SHOULDER IMPINGEMENT
As secondary impingement is primarily a problem with muscle dynamics, it commonly present in conjunction with instability, either of the scapula or at the glenohumeral joint.
A hypermobile or lax joint does not imply instability. (Laxity implies that there is a certain amount of nonpathological "looseness") in a joint so that ROM is greater in one or more directions and the shoulder complex functions normally. It is usually found bilaterally
Instability implies that the patient is unable to control or stabilize a joint during motion or in a static position either because static restraints have been injured (as would be noted in an anterior dislocation with tearing of the capsule and labrum, also called gross or anatomical instability), or because the muscles controlling the joint are weak or the force couples are unbalanced (also called translational instability).
Both primary and second impingements occur anteriorly (thus, the terms anterior primary impingement or anterior secondary impingement). Because the areas of impingement are in the supraspinatus outlet area, they are also called outlet impingement syndrome.
Jobe and colleagues believed that impingement and instability often occur together in throwing athletes and, based on that assumption, developed the following classification
⏩• Grade I: Pure impingement with no instability (often seen in older patients)
⏩• Grade II: Secondary impingement and instability caused by chronic capsular and labral microtrauma
⏩• Grade III: Secondary impingement and instability caused by generalized hypermobility or laxity
⏩• Grade IV: Primary instability with no impingement In this classification, Secondary impingement implies the impingement occurs secondarily and that the main problem is instability.
A third type of impingement is termed internal impingement or nonoutlet impingement. This type of impingement is found posteriorly rather than anteriorly.mostly in overhead athletes.
It involves contact of the undersurface of the rotator cuff (primarily supraspinatus and infraspinatus) with the posterosuperior glenoid labrum when the arm is abducted to 90° and laterally rotated fully,
If the patient history indicates instability, then at least one test cach for anterior, posterior, and multidirectional instability should be performed. Because of the interrelation of impingement and instability, tests for both should be applied if the patient history indicates that either condition may be present. Traumatic, first-time subluxatoin and dislocations may result in a torn labrum (Bankart or SLAP), Hill-Sachs lesion, osteochondral lesion, and/or capsular damage, and so the examiner should consider the possibility of these problems existing during the assessment.
Hill- sachs lesion
to translational instability (muscle weakness) (as seen with AMBRI lesions) Atrumatic cause,multidirectional wth Bilateral shoulder finding with Rehabilitation as appropriate treatment and, rarely,Inferior capsular shift surgery
Burkhart, lesion which also included pseudolaxity, includes altered glenohumeral arthrokinematics because of the presence of a SLAP lesion, a tight posteroinferior capsule, and often scapular dyskinesia.
They felt the apparent increased anterior laxity resulted from the decreased cam effect in the glenohumeral joint combined with functional lengthening of the anteroinferior capsule and glenohumeral ligament.
A posterior superior SLAP lesion allows laxity on the opposite side (circle concept of instability). With the instability tests, the examiner is trying to duplicate the patient's symptoms as well as for abnormal movement. Therefore, a response of what my shoulder feels like when it bothers me" is much more significant than the degree of laxity or translation found
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Test For Anterior shoulder Instability
Apprehension (Crank) Test for Anterior Shoulder Dislocation.
This test is primarily designed to check for traumatic instability problems causing gross or anatomical instability of the shoulder, although the relocation portion of the test is sometimes used to differentiate between instability and impingement.
The examiner abducts the arm to 90° and laterally rotates the patient's shoulder slowly By placing a hand under the gleno- humeral joint to act as a fulcrum
the apprehension test becomes the fulcrum test. Kvitne and Job recommended applying a mild anteriorly-directed force to the posterior humeral head when in the test position to see if apprehension or pain increases
Fulcrum test
posterior pain increases, this indicates posterior internal impingement. Hamner, et al. suggested that if posterior superior internal impingement is suspected, the relocation test should be done in 110° and 120° of abduction translation of the humeral head in the glenoid is less than with other tests, provided the joint is normal, because the test is taking the joint into the close packed position positive test is indicated when the patient looks or feels apprehensive or alarmed and resists further motion.
Thus, Patient's apprehension is greater than the complaint of Pain (i.s., apprehension predominates). The patient may also state that the feeling resembles what it felt the shoulder was dislocated. This test must be done slowly.
If the test is done too quickly, the humerus may dislocate.
Hawkins and Bokor noted that the examiner should observe the amount of lateral rotation that exists when the patient becomes apprehensive and compare the range with the uninjured side.
If the examiner then apply a posterior translation stress to the head of the humerus or the arm (relocation test), the patient commonly loses the apprehension, any pain that is present commonly decreases, and further lateral rotation is possible before the apprehension or pain returns
Crank and relocation test
A. Abduction and lateral rotation (crank test)
This relocation is sometimes referred to as the Fowler sign or test or the Jobe relocation test . The test is considered positive if pain decreases during the maneuver, even if there was no apprehension.
If the patient's symptoms decrease or are eliminated when doing the relocation test, the diagnosis is glenohumeral instability, subluxation, dislocation, or impingement.
If apprehension predominated when doing the crank test and disappears with the relocation test,
the diagnosis is glenohumeral instability, subluxation, or dislocation. If pain predominoted when doing the crank test and disappears with the relocation test, the diagnosis is pseudolaxity or anterior instability either at the glenohumeral joint or scapulothoracic joint with secondary impingement or a posterior SLAP lesion. The relocation test does not alter the pain for patients with primary impingement.
If, when doing the relocation test posteriorly, posterior pain decreases, it is a positive test for posterior internal impingement.
If the arm is released (anterior release or "surprise" test in the newly acquired range, pain and forward translation of the head are noted in positive tests.
The resulting pain from this release procedure may be caused by anterior shoulder instability, labral lesion (Bankart lesion or SLAP lesion-superior labrum, anterior posterior), or bicipital peritenonitis or tendinosus. Most commonly, it is related to anterior instability because the pain is temporarily produced by the anterior translation.
It has also been reported to cause pain in older patients with rotator cuff pathology and no instability. This release maneuver should be done with care, because it often causes apprehension and distrust on the part of the patient, and it could cause a dislocation, especially in patients who have had recurrent dislocations. For most patients, therefore, when doing the relocation test, lateral rotation should be released before the posterior stress is released.
The crank test may be modified to test lateral rotation at different degrees of abduction, depending on the patient history and mechanism of injury.” The Rock wood test described later is simply a modification of the crank test.
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