mechanics, movement and posture is met with no change in symp- toms the problem is not a secondary impingement. At that stage investigation is warranted to look for other causes.
There is no consensus as to the ratio of primary to secondary impingement in the shoulder pain population. Estimates vary wild-
Also consider: ● Labral lesions - very common - 83% of 120 throwing shoulders had labral lesions (Andrews & Carson 1984) - can be difficult to diagnose - can mimic other disorders ● Internal impingement - Instead of impinging on the underside of the acromion, the very mobile shoulder can rotate past the acromion to impinge on either the anterior or posterior labral rim ● Disorders of the passive restraints ● Acromio-clavicular joint ● Spinal, neural and central elements ● Long head of biceps / biceps anchor
ly from 90% primary (Neer’s original paper) to 20% primary. In this humble physiotherapist’s view there seems virtually always to be at least some component to the problem that stems from a correctable movement fault.
Principal references 1. Burkhart SS et al. The rotator crescent and rotator cable: an anatomic description of the shoulder’s suspension bridge. Arthroscopy 1993;9(6):611-616 2. Burkhart SS. Reconciling the paradox of rotator cuff repair versus debride- ment: a unified biomechanical rationale for the treatment of rotator cuff tears. Journal of Arthroscopic and Related Surgery 1994;10(1):4-19 3. Clarke JC, Harryman DT. Tendons, ligaments and capsule of the rotator cuff. Journal of Bone and Joint Surgery 1992;74A:5713-725 4. Fu FH et al. Shoulder impingement syndrome: a critical review. Clinical Orthopaedics and Related Research 1991;269:162-173 5. Magarey ME. The shoulder complex: a preliminary analysis of diagnostic agreement reached from a physiotherapy clinical examination and an arthro- scopic evaluation. Proceedings: 9th Biennial Conf. of the MPAA 1995 6. Magarey, ME. The shoulder complex: a diagnostic dilemma and manage- ment challenge. Proceedings: 10th Biennial Conf. of the MPAA 1997 7. Warner JJP et al. Scapulothoracic motion in normal shoulders and shoul- ders with glenohumeral instability and impingement syndrome. Clinical Orthopaedics 1992;285:191-9