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Shoulder Impingement Syndrome
 Shoulder complex
 What is SIS
 What leads to worsening of SIS
 Causes of SIS
 Symptoms of SIS
 Hx
 Dx
 Physical examination
 Treatment
 Rehabilitation
 Manual Physical therapy techniques
 Stretching exercises
 Preparation for strengthening exercises
 Strengthening exercises
 Physical therapist’s approaches toward SIS
 PT products used in the treatment of SIS
 Home exercise program
Shoulder complex
bones ?
cuff ?
Bursa ?
Usually, there is enough room between the acromion and the rotator cuff so
that the tendons slide easily underneath the acromion as the arm is raised.
But each time you raise your arm, there is a bit of rubbing or pinching on the
tendons and the bursa.
activities that
involve using the
arm above
shoulder level
cause some
working with the
arms raised
repeated throwing
activities, or other
repetitive actions
of the shoulder can
impingement to
become a problem
becomes a
problem when it
causes irritation
or damage to the
rotator cuff
overuse, this
can cause
irritation and
swelling of
the bursa.
If any other condition decreases the amount of space between the acromion
and the rotator cuff tendons !
Bone spurs : commonly caused
by wear and tear of the
acromioclavicular joint.
In some people, the space is too
small because the acromion
is oddly sized.
So the acromion tilts too far
down, reducing the space
between it and the rotator cuff.
joint stiffness (particularly the shoulder, neck or
upper back)
shoulder instability
bony anomalies of the acromion or AC joint
muscle tightness (particularly the rotator cuff,
pectorals and deltoid)
poor posture
inappropriate or excessive training
inadequate warm up
muscle weakness (especially the rotator cuff and
scapula stabilisers)
muscle imbalances
inadequate rehabilitation following a previous
shoulder injury or surgery
inappropriate technique (e.g. swimming stroke,
tennis serve, throwing technique)
Generalized shoulder aches in the condition's early stages
Causes pain when raising the arm out to the side or in front of the body.
As the condition worsens
The discomfort increases
Sometimes a catching sensation is felt when you lower your arm.
The joint may become stiffer
Weakness and inability to raise the arm(indicate that the rotator cuff
tendons are actually torn.)
1-Pain: Exacerbated by over head or above the shoulder activities.Night
pain often disturbing the sleep,particularly when the patient lies on the
affected side. Onset of symptoms may be acute, following an injury or
insidious. Particularly in older patients where no specific injury.
In the acute stage1 there is painful arch abducton between 60 and 120˚
increased with resistance at 90˚.
2-Loss of motion: Prolonged shoulder pain causes the patient to restrict
instinctively the range of use and often results in an initial adhesive
3-Weakness and inability to raise the arm: Indicates that the rotator cuff
tendons are actually torn.
medical history and physical examination- detailed questions about your
activities and your job
magnetic resonance imaging (MRI) scan- shows fluid inflammation in the
bursa and the rotator cuff & tear of the tendons
An arthrogram- helpful to detect rotator cuff tear.
Physical examinations
1.Manual motor testing for the rotator cuff muscles:
Geber’s lift-off test for subscapu;aris- Get the patient in standing
position. He is asked to place hand behind the back with dorsum of
his hand resting in the mid lumbar spine region. Ask to raise the hand
off the back increasing internal rotation of the humerus and extention
at the shoulder
Positive: inability to move the dorsum of the hand off the back
constitutes an abnormal lift-off test and indicates subscapularis
rupture or dysfunction
medications such
as aspirin or
2.Resting the
sore joint and
putting ice on it
3.If the pain
doesn't go away,
an injection of
cortisone into the
joint may help
4.Open Procedure
4.Physical or
Maintain the strength in the muscles of the rotator cuff.
These muscles help control the stability of the shoulder joint.
Strengthening these muscles can actually decrease the
Therapist can also evaluate your workstation or the way you
use your body when you do your activities and suggest changes
to avoid further problems
Recommended early in the recovery period.
to help maintain joint mobility and flexibility of the muscles and
tendons in the shoulder.
should not feel more than mild pain with any range-ofmotion/flexibility exercise
sharp or tearing pain while stretching, stop exercising
Preparing for strengthening exercises
The joint should always be heated for five minutes and stretched with
range-of-motion exercises before beginning strengthening exercises
Weighted pendulum stretch
Relax your shoulder muscles
While standing or sitting, keep your arm vertical and close to your
body (bending over too far may pinch the rotator cuff tendons)
Allow your arm to swing forward to back, then side to side, then in
small circles in each direction (no greater than 1 foot in any direction).
Only minimal pain should be felt.
Stretch the arm only (without added weight) for three to seven days.
Progress this exercise by adding 1 to 2 pounds (0.5 to 1 kg) each week
and gradually increasing the diameter of the movements (not to
exceed 18 to 24 inches or 45 to 60 cm )
After a few weeks this exercise should be supplemented or replaced
by other exercises to target specific areas of tightness/restriction. The
pendulum stretch may be recommended as a warm up for more
localized flexibility exercises and/or strengthening exercises.
necessary to improve shoulder muscle strength and help to prevent
further injury.
These exercises can often be started approximately one to two weeks
after beginning the pendulum stretch exercises, once any acute
inflammation has resolved, or after having a steroid injection into the
shoulder joint.
Strengthening exercises for the rotator
cuff tendons
Part A:hold the elbow at 90°, close to the side. The rubber
band is hooked onto a door handle and grasped with the
hand. The forearm is slowly moved towards the body 2 to 3
inches, and held for 5 seconds. The hand should not rotate as
the forearm moves.
Part B: The outward rotation isometric exercise is performed
with the elbows at 90°, close to the sides. The rubber band is
grasped with the hands. The formearms are moved outward 2
to 3 inches and held for 5 seconds. Sets of 15 to 20 exercises,
each held for 5 seconds, should be performed daily.
Lie on the back with your knees bent and feet flat.
arms should be straight out,15 to 30 cm away from the side of the body,
with palms facing upward.
Keeping the low back flat against the ground, squeeze your shoulder
blades downward and towards each other, towards the spine.
Do not shrug the shoulders and keep the neck relaxed.
Doer should feel the lower muscles between the shoulder blades
contracting. Hold for five seconds and repeat 20 times.
 Do this exercise two to three times per day.
Outward rotation exercise
Hold your elbows at 90 degrees, close to your sides; holding a
towel between your torso and the inside of your elbow will cue
you to keep your elbow by your side.
 Hold one end of a rubber band in each hand and rotate the
affected forearm outward two or three inches
 Holding for five seconds
Physiotherapy for shoulder
Ensure an optimal outcome and reduce the likelihood of recurrence in all patients
with shoulder impingement.
soft tissue massage
electrotherapy (e.g. ultrasound, TENS etc)
joint mobilization
joint manipulation
ice or heat treatment
exercises to improve strength, flexibility, posture and scapula stability
correction of abnormal biomechanics or technique
postural taping
the use of a posture support
anti-inflammatory advice
activity modification advice
a gradual return to activity program
Physiotherapy products for shoulder
Some of the most commonly recommended products by physiotherapists to
hasten healing and speed recovery in patients with shoulder impingement
Shoulder Supports
Ice Packs
Sports Tape (for postural taping)
Posture Supports
Resistance Band (for strengthening exercises)
TENS Machines (for pain relief)
Therapeutic Pillows
Home exercise program