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Each person will likely present differently, which will require a variations on how you approach their rehabilitation. Location of impingement Structures involved Cause of impingement Each of these can significantly vary the treatment approach and how successful you are helping each person.
Location of Impingement The first thing to consider when evaluating someone with shoulder impingement is the location of impingement. This is generally in reference to the side of Keys to successful teaching rotator cuff that the impingement is located, either the bursal side or articular side.
See the photo of a shoulder MRI above.
The bursal side is the outside of the rotator cuff, shown with the red arrow. More about these later when we get into the evaluation and treatment treatment. Impinging Structures To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against.
As you can see in the pictures below both side viewsyour subacromial space is pretty small without a lot if room for error. Impingement itself is normal and happens in all of us, it is when it becomes excessive or abnormal that pathology occurs.
I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation.
There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below. Cause of Impingement The next thing to look at is the actual reason why the person is experiencing shoulder impingement.
Primary impingement means that the impingement is the main problem with the person. A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below.
Many acromions are flat or curved, but some have a hook or even a spur attached to the tip drawn in red: The most simply example of this is weakness of the rotator cuff. The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.
The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid. The deltoid and larger muscles power the ship and move the arm. Both muscles groups need to work together.
In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion: Other common reasons for secondary impingement include mobility restrictions of the shoulder, scapula, and even thoracic spine.
We see this a lot at Champion. In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.
If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited.
The funny thing about this is that people are almost never aware that they even have this limitation until you show them. There are specific tests to assess each type of impingement we discussed above. The two most popular tests for shoulder impingement are the Neer test and the Hawkins test.
In the Neer test below leftthe examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion. In the Hawkins test below right the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.
You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement. This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.
The Hawkins test below left can be modified and performed in a more horizontally adducted position. Another shoulder impingement test below right can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.
There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement acromial versus coracoacromial arch by watching for subtle changes in symptoms with the above four tests.
Internal impingement is a different beast. This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction.
As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc. The test for this is simple and is exactly the same as an anterior apprehension test.
The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms. Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms.
Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder below left. Ween the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes below right.52 KEYS TO EFFECTIVE LD TEACHING PRACTICE p Key #2: Provide Instructional Adaptations and Accommodations These two terms often apply to the same tools and approaches that make a learning task more manageable.
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