Introduction

Shoulder pain generally is a common condition and the majority of this pain result from impengiment of some structures. Impingement syndrome is a dynamic condition that can result in tendonitis and bursitis. Impingement syndrome may result from compression/squeezing of the SITS(Suprasinatus, Infraspinatus, Teres Minor and Subscapularis) tendons under the subacromial bursa.

impengiment
Figure 1: Impingement. Courtesy of Universityof California. San Diego

When the four SITS tendons have been impinged upon under the subacromial bursa, the resulting friction inflames the tendons and the subacromial bursa. This leads to shoulder pain, especially while raising the arm over the head, such as when swimming, reaching for something on a top shelf, arm positioning during sleep and other activities.

If irritation to the tendons persists for a long time, it may result in fraying, tears, and sometimes going to the extremes of complete disruption.


Physical Examination for Impingement Syndrome:

You may follow the following sequence but that doesn't mean it always has to be done like this:

Subacromial Palpation

Subacromial Palpation
Figure 2: Neer's Test For Impingement. Courtesy of Universityof California. San Diego
  • Firstly, identify the acromium by walking your fingers along the scapulospine until you reach its lateral end point, the acromium.
  • Gently palpate in the region of the subacromial space
  • Palpation may cause pain if the tendons/bursa are inflamed

Neer's Test for Shoulder Impingement:

  1. Place one of your hands on the patient's scapula, and grasp their forearm with your other
  2. The arm should be internally rotated such that the thumb is pointing downward.
  3. Gently flex the arm, positioning the hand over the head.
  4. Pain suggests impingement.
  5. Neer's test
    Figure 3: Neer's Test For Impingement. Courtesy of Universityof California. San Diego

Hawkin's Test(for more subtle impingement)

  1. Raise the patient's arm to 90 degrees forward flexion.
  2. Then rotate it internally (i.e. thumb pointed down).
  3. This places the greater tubercle of the humerus in a position to further compromise the space beneath the acromion.
  4. Pain with this maneuver suggests impingement.

Evaluation of Rotator Cuff Muscles

Supraspinatus muscle

This is the mostly injured mucle among te rotator cuff muscl. Tests:

Empty can test:

Empty can test
Figure 4: Empty Can Test. Courtesy of Universityof California. San Diego
  1. Have the patient abduct their shoulder to 40 degrees, with 30 degrees forward flexion and full internal rotation (i.e.turned so that the thumb is pointing downward). This position prevents any contribution from the deltoid to abduction
  2. Direct them to forward flex the shoulder, without resistance.
  3. Repeat while you offer resistance.
Partial tear of the muscle or tendon, the patient will experience pain & perhaps some element of weakness with the above maneuver.
Complete disruption of the muscle will prevent the patient from achieving any forward flexion.
These patients will also be unable to abduct their arm, and instead try to "shrug" it up using their deltoids to compensate.

Drop Arm Test: For Supraspinatus

Adducting the arm depends upon both the deltoid and supraspinatus muscles. When all is working normally, there is a seamless transition of function as the shoulder is lowered, allowing for smooth movement. This is lost if the rotator cuff has been torn. Specifics of testing:
  1. Fully abduct the patient's arm, so that their hand is over their head.
  2. Now ask them to slowly lower it to their side.
  3. If the supraspinatus is torn, at ~ 90 degrees the arm will seem to suddenly drop towards the body. This is because the torn muscle cant adequately support movement thru the remainder of the arc of adduction.
Deltoid: Not a muscle of the rotator cuff, but important for the later aspects of abduction and flexion. The upraspinatus is responsible for the early component of abduction. The deltoid is readily visible on exam and not commonly injured

Infraspinatus and Teres Minor (External Rotators):

Infraspinatus

  1. Have the patient slightly abduct (20-30 degrees) their shoulders, keeping both elbows bent at 90 degrees.
  2. Place your hands on the outside of their forearms.
  3. Direct them to push their arms outward (externally rotate) while you resist.
  4. Interpretation: Tears in the muscle will cause weakness and/or pain

Teres Minor

Teres Minor Test
Figure 5:Teres Minor Test. Courtesy of Universityof California. San Diego
  1. Have the patient slightly abduct (20-30 degrees) their shoulders, keeping both elbows bent at 90 degrees.
  2. Place your hands on the outside of their forearms.
  3. Direct them to push their arms outward (externally rotate) while you resist.
  4. Interpretation: Tears in the muscle will cause weakness and/or pain

Subscapularis

Gerbers Lift off Test (For Subscapularis):
Subscapularis
Figure 6:Gerbers Lift off Test (For Subscapularis) Courtesy of Universityof California. San Diego
  1. Have the patient place their hand behind their back, with the palm facing out.
  2. Direct them to lift their hand away from their back. If the muscle is partially torn, movement will be limited or cause pain
  3. Complete tears will prevent movement in this direction entirely

References:


Cardiopulmonary Physiotherapy
Chimwemwe Masina, PT

Author: Chimwemwe Masina

Chimwemwe Masina is currently working as a Resident Physiotherapist at DDT College of Medicine in Gaborone, Botswana. Before joining DDT College of Medicine, he worked in the Ministry of Health at Kamuzu Central Hospital in Malawi, MagWaz Physiotherapy and Wellness Services in Lilongwe, Malawi. as well as Volunteering at Physiopedia.
His interest is in Neuromusculoskeletal Physiotherapy and currently he is an assisting lecturer in Manual Therapy and Lumbar Spine Management.

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