Case Study 9 - musculoskeletal (shoulder impingement)

Case Study 9 - musculoskeletal (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.Subjective24 year old maleDiagnosed with impingement syndromeIncreased problem in left shoulder for past 4 weeksPain first started in deltoidPain used to be intermittent but now it fairly constantOverhead exercises is especially painful (badminton, stacking shelves in library)PMH - NilDH - NilSH - Works in a library stacking shelves, lives with parents and brothers and sisters.

Demonstrate these where appropriate on your model.
bony parts:
clavicle, coracoid process, spine of scapula,acromium process, medial border of scapula, acromium process, inferior border of scapula,bicipital groove, greater tuberosity (lateral of bicipital groove ) & lesser tuberosity ( medial to bicipital groove ) of humerus surgical and anatomical neck of humerus
Muscles -
origin/insertion - action - demonstrate these on your model
Levator Scapulae - C1-C4/upper medial scapular border - elevates scapula
Rhomboid Minor and Major - C7-T1/
medial scapular border - retracts scapula
Serratus Anterior - upper 8,9 ribs/anterior scapular fossa - protracts scapula
Pectoralis Major - clavicular & sternal heads - adducts & medially rotates shoulder
Teres Major- inferior lateral border scapula/bicipital groove - medially rotates adducts shoulder Teres Minor- lateral border scapula/posterior of greater tubercle of humerus
Deltoid- clavicle,acromium,scapula/deltoidtuberosity-flex,extend,medial,lateral abduct shoulder Supraspinatus - hollow above sacpular spine/greater tubercle - initiates abduction
Infraspinatus - below scapular spine/greater tubercle - laterally rotates shoulder
Joints :
Shoulder Joint - ball and socket Acromioclavicular joint - gliding joint Sternoclavicular joint - double arthroidal joint

Shoulder impingement syndrome is caused by compression of the tendons of the rotator cuff between a part of the shoulder blade and the head of the humerus. This can become a chronic inflammatory condition that may lead to a weakening of the tendons of the rotator cuff, a situation that may result in a torn rotator cuff. Initial treatment for an impinged shoulder includes rest, ice, and anti-inflammatory medications (sometimes including steroid injections)

Impingement Syndrome can be classified as external or internal:

External impingement, which can be either primary or secondary:
Primary
Is usually due to bony abnormalities in the shape of the acromial arch.
Can sometimes be due to congenital abnormalities (known as os acromiale), or due to degenerative changes, where small spurs of bone grow out from the arch with age, and impinge on the tendons.

Secondary
Usually due to poor scapular (shoulder blade) stabilization which alters the physical position of the acromion, hence causing impingement on the tendons.
Is often due to weak serratus anterior and tight pectoralis minor muscles
Other causes can include weakening of the rotator cuff tendons due to overuse (e.g. throwing and swimming) or muscular imbalance with the deltoid muscle and rotator cuff muscles.

Internal impingement
Occurs predominantly in athletes where throwing is the main part of the sport (e.g. pitches in baseball)
The under side of the rotator cuff tendons are impinged against the glenoid labrum – this tends to cause pain at the back of the shoulder joint as well as sometimes at the front.

Symptoms of impingement syndrome:
External impingement symptoms:
Primary
Pain at the front and/or side of the shoulder joint with overhead activity such as throwing, front crawl swimming.
Secondary
Pain at the front and/or side of the shoulder joint with overhead activity such as throwing, front crawl swimming.

Internal impingement symptoms:
Pain at the back and/or front of the shoulder when the arm is held out to the side (abducted) and turned outwards (external rotation)

Objective
Sit patient on plynth
Observation: Skin colour, Swelling, Posture, Muscle Bulk, Deformity

Active Physiological Movements:
Shoulder Girdle
Depression
Elevation
Protraction
Retraction

Glenohumeral
Flexion
Extension
Abduction
Adduction
Lateral rotation
Medial rotation
Horizontal flexion
Horizontal extension
Hand behind back (HBB)
Hand behind back (HBN)

Passive Physiological Movements
Applying extra pressure to the active movement the patient is already doing is a simple way of checking the passive range.

Resisted Tests - Glenohumeral
Flexion
Extension
Abduction
Adduction
Lateral rotation
Medial rotation
Horizontal flexion
Horizontal extension

Shoulder Girdle
Depression
Elevation
Protraction
Retraction

Always ensure you do the movements to both shoulders so you are able to compare the differences between the two.

Special Tests
The Hawkins Kennedy test is used to assess shoulder impingement. In this test the physio stabilizes the patients shoulder with one hand and, with the patient's elbow flexed at 90 degrees, internally rotates the shoulder using the other hand. Shoulder pain produced by internal rotation represents a positive test.Range of motion can also be measured using a genometer and pain levels can be measured.

Possible treatment for this injury is ice therapy or even a sling if the shoulder needs rest.