Case Study : Shoulder Impingement

Robert Simons is a 24 year old student who has experienced increasing problems with
his left shoulder over the last 4 weeks. His GP has referred him to Physiotherapy with
a diagnosis of Impingement Syndrome. The problem began with a sharp twinging
pain over the deltoid region whilst working shelf stacking in the library. The
symptoms have now worsened to a constant ache and are made worse by racquet
sports and overhead activities at the gym. Robert lives with his parents and younger
brother and sister who are both of school age. He is otherwise fit and well and takes
no medications.

Anatomy & Pathology

The rotator cuff muscles help prevent posterior dislocation of the shoulder. They are
comprised of

The supraspinatus : abducts the humerus

The Teres minor : laterally rotates the humerus
The infraspinatus : laterally rotates the humerus
The subscapularis : medially rotates the humerus.

These muscles pass through and close to the coracoacromial arch.

Compression of the tendons of the rotator cuff under the coracoacromial arch can
particularly affect the supraspinatus – impinging its activity - and can eventually
result in a full rotator cuff tear ( usually the supraspinatus tendon tears first – and this
tear can extend posterior and anterior.

Subjective Examination
Where\What : The patient complains of a sharp twinging pain over deltoid leading to
a general ache. A gradual anterior and lateral spread of pain would reflect this
condition.

When: Last 4 weeks

How: Overhead work

0-10 rating: Expect this to be increasng

24 hour cycle: Expect the patient may have difficulty sleeping and experience night
pain.

Better for: expect rest

Worse for: overhead work & raquet sports

Type of pain: ask patient this

Past Medical History/ General History: none

Red Flags and general concerns: could be misdiagnosed frozen shoulder ( good
observable range of motion will exclude this)

SH: lives with parents and 2 siblings

DH: none

Patients main outcome: ask patient this – may expect his to say pain relief or to play
racquet sports again

Objective Examination

Working Hypothesis:
Check for impingement – discoever has it progressed to a full tear – and rule out
misdiagnosis of rotator cuff tear.

Advice & Consent:

Explain forthcoming procedures and obtain consent

General Observations:
Watch patients walk in and sit down

Acute Observations:
Skin colour: n/a
Swelling : n/a
Posture : shoulders asquew ?
Muscle bulk : any atrophy of supraspinatus and infraspinatus indicate rotator cuff tear
Deformity : n/a

Active Tests:
Patient sitting on side of bed (>50% range in all movements not = frozen shoulder )

Flexion
Extension
Abduction -expect pain from impingement or tear of supraspinatus
Adduction
Medial rotation – possibly some pain if r.c. tear progressing - subscapularis
Lateral rotation – possibly some pain if r.c. tear progressing – teres minor
infraspinatus

Passive Tests:
Flexion
Extension
Abduction – Impingement syndrome may reveal crepitus
Adduction
Medial rotation
Lateral rotation

Resisted Tests:
Flexion
Extension
Abduction - loss of capacity with some impingement syndrome – always with r.c.
tears
Adduction
Medial rotation – loss if tear progressing
Lateral rotation – loss if tear progressing

Special Tests:
Hawkins Kennedy Test - Flex elbow – flex shoulder – internal rotate at 90 degress –
positive sign is pain and this indicates at least impingement syndrome.

Empty Can Test – internal rotation at 90 degrees – hold down scapula and grasp
forearm – resisted test – positive sign is pain – againg indicates at least impingeent
syndrome
Drop Arm Test - unresisted – no smooth eccentric contraction of arm from abduction
– it drops in mid 60 degrees = definite shear

Functional Tests:
1. Ask patient to raise arms and swing arms if possible above head height –
watch for scapula shrugging up to effect movement => impingement and or
rotator cuff tear.
2. Ask patient to catch ball above their head if possible – pain or difficulty =>
impingement and or rotator cuff tear

Palpation:
Expect with impingement or r.c. tear that Palpation over greater tuberosity &
subacromial bursa elicits tenderness – feel for crepitus with shoulder movement – feel
for the wasting of infraspinatus and supraspinatus that would indicate a full rotator
cuff tear.

Measurements:
Active abduction before pain – keep scale of pain (0-10)

Advice & Possible Treatment:

patient may feel worse after examination – rest ice and nsaids may help.

Drop arm test can be carried out after an injection of anesthetic into the subacromial
bursa – this definitely indicates a rotator cuff tear – if reaction still positive. Steroids
may be prescribed for rotator cuff tears – but care should be taken because steroids
can weaken tendons. If impingement is the only problem home exercises alone may
be enough to remedy the condition.