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Anterior Impingement Syndrome

• Occurs beneath the coraco-acromial arch.

• Vulnerable structures:

  • Greater tuberosity

  • Supraspinatus tendon

  • Long head of biceps

• Major site of compression is slightly anterior to the angle of the acromion.

• Also referred to as painful arc syndrome.

Causes of Impingement Syndrome

• Complete or partial rupture of rotator cuff.

• Supraspinatus tendinitis.

• Calcific deposits.

• Subacromial bursitis.

• Subdeltoid bursitis.

• Periarthritis.

• Bicipital tenosynovitis.

• Fracture of greater trochanter.

Clinical Features/Presentation

• Common symptoms:

  • Pain,

  • Swelling,

  • Limitation of shoulder movements,

  • Muscle atrophy,

  • Tenderness over the greater tuberosity.

• Types of shoulder pain:

  • Chronic: Diffuse posterior shoulder girdle pain, seen in throwing athletes with internal impingement. Pain increases during the late-cocking phase of throwing when the arm is in 90° abduction and full external rotation.

  • Acute: Non-throwing athletes report acute shoulder pain post-injury.

• Functional impairments:

  • Decrease in throwing velocity or loss of control in overhead athletes.

  • "Dead arm" sensation post-throwing with symptoms of weakness and shoulder slipping.

  • Muscular asymmetry between dominant and nondominant shoulder, often noted in overhead athletes.

Pathophysiology

• Muscular/Neuromuscular Imbalance:

  • Commonly seen in the shoulder complex due to improper neuromuscular control.

• Increased Laxity:

  • May present with global laxity or isolated anterior laxity in the dominant shoulder.

• Anterior Instability:

  • Patients may report instability symptoms such as apprehension or sensation of subluxation in abduction and external rotation positions.

• Rotator Cuff Pathology:

  • Symptoms may mimic other rotator cuff pathologies. In young athletes, suspicion for internal impingement should be raised due to overlap of symptoms.

  • Signs of muscle balance disruption among the four rotator cuff muscles (infraspinatus, supraspinatus, teres minor, and subscapularis).

Grades/Staging of Impingement Syndrome

• Grade I:

  • Affects young adults/athletes (ages 18-30).

  • Caused by overstress and repeated overhead activity.

  • Supraspinatus inflammation leading to painful arc during shoulder abduction (40 to 120°).

  • Pain occurs in late-cocking and early acceleration phases of throwing; daily activities are usually pain-free.

• Grade II:

  • Affects individuals aged 40-45.

  • Associated with supraspinatus tendinitis or subacromial bursitis.

  • Overuse or degeneration, with localized pain in the posterior shoulder in throwing phases.

• Grade III:

  • Occurs in those over 45 years of age.

  • Linked with occupational overuse, falls, or sudden activity increases leading to degenerative changes in rotator cuff.

Clinical Examination Techniques

• Basic Examination:

  • Palpation of the shoulder complex.

  • Observation of muscle symmetry between shoulders.

  • Gross strength testing of shoulder and rotator cuff muscles.

  • Assessment of joint accessory mobility across GH/ST/AC/SC joints.

  • Flexibility tests for shoulder, thoracic, and cervical spine.

  • Range of motion assessments for the GH/scapulothoracic joints and cervical/thoracic spine, noting dysfunction can affect shoulder performance.

Findings in Examination

• Tenderness to palpation in the posterior shoulder/joint line.

• Involved shoulder may show increased muscle bulk and altered position compared to the unaffected side.

• Abnormal scapulothoracic rhythm and movements.

• Weakness in rotator cuff, middle/lower traps, rhomboids, and serratus anterior muscles.

• Decreased dorsal glenohumeral glide and tightness in posterior capsule.

Variable Considerations in Assessment

• Muscular imbalances in pectoralis muscles, latissimus dorsi, and upper trap.

• Decreased internal rotation and increased external rotation at GH joint typically noted.

• SICK Scapula: Scapular protraction, malposition, coracoid pain, and dyskinesis identified during examination.

Investigations

• Plain X-rays are less useful.

• MRI and arthrography provide reliable diagnostic information.

Management Strategies

• Conservative treatment:

  • NSAIDs, hydrocortisone injections, subacromial steroid injections, active and passive exercises, temporary immobilization, and massage.

  • High recovery rate (90%) with conservative measures.

Physiotherapy Measures

• Strengthening:

  • Closed kinetic chain exercises for rotator cuff stabilization.

  • Addressing GIRD (glenohumeral internal rotation deficit) and posterior capsule strengthening.

• Phase One Rehabilitation:

  • Soft tissue mobilization, scapula setting, joint mobilization, and improving shoulder ROM.

  • Neuromuscular re-education for recurrence prevention and restoring muscle balance.

• Phase Two Rehabilitation:

  • Focus on dynamic stability and muscle balance restoration with complex exercises.

  • Start introducing eccentric and open kinetic chain exercises tailored to athletic movements.

• Phase Three Rehabilitation:

  • Functional rehab plans for athletes focusing on returning to full activities, progressing plyometric exercises with controlled movements.

Post-Surgery Physiotherapy

• Recommend initial immobilization for three weeks.

• Encourage active movements in elbow, hand, and wrist early on.

• Begin strong isometric deltoid exercises after ten days, maintaining conservative post-operative measures.

Anterior Impingement Syndrome Q&A

Q1: What is Anterior Impingement Syndrome?A1: Anterior Impingement Syndrome occurs beneath the coraco-acromial arch, affecting vulnerable structures like the greater tuberosity, supraspinatus tendon, and long head of biceps, with compression most prevalent just anterior to the angle of the acromion.

Q2: What are the primary causes of Impingement Syndrome?A2: Causes include:

• Complete or partial rupture of the rotator cuff

• Supraspinatus tendinitis

• Calcific deposits

• Subacromial and subdeltoid bursitis

• Periarthritis

• Bicipital tenosynovitis

• Fracture of the greater trochanter

Q3: What are the common clinical features or symptoms of this syndrome?A3: Common symptoms are pain, swelling, limited shoulder movements, muscle atrophy, and tenderness over the greater tuberosity. There are different types of shoulder pain:

• Chronic: Diffuse posterior shoulder girdle pain, typical in throwing athletes with internal impingement, with pain increasing in the late-cocking phase of throwing.

• Acute: Reported by non-throwing athletes post-injury.

Q4: How does Anterior Impingement Syndrome affect athletic performance?A4: Functional impairments include decreased throwing velocity, loss of control in overhead athletes, and a "dead arm" sensation post-throwing, with symptoms of weakness and perceived shoulder instability.

Q5: What is the pathophysiology behind Anterior Impingement Syndrome?A5: Key aspects include:

• Muscular/Neuromuscular Imbalance: Commonly due to improper control in the shoulder complex.

• Increased Laxity: Present as global or isolated anterior laxity.

• Anterior Instability: Symptoms such as apprehension or feelings of subluxation in specific arm positions.

• Rotator Cuff Pathology: Overlap of symptoms with other rotator cuff issues, especially in younger athletes.

Q6: How is Anterior Impingement Syndrome graded or staged?A6: The grading system includes:

• Grade I: Affects young adults (18-30); caused by overstress, leading to supraspinatus inflammation and painful arc during abduction (40° to 120°).

• Grade II: Affects those 40-45 years; associated with supraspinatus tendinitis or subacromial bursitis.

• Grade III: Occurs in individuals over 45; linked to degenerative changes from overuse or falls.

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Q7: What examination techniques are used to assess Anterior Impingement Syndrome?A7: Basic techniques involve palpation, muscle symmetry observation, strength testing, and range of motion assessments for relevant joints. Additional tests include flexibility tests and assessing joint accessory mobility.

Q8: What findings might be observed during the examination of a patient with this syndrome?A8: Possible findings include tenderness in the posterior shoulder, increased muscle bulk on one side, abnormal scapulothoracic movements, and weakness in specific muscle groups.

Q9: What additional considerations should be made during assessment?A9: Consider muscular imbalances in pectoralis muscles, latissimus dorsi, and upper trap, as well as altered internal and external rotation in the glenohumeral joint.

Q10: Which imaging investigations are useful for diagnosing Anterior Impingement Syndrome?A10: Plain X-rays are generally less useful, while MRI and arthrography provide reliable diagnostic information.

Q11: What are the management strategies for Anterior Impingement Syndrome?A11: Conservative treatment may include NSAIDs, steroid injections, exercises, and temporary immobilization. Recovery rates are high (90%) with these measures. Rehabilitation is phased:

• Phase One: Soft tissue mobilization, scapula setting, joint mobilization.

• Phase Two: Dynamic stability and muscle balance restoration exercises.

• Phase Three: Functional rehabilitation focusing on returning athletes to full activities.

Q12: What post-surgery physiotherapy is recommended?A12: Initial immobilization for three weeks, early active movement in elbow, hand, and wrist, followed by strong isometric deltoid exercises after ten days, while maintaining conservative measures post-operatively.

Case Studies on Anterior Impingement Syndrome

Case Study 1: Young Athlete with Grade I Impingement

• Profile: 22-year-old male baseball pitcher.

• Symptoms: Reports a painful arc during shoulder abduction (40° to 120°), primarily during practice. Experiences pain in the late-cocking phase of throwing.

• Evaluation: Mild supraspinatus inflammation noted during examination, with tenderness around the greater tuberosity.

• Management: Treated with NSAIDs, physiotherapy focused on soft tissue mobilization and scapula setting, with emphasis on shoulder ROM exercises.

• Outcome: After 6 weeks of rehabilitation, the athlete returned to pitching with no pain.

Case Study 2: Middle-Aged Individual with Grade II Impingement

• Profile: 43-year-old female recreational tennis player.

• Symptoms: Complains of localized pain in the posterior shoulder, especially while serving or performing overhead motions. Limited shoulder mobility observed.

• Evaluation: Examination reveals tenderness over subacromial space and signs of subacromial bursitis.

• Management: Injections of corticosteroids, in combination with a structured physiotherapy program focused on strengthening and improving shoulder stability.

• Outcome: Improved shoulder function and reduced pain after 8 weeks; able to return to recreational play without significant discomfort.

Case Study 3: Older Adult with Grade III Impingement

• Profile: 58-year-old male construction worker.

• Symptoms: Experiences severe shoulder pain after a fall, with acute limitation in shoulder mobility. Reports difficulty lifting objects and persistent “dead arm” sensation.

• Evaluation: Examination confirms significant weakness in rotator cuff muscles and radiologic imaging shows changes consistent with degenerative rotator cuff disease.

• Management: Surgery indicated due to severe symptoms and structural changes. Post-operative management included a progressive rehabilitation program emphasizing strength restoration and functional activities.

• Outcome: After 3 months of rehabilitation, the patient reports significant improvement and is able to perform work-related activities with minimal pain.

Assessment Diagnosis and Physiotherapy for Anterior Impingement Syndrome Case Studies

Case Study 1: Young Athlete with Grade I Impingement

• Assessment Diagnosis: Physical examination reveals mild supraspinatus inflammation, tenderness around the greater tuberosity, and a painful arc in shoulder abduction (40° to 120°).

• Physiotherapy Management:

  • Focus on soft tissue mobilization and scapula setting.

  • Progress shoulder range of motion (ROM) exercises to alleviate symptoms.

  • Strengthening exercises once pain decreases, with adjustments based on tolerance.

Case Study 2: Middle-Aged Individual with Grade II Impingement

• Assessment Diagnosis: Examination shows tenderness over the subacromial space and limited shoulder mobility, indicating subacromial bursitis.

• Physiotherapy Management:

  • Initiate with corticosteroid injections for inflammation control.

  • Structured physiotherapy program focusing on strengthening rotator cuff and scapular stabilizers.

  • Emphasis on functional movements related to overhead activities, restoring mobility and reducing pain.

Case Study 3: Older Adult with Grade III Impingement

• Assessment Diagnosis: Significant weakness in rotator cuff muscles confirmed via examination; radiologic imaging displays degenerative changes linked to recurrent shoulder pain after a fall.

• Physiotherapy Management:

  • Post-operative rehabilitation focusing on strength restoration and gradual return to functional activities.

  • Emphasize progressive exercises, including concentric and eccentric strengthening of rotator cuff, along with scapular stabilization.

  • Prioritize pain management and gradual reintroduction to work-related activities.