Impingement Syndrome Case Study
The arm Is kept. In Its place In the shoulder socket by a part called the rotator cuff. The rotator cuff Is made of up muscles and tendons. The upper arm bone Is attached to the shoulder blade by the rotator cuff. “The crimson is the bone on the top of the shoulder. Between the rotator cuff and the crimson is a lubricating sac called the bursa.
The purpose of the bursa is to assist the tendons to glide freely when the arm is moved”. Shoulder impingement occurs when the arm is raised to shoulder height.
When the arm is raised there is a rowing of the space between the rotator cuff and the crimson. “During this narrowing, the crimson may impinge on the bursa and the tendon. This impingement can lead to pain and irritation”.
“The area known as the Impingement Interval is the area between the superior aspect of the humeral head and the underscore of the crimson. This normally narrow space Is maximally narrowed when the arm Is abducted. Any factor or condition that causes a further narrowing of that space can result in impingement” .
Impingement may result from meanness or loss of competency of the rotator cuff. Several extrinsic factors can lead to the impingement. Once the rotator cuff is weakened, that leads to a superior movement of the humeral head.
“The superior movement of the humeral head increases the impingement, which leads to an ongoing cycle, thus reinforcing the impingement”. Inflammation of the bursa is referred to as bursitis. This leads to pain and a loss of motion. The loss of motion can lead to a thickening of the rotator cuff and its bursa.
This thickening causes the surrounding tissue to Impinge upon the bones around the shoulder. This Is more commonly referred to as Impingement syndrome. There are many processes that may compromise the normal gliding function of the shoulder’s tendons thus causing an impingement. Simple degeneration and weakening Walton ten tendon can occur Owe to age.
In some people tender Is a normal variant to the anatomy of the crimson. Acute trauma to the shoulder can cause impingement. The normal crimson is flat.
Type II and type Ill crimson are curved or hooked and dip downward. This variation in shape causes an obstruction at the outlet for the spirituals tendon leading to impingement.
Calcification of the chromatically ligament, which can be due to trauma or Joint arthritis, has been associated with impingement syndrome. The formation of bone spurs in the subliminal space will lead to further narrowing of the space. Other causes can be a buildup of calcium deposits within the space, or poor posture and poor muscle strength.
One of the most common causes of shoulder impingement is overuse injury. This cause is seen mostly in people who often use there arm in a repetitive overhead motion.
Certain sports such as tennis, baseball, especially pitching, and swimming in which the athlete uses there arm overhead repetitively are very susceptible to impingement syndrome. Also professions or hobbies such as painting, paper hanging, and many construction Jobs make the shoulder more vulnerable” . It is primarily prevalent among adults.
Younger adults are frequently seen with Stage l, often associated with overuse injury and reversible at this point. Stage II is usually seen in adults aged 25 to 40, where there are more evident fibrosis and tendon changes. This is often a combination of overuse injury and advancing age.
It is also frequently seen in adults over age 50. This may be related to the aging process, but can be exacerbated by an acute trauma or overuse injury. There is essentially no extreme difference in its prevalence among various ages or gender, since there are a variety of different causes that affect different age groups and gender.
Its prevalence is more related to activities of an individual, which could be considered a certain culture, such as athletes and people whose occupations involve repetitive horizontal and overhead arm use, rather than age or gender. Dynamited, 2014).
Pain is usually the primary symptom that patients report. The pain is usually located in the lateral and anterior aspect of the shoulder, described as radiating from the front of the shoulder to the side of the arm.
It may be more sudden in nature when the patient lifts or does a reaching movement and worsened by elevation of the arm and lowering of the arm, with weakness in the arm and shoulder and decreased range-of- motion. “Movement may be limited, and described as tender; there is often loss of strength and motion, and difficulty with certain activities that require lifting the arm p or behind the back”. Sleep disturbance is often reported, especially when lying on the side of the affected shoulder.
The neck should be evaluated for pain because pain from underlying shoulder pathology may radiate to the neck due to spasms from the trapezium muscle and also because cervical pathology should be ruled out since it can mimic shoulder pain.
“Pain that radiates below the elbow is usually not related to shoulder pathology’. Shoulder pain can have many causes. Many conditions must be considered as a differential diagnosis when assessing a person for shoulder pain.
Calcium deposits can lead to a painful condition called calcify tendonitis. Cardiovascular arthritis can exist by itself or can cause impingement. Other differential diagnosis Tanat snout a De consolable are a rupture AT ten Addles tendon, a rotator cur tear, adhesive capitalists, also known as frozen shoulder, Lupus and Lame’s disease.
Many forms of arthritis, such as cardiovascular, rheumatoid, galvanometer and septic arthritis can mimic shoulder impingement. Cervical radiotherapy or a growth such s a tumor can cause shoulder pain and should be considered.
History The chief complaint a patient usually presents with when there is a diagnosis of impingement syndrome is shoulder pain. The pain is often described as a dull and deep ache, in the anterior aspect of the shoulder, worsening with elevation of the arm overhead or to shoulder level. The complaint often includes weakness in the arm and shoulder and a loss of movement. The history of the present illness is sometimes acute in onset, especially when caused by trauma, or may be more gradual in onset hen caused over time by overuse activities or may be due to weakening and degeneration of the tendon due to the aging process.
Chief complaint: What is that brings you to this appointment today? History of present illness: Can you tell me when the pain first began? Was it a sudden onset or gradual? Can you tell me exactly where in your shoulder area the pain is located? Can you point to where you feel the pain? Is it a constant pain, or does it come and go? Can you describe the pain; is it dull or sharp, throbbing, burning or aching? How would you rate your pain on a 0-10 main scale? Is there any activity that worsens or brings on the pain?
Is the pain worse when you elevate your arm to shoulder height, above your head, behind your back or when you rotate your arm? Pain in relation to these movements is very indicative of shoulder impingement and would further direct your physical and diagnostic approach. Is there anything that you have tried that helps to alleviate the pain? Does it wake you at night? Does the pain radiate anywhere else? Have you had a recent injury to that arm or shoulder, or been involved in any type of trauma? Has it had an effect on your activities of daily living?
Are there any activities you are unable to perform due to the pain? Is there any weakness, loss of motion, numbness or tingling in your arm or shoulder? Are you having any pain in your neck? Shoulder problems can cause pain to radiate to the neck, and cervical problems can sometimes cause shoulder pain. Do you have pain, weakness or stiffness in any other Joints, or anywhere else? This question would help to assess for possible causes such as arthritis, lupus or Lame’s disease. Have you had a fever or chills recently? This would be asked to assess for the preferential diagnosis if septic arthritis.
Do you have any thoughts on what might be going on? Are you currently taking any prescription, over-the-counter, herbal, or recreational drugs/medications? Do you have any allergies to drugs, food or environmental allergies? Past medical history: Do you have any current medical problems you are being treated for? Have you had any medical problems or conditions in the past, if so, when, and how were they resolved? Can you tell me about any previous hospitalizing or surgeries you may have had? Have you ever had any problems with your shoulder in the past; an injury?
If yes, when did it occur and how has it treated? Past history of the same type of problem and the resulting treatment can assist with possible diagnosis and treatment this time.
Psychosocial history: Have you engaged in any new physical activities recently or recently resumed a level AT Pensacola actively rater a pergola AT decreased actively Have you recently started a new sport or hobby, especially one in which you would be raising your arm over your head repetitively, such as swimming, an aerobic exercise program, or done anything such as painting your home?
Overuse activities are a fairly moon cause of shoulder impingement, and asking about activities involving the arm and shoulder may help to narrow down the diagnosis. Is there a family history of rheumatoid arthritis or any other auto-immune disease? Are you married? Who else resides with you? What is your occupation? Do you smoke? Do you consume alcohol or recreational drugs? If yes to either how much, how often and for how long? Do you feel safe? Review of systems: General: Assess for weight loss or weight gain, fatigue due to difficulty sleeping or awakening with pain, appetite changes, fever or chills.
Neck: Assess for pain or stiffness, difficulty moving head or neck. Musculoskeletal: Assess for pain in shoulder or arm, location, and if the pain radiates anywhere, range-of-motion with lifting and raising arm above head, shoulder stiffness, weakness in arm and shoulder, pain in other Joints, muscles or bones. Neuron: Assess for numbness or tingling.
Physical Exam Overall appearance, mood and alertness should be assessed. Height and weight should be obtained, along with vital signs including blood pressure, pulse, respiratory rate and temperature. Visual inspection of the shoulder, shoulder girdle interiorly and the scapula and related muscles posterior, assessing for any deformity, edema, muscle atrophy or the appearance of a tumor, posture, skin color, and for proper or abnormal positioning of the arm in relation to the shoulder”. Range of motion should be evaluated. “If active range of motion is limited due to symptoms such as weakness or pain, then passive range of motion testing should be performed.
The typical pain seen during physical exam is when the pain is seen to increase the higher the arm is elevated, and may occur with rotation of the arm. Hawkins’s impingement test, which is done by internally rotating the shoulder while stabilizing the scapula is considered positive for impingement if there is pain. Nerds impingement test is when the patient elevates their arm to full extension and is considered positive if pain is elicited”. All of the range-of-motion tests involve “moving the shoulder passively.
The provider assesses for pain when the shoulder is moved though forward flexing, adduction, and external and internal rotation with the arm adducted and abducted at 90 degrees”.
Pain during hose shoulder movements, that is then relieved when the arm is again at rest, is suspicious for shoulder impingement. Palpation should be performed, assessing for tenderness in the shoulder girdle muscles, cardiovascular Joint, ligaments of the shoulder, rotator cuff insertion site, and the biceps tendon.
Appropriate diagnostic studies should be ordered or performed. Imaging tests may help exclude the diagnosis of shoulder impingement, or show conditions that are involved in shoulder impingement, but there is not a conclusive diagnostic test to confirm the diagnosis. Four views, along with an outlet view X-ray may show outlet strolling caused Day a Done spur, or anatomic variants sun as type I or type II crimson”.
They may also be helpful in assessing for calcify deposits.
X-rays can also help rule out fracture or dislocation. Magnetic resonance imaging and ultrasound may allow for better imaging of the soft tissue and may reveal inflammation or fluid accumulation in the bursa and rotator cuff causing a greater than normal narrowing. The use of MR. and ultrasound are also valuable to rule out any suspected pathology.
Complete blood count would be obtained if patient reported fever or chills to assess for infection from a condition such as septic arthritis .
Management Treatment guidelines, according to Agency for Healthcare Research and Quality, National Guideline Clearinghouse, state that the treatment guidelines to be followed must be acquired by first having an initial evaluation of the patient to determine a diagnosis, which will then determine the course of treatment. In the case of Samaritan, a 68 year old who presents with right shoulder pain, if the history ND physical exam determine shoulder impingement syndrome due to degenerative changes, initial conservative treatment is recommended.
The following plan of care based on current guidelines is recommended for this patient: “First visit, diagnosis is made and treatment is initiated. There should be an alteration of activity: no activities that involve lifting arms overhead. Exercise therapy such as gentle range-of- motion exercises are taught.
Analgesics for pain relief such as Acetaminophen or Nasals. Instructions for returning to work or activities of daily living. If activities of ark involve repetitive overhead activity, evaluate for ergonomic changes. The second visit should be about two weeks after the first visit.
Progress should be documented, if not significantly improved further treatment options should be initiated. Gentle physical therapy should be initiated: range-of-motion and exercises to strengthen the rotators and to stabilize the scapula, 3 visits per week for 2 weeks.
The third visit about 2 weeks after the second visit. Document progress again, if not significantly improved, advance treatment options. Consider corticosteroid injection to decrease swelling and help resolve the impingement. Anesthetic injection under the crimson for pain relief may be done.
Continue physical therapy, changing from passive to active modality, two visits per week.
Teach home exercises”. Some differences in the recommendations for treatment were noted between the different guidelines and some of the scholarly articles reviewed by the author. One such difference was noted in Essentials Evidence Plus, “cryptography, the application of ice applied to the affected are, usually relieves the pain” .
The recommendation that” ice may be applied to the shoulder area, three to four times per day, for 20 minute intervals” also appeared in several Journal articles. This will help to decrease swelling and pain. The author also noted that, according to Bonhomie, the arm and shoulder should not be immobilizers, such as with a sling, because the adhesive capitalists could result.
Referral to a specialist or a surgeon may be warranted if the diagnosis remains unclear, or in treatment does not alleviate the condition . Patient education is always important, and will greatly enhance proper annealing to take place. “education auto Doctors Tanat affect annealing, sun as Testily behaviors, willingness to adhere to the plan of care, nutrition, exercise, motivation, the knowledge that this is a long and slow process of recovery will help the patient stay diligent with her efforts”.
General patient education for this condition should involve explaining the mechanism of the condition to the patient and how abduction of the arm worsens he impingement and ways to prevent musculoskeletal injury and to preserve musculoskeletal function. The arm movements that need be avoided should be shown to the patient.
Demonstration of stretching and gentle range-of-motion exercises should also be demonstrated, and the patient should perform a return demonstration to assess for correct application.
The use of analgesics, and the possible side effects should be explained. Take all medication as prescribed. Take Nasals with food. Report any adverse reactions such as hives, swelling or difficulty breathing to the provider immediately. For the application of ice to the affected area, the patient should be instructed to not leave the ice on more than 20 minutes, and to not apply directly to the skin, to place a barrier such a thin cloth between the skin and the ice pack to avoid skin damage.
Patient education should include symptoms that would need to be reported to a provider immediately.
The importance of follow up visits in a timely matter needs to be reinforced also, if treatment is not leading to an improvement in the condition, changes should be made without delay. If the impingement is due to degenerative changes occurring tit age, the patient needs to understand the recommendations for rest and arm use are more likely permanent changes that must be incorporated into their lifestyle to avoid worsening or aggravating the condition. If the condition is related to overuse activity, the importance of temporary discontinuation of that activity, and the likelihood on ongoing modification of that activity should be explained. The patient also needs to be explained that this is usually a multidisciplinary approach, and referral to a specialist may be made, and other courses of treatment such as injections or surgery may be an option in the future if conservative treatment is not successful.
Walks every day.
HPI:HIPin in the right anterior aspect of the shoulder, first noticed about six weeks ago. Dull ache most of the time, with sharp pain felt when raising arm overhead, lowering arm, lifting objects and reaching. Pain radiates down side or arm sometimes, increasing with severity over the past 3 weeks. Without movement rated as a “3”, with movement a “7”. Recent night awakenings due to pain. Difficulty with ADLsAddlest involve overhead raising of arm such as washing hair, putting clothing on overhead, accessing of upper shelves of closets and cabinets.
Has tried TyleEthyleneh some pain relief for 1-2 hours. No recent trauma No numbness or tingling. No neck pain or pain in any other Joints. No fever or chills. Active medical problems: None. currCurrents: AcetAcetaminophenmMug or two times aallally Tortnplan Tortt t weeks.
No other medications or herbal treatments. Daily multivitamin with calcium. Allergies: NKDAANDuImmunizationfluenza and pneupneumaticss year. PMH:MPH surgeries, injuries, or major illness. Has never been hospitalized.
No arthritis or any known Joint disease. No history of previous shoulder pain or injury.
Family History: No family history of arthritis or Joint disease. Psychosocial: Lives alone, widowed, retired 2 years, previously a homemaker then a receptionist past 10 years, stays active at community center, bingo and cards weekly, walks 1 mile daily near home. No new activities. No tobacco, alcohol or drug use.
No abuse, feels safe. ROS:ROSSneral: No weight loss or weight gain, recent fatigue due to difficulty sleeping and wakening with pain, no appetite changes, no fever or chills. Neck: No pain or stiffness, no difficulty moving head or neck.
Musculoskeletal: Pain in right shoulder and sometimes radiates into the right arm, stiffness in shoulder and difficulty with lifting and raising arm above head, weakness in arm and shoulder, no pain in other joints, muscles or bones. NeurNeuron numbness or tingling. Objective General appearance: Caucasian adult female, 68 years old, appears her stated age, appropriately dressed.
SamaSamaritanalert and attentive, oriented to person, place and time, recent memory intact. Does not appear to be in any distress. Neck: Full range of motion no pain. Lymph nodes nonpunflappablesculoskeletal: No edema, muscle deformity or abnormal shape noted in shoulder bilaterally. Good shoulder posture, normal positioning of arm at side bilaterally.
Skin color normal, warm to touch bilaterally. Palpation elicits pain in anterior aspect of right shoulder. No growth or edema palpable. Positive Hawks impingement test and positive NeerNerdsingement test. Shoulder pain relieved when arm resting at side. No pain in other Joints, muscles or bones NeurNeuronsitive weakness in right arm.
Assessment Shoulder Impingement Syndrome Plan Diagnostic tests: X-rays of right shoulder: 4 views including an outlet view. CBC.CBssible MRI MR.next appointment if no improvement. OTC:ETCuprofen 400mMGM Ash 2 weeks. Stop acetaminophen.
ADLsAddles overhead reaching or lifting: wear button shirts, use step stool to access items or have someone temporarily move to lower shelf. Exercise therapy: Begin gentle range of motion exercises as taught and presented in the handout given. CryoCryptographye applied to right shoulder, three times daily, 20 minutes each time.
Education: Verbal explanation and handouts given for shoulder impingement syndrome ana Anage-or-motion exercises. RelnRelocateortance 0T nAT strastraggling tenulder and avoiding excess use or trauma. Safe application of ice.
Safe use of Ibuprofen and possible side effects. Discussed signs and symptoms that should be reported to the provider immediately. Referrals: None at this visit. Referral toa toocialist or a surgeon may be warranted if the diagnosis remains unclear, or if treatment does not alleviate the condition Follow-up: Return to office in two weeks to evaluate effectiveness of overall treatment plan.