physical Medicine and Rehabilitation

Journal of Electromyography and Kinesiology

Journal of Shoulder and Elbow Surgery

Clinical Biomechanics

Journal of Hand Therapy

Arthroscopy

Archives of Physical Medicine and Rehabilitation

Archives of Physical Medicine and Rehabilitation

Journal of Shoulder and Elbow Surgery

Clinical Biomechanics

Journal of Shoulder and Elbow Surgery

Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome

Journal of Orthopaedic and Sports Physical Therapy

Scapular angular positioning at end range internal rotation in cases of glenohumeral internal rotation deficit

Journal of Orthopaedic and Sports PhysicalTherapy

The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals

Journal of Orthopaedic and Sports Physical Therapy

Trapezius activity and intramuscular balance during isokinetic exercise in overhead athletes with impingement symptoms

Scandinavian Journal of Medicine and Science in Sports

Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms

American Journal of Sports Medicine

Evaluation of isokinetic force production and associated muscle activity in the scapular rotators during a protraction-retraction movement in overhead athletes with impingement symptoms

British Journal of Sports Medicine

Functional anatomy of the shoulder complex

Journal of Orthopaedic and Sports Physical Therapy

Scapulothoracic and glenohumeral kinematics following an external rotation fatigue protocol

Journal of Orthopaedic and Sports Physical Therapy

3rd International conference on movement dysfunction 2009
Shoulder impingement: Biomechanical considerations in rehabilitation