Mechanical compression and irritation of the soft tissues (rotator cuff and subacromial bursa) in the suprahumeral space is called impingement syndrome and is the most common cause for shoulder pain.

Based on impaired tissues injuries can include:

• Supraspinatus tendonitis
• Infraspinatus tendonitis
• Bicipital tendonitis
• Subdeltoid (subacromial) bursitis
• Other musculotendinous strains (specific to type of injury or trauma)

Factors that contribute to Painful shoulder syndrome:

Intrinsic factors-

• Intrinsic factors are those that are directly associated with encroachment of the subacromial space. The include vascular changes In the rotator cuff tendons, structural variations in the acromion, hypertonic degenerative changes of the AC joint, or hypertrophic changes in the coracoacromial arch or humeral head.

Extrinsic Factors-

• Factors that result in decreased suprahumeral space and repetitive trauma to the soft tissues during the elevation of the arm include posterior capsular tightness, poor neuromuscular control of the rotator cuff or scapular muscles, faulty scapulothoracic posture with muscle imbalances, or a partial or complete tear of the tissues in the suprahumeral space.

Tendonitis/Bursitis

Supraspinatus Tendonitis

• With supraspinatus tendonitis the lesion (area of damages tissue) is usually near the musculotendinous junction, resulting in a painful arc with overhead reaching. Pain occurs with the impingement test (forced humeral elevation in the plane of the scapula while the scapula is passively stabilized so the greater tuberosity impacts against the acromion or with the arm in internal while flexing the humerus). There is pain on palpation of the tendon just inferior to the anterior aspect of the acromion when the patient’s hand is placed behind the back. It is difficult to differentiate tendonitis from subdeltoid bursitis because of the anatomical proximity.

Infraspinatus Tendonitis

• With infraspinatus tendonitis, the lesion is usually near the musculotendinous junction, resulting in a painful arc with overhead or forward motions. It may present as a deceleration (eccentric) injury due to overload during repetitive or forceful throwing activities. Pain occurs with palpation of the tendon just inferior to the posterior corner of the acromion when the patient horizontally adducts and laterally rotates the humerus.

Bicipital tendonitis

• With bicipital tendonitis, the lesion involves the long tendon in the bicipital groove beneath or just distal to the transverse humeral ligament. Swelling in the bony groove is restrictive and compounds and perpetuates the problem. Pain occurs with resistance to the forearm in a supinated position while the shoulder is flexing (Speed’s sign) and on palpation of the bicipital groove. Rupture or dislocation of the humeral depressor may escalate impingement of tissues in the superhumeral space.

Bursitis (subdeltoid or subacromial)

• When acute, the symptoms of bursitis are the same as those seen with supraspinatus tendonitis. Once the inflammation is under control there are no symptoms with resistance

Physiotherapy for Painful shoulder syndrome:

Control inflammation and promote healing

• Modalities offered to help with healing and control are Ultrasound, Laser treatment and Electric stim with heat pad.
• Manual muscle work done by physiotherapist is also used in addition to the modalities.

Patient Education

• During this stage the patients must know the environment and habits that provoke the symptoms and must be modified and/or avoided.
• Guidelines must be given to patient for recovery as well as informed on the mechanics of the irritations.

Maintain integrity and mobility of the soft tissues

• Passive, active-assisted or self-assisted ROM in pain free ranges.
• Focus is to stimulate the stability of the rotator cuff, biceps brachii and scapular muscles at an intensity tolerated by the patient.

Control pain and maintain joint integrity

• Use of pendulum exercises without weights to cause pain-inhibiting grade II joint distraction and oscillation motions.

Develop support in related regions

• Postural awareness and correction techniques such as cues and reminders are used.
• Supportive techniques such as shoulder strapping, or scapular taping can be used for reinforcement.

Management: Controlled Motion

• Once the acute symptoms have been controlled a large emphasis is on the movement and proper mechanics while tissues are healing in the area
• Developing strength in the stabilizing muscles of the scapula and glenohumeral joint

Develop a Strong Mobile Scar

• Physiotherapists will use manual therapy techniques like cross-fiber or friction massage
• After massage is completed, the physiotherapist will prescribe isometric exercises that the patient will complete after the massage and at home

Improving Postural Awareness

• Always reinforce postural control by verbal and tactile cues when performing an exercise make sure the shoulders are pulled back and the head is up straight
• Correcting posture results in significant increases in ROM; flexion, abduction and scaption
• Taping also has a positive effect on postural control in the thoracic and scapular regions

Modify Joint Tracking and Mobility

• Mobilization with movement is useful for joint tracking and reinforcing full movement when there is pain a mobilization belt can help to progress the limb to an end range of motion

Balance Length and Strength in Shoulder Girdle Muscles

• Stretch Shortened Muscles
  • Includes the pec major, latissimus muscles, and scapular muscles
• Strengthen and Train Scapula
  • The patient will learn to avoid scapular elevation when raising the arm by practicing scapular depression
• Strengthen the rotator cuff muscles

Develop Muscle Stabilization and Endurance

• Isometric Resistance
• Scapular and Glenohumeral Patterns
  • Combined using flexion, abduction, and rotation
• Closed-Chain Stabilization

References

1. Therapeutic Exercises Carolyn Kisner. Lynn Allen Colby

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