Case study: Subacromial impingement with RCRSP in a middle aged women.
A success story following five months of rehab with middle aged female who was referred by her GP with a 12 month history of left lateral shoulder and upper arm pain. She increased her Pilates 12 months ago but otherwise could not recall any changes in her daily routine, activity or loading nor any trauma or specific onset. Her pain began gradually, an ache after activity and stiffness in the shoulder on waking. This pain then developed into a sharp shooting pain down the upper forearm with certain movements to the point where she struggled to lift items, lie on that side or raise her arms above her head pain free. She is otherwise medically fit and well and denied any red flags (screening questions to raise signs of more sinister pathology).
On assessment she had a forward sitting head of humerus on the right side which was correctable with an AP pressure (soft end feel), restricted right cervical spine rotation (again, correctable with passive movement), a painful arc of shoulder movement on the right between 80 to 100 degrees of abduction but full range of movement at the GHJ bilaterally, she had weakness into end range external rotation but not into internal of the shoulder. She had normal myotomes, dermatomes and reflexes and neurodynamics were also normal. Her scapulohumeral rhythm/neuromuscular control was good as was her thoracic movement. Given her subjective history and overall objective presentation my clinical impression was that she was experiencing some type of subacromial impingement likely secondary to chronic rotator cuff pathology in form of weakness. Both of these can be classed together as I do not believe you can be structure specific and this is a clinical impression rather than a diagnosis, all of which I discussed with the patient.
Rotator cuff tendinopathy incidence ranges from 0.3 to 5.5% in the UK and evidence for predisposing features is limited. It is more likely in over 40s. There are different stages of a tendinopathy (that's for another blog post!) and treatment varies depending on this. Changes in the soft tissues of the rotator cuff can impact the strength, function and control of the shoulder. This leads to changes in the way the head of the humerus (upper arm bone - the ball of the ball and socket joint) interacts with the scapula (the socket of the ball and socket joint). This can eventually lead to contact between the head of humerus and the coracoid acromion and sub acromial space (think the floor (or the RC tendons on top of the head of humerus) moving up to the ceiling (the subacromial space) during movement). Therefore, the weakness in the rotator cuff muscles and tendons is likely leading to impingement in the shoulder. Given her subjective history I suspect her rotator cuff weakness/dysfunction came first and she then developed a secondary impingement.
Given her symptoms were not acute (suggesting she was not in a reactive tendinopathy stage) and her presentation I began with the following:
A graded strengthening programme for the rotator cuff, trapezius, rhomboids, serratus anterior and deltoids. Starting with movements at mid range and working on control of the movement (RC tendinopathy is insertional so doing movements close to the body can make things worse due to higher compressive forces - This is why it didn't like her lying on this side). I gave her proprioceptive exercises for the GHJ (Supine lying with a weight drawing the alphabet on the ceiling whilst maintaining scapula control, GHJ setting) and the scapula (Wall push up, 4 point kneeling reaches, upright rows, scapula press up),
A Stretching and mobility regime for her pectorals ,scalene and SCM (likely tight due to pain and/or weakness at the shoulder) such as corner wall push and release stretch for pectorals and CSP side flexion with over pressure for scalene.
Pain management: Trialling icing in the evening (given the pain had passed the acute stage but seemed to be stuck in the healing continuum) as there can be inflammatory aspects to impingement and tendinopathy.
Due to pressures on NHS services at the moment we were only able to fit in one face to face session during this time where we worked through the exercises to ensure good technique and I provided some manual therapy and proprioceptive input at the shoulder.
She now reports 90%improvement in her symptoms since our initial session, she gets the occasional twinge when she reaches overhead but is back doing her Pilates classes. She feels she can now manage her symptoms with everything I taught her.
Gebremariam, L., Hay, E. M., Van der Sande, R., Rinkel, W. D., Koes, B. W., & Huisstede, B. M. (2013). Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. British Journal of Sports Medicine, 48(16), 1202-1208. https://doi.org/10.1136/bjsports-2012-091802
Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment? British Journal of Sports Medicine, 43(4), 259-264. https://doi.org/10.1136/bjsm.2008.052183
Littlewood, C., Malliaras, P., & Chance-Larsen, K. (2015). Therapeutic exercise for rotator cuff tendinopathy. International Journal of Rehabilitation Research, 38(2), 95-106. https://doi.org/10.1097/mrr.0000000000000113
Littlewood, C., May, S., & Walters, S. (2017). Epidemiology of rotator cuff tendinopathy: A systematic review. Shoulder & Elbow, 5(4), 256-265. https://doi.org/10.1111/sae.12028
Seitz, A. L., McClure, P. W., Finucane, S., Boardman, N. D., & Michener, L. A. (2011). Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? Clinical Biomechanics, 26(1), 1-12. https://doi.org/10.1016/j.clinbiomech.2010.08.001