SHOULDER IMPINGEMENT

not the sole determinant of the right thing to do (13).

Figure 4 (posterior view) shows right upper trapezius hypertrophy/lower trapezius atrophy, right scapula winging and protrac- tion and right trunk side flexion showing latissimus dorsi shortening.

Figure 4

Figure 5 (side view) shows a head forward position with increased cervical extension, thoracic kyphosis and an anteriorly posi- tioned humeral head.

Figure 6 (anterior view) shows a head posi- tion deviating to the right indicating mus- cle shortening, internal rotation of the right arm indicating subscapularis, pec- toralis major/minor, shortening increased pectoral muscle bulk right side and right trunk side flexion.

Figure 5

PHYSICAL TESTS Before proceeding with specific shoulder testing, always clear the cervical spine as the shoulder is covered by C5 dermatome. Testing active (AROM) and passive range of movement (PROM) is useful in differentiat- ing between contractile and non-contrac- tile structures as a source of pain (14).

■ PROM - it should be considered that

PROM is useful for determining muscle lengths and as such, does not therefore only test non-contractile structures. Passive range may be limited due to muscle imbalances or as a result of pos- tural issues. Classically subscapularis can be implicated when shoulder girdle protraction combined with thoracic kyphosis exists. The muscle is in a short- ened position giving pain and limitation to range of flexion, abduction and/or external rotation.

Figure 6

Figures 4, 5, 6: Demonstration of typical shoulder impingement posture and muscle imbalances

■ AROM - the range, quality and presence of pain should be noted during active movements. Particular attention should be paid to scapulohumeral rhythm. Normal scapulohumeral rhythm should be smooth and in synchrony. Scapula upwards rotation should be more or less

TABLE 1: SIMPLE TABLE WITH LIKELY CAUSES OF SYMPTOMS Painful and strong

Minor lesion

Painful and weak Painless and strong Painless and weak

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Partial cuff tear Normal

Neurogenic or complete cuff tear

linear through range regardless of speed or loading (15). Scapula movement dur- ing elevation should show lateral rota- tion and anterior tilt occurring beyond 90º. It has been observed that scapula rotation is reduced towards 60º of eleva- tion and anterior tilt occurs approaching 120º in the presence of SIS with even greater dysfunction occurring under loading (16). In this study EMG analysis showed reduced serratus anterior activa- tion. It is not know whether scapulo- humeral rhythm dysfunction is the cause or effect of SIS, however, in my experi- ence it is always present and should be a focal point when treatment planning.

■ Resisted tests - aimed at testing con- tractile structures primarily but it is important to remember that when there is rotator cuff weakness present the compensatory action of deltoid draws the humeral head superiorly and this will therefore compress the subacromial bursa (17). Tests should always be performed in the neutral position and isometrically to reduce tension and involvement of non-contractile structures. Assess pain and strength of the contraction in comparison to the unaffected side. The Oxford Scale may be used, but a simple painful and strong/painful and weak/painless and strong/painless and weak scenario may be used in preference.

PALPATION Palpation should be the last part of the assessment and based on all the previous findings. Long head of biceps, supraspina- tus, subscapularis teno-osseous junction, infraspinatus and teres minor should all be palpable. Accuracy of palpation can be confirmed by actively resisting the muscle action during palpation.

General palpation for muscle tightness is useful, particularly the pectorals and latis- simus dorsi. In addition to the contractile structures the ACJ is well localised.

SPORTS SPECIFIC ASSESSMENT When dealing with SIS in sports, an impor- tant part of assessment may also include analysis of technique. Many injuries can be the result of poor technique. Combined assessment with an appropriately qualified sports coach can be extremely useful, particularly if using digital recording tech- nology to enable pause/freeze frame and

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