Impingement syndrome. Clinical features. Management. Rotator cuff tear diagnosed. Go to rotator cuff tear

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Peter Cain
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1 Impingement syndrome Clinical features Management Poor response Good response Refer to orthopaedic surgery R Review as appropriate Investigations Rotator cuff tear diagnosed Go to rotator cuff tear Consider surgical intervention Follow-up Page 1 of 7

2 1 Impingement syndrome Impingement syndrome: resulting from compression upon shoulder flexion and internal rotation of the rotator cuff (typically the supraspinatus tendon) or swollen subacromial bursa, between the lateral portion of acromion and the head of the humerus tendons become trapped leading to compression, inflammation and damage can lead to rotator cuff tendonitis is caused by: injury general wear and tear an occupational or sporting activity requiring repetitive use of the shoulder, eg tennis or cricket 2 Clinical features The symptoms and signs of impingement syndrome, rotator cuff tendonitis and subacromial bursitis are similar and there may be some overlap between the conditions they include: pain and tenderness to upper arm, subacromial space and lateral deltoid night pain pain with upward reaching movements reduced shoulder strength, especially abduction and external rotation in the presence of a tear possible muscular atrophy usually a full range of passive movement but limited active movement due to pain and rotator cuff weakness may be reduced range of movement in the presence of a rotator cuff tear or adhesive capsulitis low painful arc of motion, with maximum pain at , is typical for impingement inability to maintain painful arm at 90 angle when arm is passively abducted and then released indicates possible tendon rupture 3 Management Consider the following: patient education advise to avoid activities that aggravate symptoms simple analgesia or non-steroidal anti-inflammatory drugs (NSAIDs) to minimise inflammation, unless contra-indicated NSAIDS: provide short-term symptomatic relief, but are associated with adverse effects contra-indications include: patients with severe renal disease Page 2 of 7

3 pregnancy patients with aspirin allergy prescribe with caution in patients with: hypertension gastrointestinal complaints mild liver or kidney disease use lowest effective dose and monitor renal function asthma monitor adverse effects gentle exercises to restore range of motion: stretching exercises to maintain shoulder elevation and internal and external rotation shoulder strengthening exercises once range of motion is restored advise to apply ice packs intermittently to the painful and inflamed area discourage use of arm slings if no response, consider corticosteroid and local anaesthetic injection into subacromial space: may provide symptomatic relief in the short-term for those with tendonitis or partial tears three injections in total, separated by 6 weeks in patients with diabetes, monitor blood sugar levels following intra-articular injection NB: Consider immediate referral to an orthopaedic specialist for early surgical assessment if there is any suspicion of a severe rotator cuff tear. Speed C. Shoulder pain. Clin Evid 2008; 1: Poor response Poor response: some or all of the patient's symptoms, including pain, persist treatment does not fully restore the patient's ability to perform normal daily activities, including work, sleep, recreational and other activities 5 Good response Good response: symptoms, including pain, improve treatment restores the patient's ability to perform normal daily activities, including work, sleep, recreational and other activities 8 Investigations imaging may involve ultrasound scan, X-ray, or magnetic resonance image (MRI) as judged clinically appropriate, to: confirm or exclude diagnosis evaluate for any underlying pathology check the integrity of rotator cuff tendons Page 3 of 7

4 shoulder X-ray may be used to exclude other bony injury or to demonstrate contributory factors to impingement, eg bone spurs either ultrasound scan or MRI may be used to demonstrate rotator cuff tears New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders. Wellington: NZGG; Dinnes J, Loveman E, McIntyre L et al. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003; 7: Rotator cuff tear diagnosed Rotator cuff tears: can be painless or painful most patients have a longstanding history of painful shoulder condition, such as impingement syndrome or subacromial bursitis are related to repetitive use of the rotator cuff and therefore incidence increases with age; they are relatively rare before age 35 years occasionally tendon tear can be caused by acute trauma, sprain or sudden jerking injury to the shoulder may be partial or full thickness Risk factors include: subacromial spurs or impingement syndrome osteoarthritic thickening of the acromioclavicular (AC) joint systemic inflammatory conditions of the shoulders, such as rheumatoid arthritis or gout prolonged, excessive or unaccustomed use of the shoulder in the impingement position American Academy of Orthopaedic Surgeons (AAOS). AAOS clinical guideline on shoulder pain. Rosemont, IL: AAOS; New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders. Wellington: NZGG; Consider surgical intervention Surgical intervention may involve diagnostic arthroscopyto confirm diagnosis and a combination of the following therapeutic procedures: acromioplasty decompression rotator cuff repair New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders. Wellington: NZGG; Page 4 of 7

5 Speed C. Shoulder pain. Clin Evid 2005; Follow-up Follow-up: will depend upon the therapeutic procedure performed if rotator cuff is torn and a surgical repair has been performed: encourage patient to take passive exercise for 6-8 weeks discourage patient from making active movements for 6-8 weeks protect arm in a sling for up to 3 months if rotator cuff does not require repair: advise patient to begin active and passive movement exercises after surgery, as soon as pain is under control full recovery after procedure may take up to 9 months Page 5 of 7

6 Key Dates Due for review: 31-May-2011 Last reviewed: 30-Oct-2009, by International Updated: 30-Oct-2009 Accreditations The editorial process used to create this pathway is accredited by: NHS Institute for Innovation and Improvement: Accreditation attained: 30-Oct-2009 Due for review: 31-May-2011 Disclaimer Certifications The evidence for this pathway is certified by: BMJ Publishing Group Ltd: Disclaimer Evidence summary for Impingement syndrome The pathway is based on our interpretation of the following guidelines (9, 2, 6). All of these guidelines have been graded for quality and prioritised for inclusion based on their methodological quality. All intervention nodes (ie. those concerning therapy and therapeutic advice) have been graded for the quality of the evidence underlying them. Key non-interventional nodes are also referenced. Search date: May-2006 Evidence grades: Evidence grading: Intervention node supported by level 1 guidelines or systematic reviews Intervention node supported by level 2 guidelines Intervention node based on expert clinical opinion Non-intervention node, not graded Graded node titles that appear on this page Evidence grade Reference IDs Impingement syndrome 2, 3 Clinical features 2, 3 Management 2, 3, 10 Investigations 2, 9, 3, 6 Rotator cuff tear diagnosed 9, 3, 2, 1 Consider surgical intervention 9, 2, 3, 10 References This is a list of all the references that have passed critical appraisal for use in the pathway Shoulder pain ID Reference 1 American Academy of Orthopaedic Surgeons. AAOS clinical guideline on shoulder pain. Rosemont, IL: American Academy of Orthopaedic Surgeons; Australian Acute Musculoskeletal Guidelines Group. Acute Shoulder Pain. Canberra: National Health and Medical Research Council; Page 6 of 7

7 ID Reference 3 Brigham and Women's Hospital. Upper extremity musculoskeletal disorders. A guide to prevention, diagnosis and treatment. Boston, 4 Clinical Knowledge Summaries (CKS). Shoulder pain. Newcastle upon Tyne: CKS; Clinical Knowledge Summaries (CKS). Osteoarthritis. Newcastle upon Tyne: CKS; Dinnes J, Loveman E, McIntyre L et al. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003; 7: Gotzsche P. Non-steroidal anti-inflammatory drugs. Clin Evid 2002; National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave lithotripsy for calcific tendonitis (tendinopathy) of the shoulder. Interventional Procedure Guidance 21. London: NICE; 9 New Zealand Guidelines Group. The diagnosis and management of soft tissue shoulder injuries and related disorders. Wellington: New Zealand Guidelines Group; Speed C. Shoulder pain. Clin Evid 2008; Disclaimers NHS Institute for Innovation and Improvement It is not the function of the NHS Institute for Innovation and Improvement to substitute for the role of the clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own professional judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness or completeness. The information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date. BMJ Publishing Group Ltd The updates supplied by the BMJ Group Ltd for the Evidence Summary are prepared by systematically reviewing certain published medical research and guidelines relevant to the topics covered, as agreed with Map of Medicine Ltd. Readers should be aware that professionals in the field may have different opinions and not all studies are covered. Because of this fact and also because of regular advances in medical research, we strongly recommend that readers independently verify any information they choose to rely on. Ultimately it is the readers' responsibility to make their own professional judgements. The BMJ Group Ltd does not independently verify the accuracy of the published research or guidelines and is not responsible for changes being made within the Map of Medicine as a result of the evidence. The updates to the Evidence Summaries are supplied on an "as is" basis without warranty of any kind express or implied and to the fullest extent permitted by law, accepts no liability for losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information, errors or omissions in the updates supplied for the Evidence Summary, the Pathways covered by it or the research referred to in it. Page 7 of 7

Anatomy Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Anatomy Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). Shoulder Impingement/Rotator Cuff Tendinitis One of the most common physical complaints is shoulder pain. Your shoulder is made up of several joints combined with tendons and muscles that allow a great