Posts tagged impingement
Will The Bone Spur In My Shoulder Cause A Future Rotator Cuff Tear?
Photo Credit: radiopaedia.org

Photo Credit: radiopaedia.org

One commonly sighted reason to perform surgery is to prevent a worsening of an existing pathology. In the shoulder, clinicians aim to preserve important structures such as the rotator cuff with early vs. late surgical interventions despite prior research showing little to no change in progression of tears of rotator cuff tears in patients with a high grade tear. Choosing to delay surgery, without risk of rotator cuff progression, allows a patient to benefit from Physical Therapy. Evidence shows equivocal outcomes between Physical Therapy and surgery for patients with rotator cuff tears. Another structure of concern on a shoulder x ray is a acromion bone spur. In theory, bone spurs on this structure could reduce space between the ball of the shoulder joint and the overlying end of the shoulder blade. New research demonstrates these bone spurs are not as problematic as first theorized.

It has been suggested that a bone spur can lead to shoulder impingement and eventual tearing of the rotator cuff. A recent retrospective study challenged this theory. Yoon et al. examined 119 patients with an intact rotator cuff, diagnosis of impingement, and a 3mm sub-acromial bone spur (Arch Ortho Trauma Surg. 2018). The patients received conservative care including Physical Therapy and received a follow up image to check the cuff integrity as early as 2 years, but as late as 5 years after their initial x ray. The authors found no progression of rotator cuff tears in the 2-5 years after the initial evaluation suggesting the lack of importance the spur relating to tears in the cuff.

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No Additional Benefit Of Injection Over Physical Therapy Interventions For Shoulder Pain
injection-shoulder-pain-exercise-impingement

Subacromial impingement syndrome is the most common cause of shoulder pain. These symptoms are easily treated with Physical Therapy interventions including manual therapy and exercise. Specifically, strengthening exercises for the shoulder blade and shoulder muscles improve both the quantity and quality of shoulder movements treating both the source of impingement pain and the underlying cause. Physical Therapy exercises remain the gold standard for treatment of impingement, but injections are still utilized by physicians to treat these symptoms. A recent research paper examined the benefits of an injection combined with Physical Therapy compared to Physical Therapy alone.

A randomized controlled trial in the British Medical Journal compared these two treatment approaches in 232 patients with shoulder impingement (Crawshaw et al. 2010). Patients were randomized to either a manual therapy, exercise, and an injection or manual therapy and exercise alone. Treating Physical Therapists were able to select the most appropriate manual therapy and exercise interventions based on the patient’s needs. Authors reported both groups improved over time, but no differences between groups on either pain or function were found at long term follow up. Thus, the improvements in shoulder pain and function can be attributed to the manual therapy and exercise interventions. No further benefit was found in the patients receiving injections.

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Including Dry Needling More Cost Effective Than Exercise Alone For Shoulder Pain
boulder-dry-needling-shoulder-pain

Shoulder impingement is the most common cause of shoulder pain and is commonly treated with Physical Therapy interventions including upper body strengthening and manual therapy.  Dry needling is gaining traction in both clinical practice and the medical research as an effective treatment option for musculoskeletal pain.  When combined with other forms of manual therapy, including joint mobilization and manipulation, and exercise, dry needling offers patients an effective choice for their symptoms.  A recent article examined the cost effectiveness of adding dry needling treatments to exercise for patients with shoulder impingement.

Fifty patients with subacromial impingement were randomized to shoulder strengthening (twice per day x 5 weeks) or shoulder strengthening and dry needling (Arias-Buria, J. Pain Med. 2018).  Patients undergoing dry needling treatments received dry needling to the shoulder complex on their 2nd and 4th Physical Therapy sessions.  Patients in the exercise only group made more visits to their physicians and received higher amounts of outside treatments for their symptoms.  In addition, patients in this group lost more time from work and reported lower satisfaction levels than the dry needling and exercise group.  Authors concluded dry needling was a cost effective treatment for shoulder pain due to its' ability to reduce time lost from work.

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Physical Therapy Improves Outcomes After Hip Impingement Surgery
boulder-physical therapy-treatment-hip-pain-impingement

Hip impingement, femoracetabular impingement, is a common source of pain for patients.  Much research is needed on this more recent diagnosis secondary to the high rates of impingement found in pain free athletes.  In addition, more research is needed on the comparison of conservative versus surgical management of the condition.  Patient's undergoing arthroscopic surgery to resurface the joint and remove the bony impingement often are prescribed a formal post operative Physical Therapy program.  A recent randomized, controlled trial compared the effectiveness of this program to a general, unsupervised exercise program.

hip-pain-surgery-labrum-FAI-treatments

Bennell and colleagues in the British Medical Journal compared these two programs in 30 patients who underwent surgery for hip impingement (2017).  The Physical Therapy group included 1 pre operative and 6 post operative sessions focused on manual therapy and progressive exercise.  The control group did not receive post operative rehabilitation.  The authors reported a superior recovery for the patients in the PT group at 14 weeks post operatively, but these changes were insignificant at 6 months.  Similar to other post operative Physical Therapy trials, PT has been shown to accelerate the recovery of patients undergoing surgery by allowing them to return to activities sooner than patients not receiving the same care. 

What are the most effective treatments for Shoulder Impingement?
boulder-shoulder-pain-impingement-treatment

Shoulder pain remains one of the most common reasons patients seek out care from both primary care physicians and Physical Therapists.  Shoulder impingement or the compression of shoulder tissues, including the rotator cuff tendons and bursa, is the most common diagnoses behind these patients' symptoms.  Physical Therapy remains a gold standard treatment for this condition to both identify the contributing causes for the symptoms and assist in the healing of the injured tissues.   A recent review of the evidence highlighted the most effective treatments for patients with shoulder impingement. 

Steuri and colleagues in the British Journal of Sports Medicine conducted a review of 177 articles on the treatment of shoulder impingement (2017).  The authors highlighted the effectiveness of manual therapy and exercise interventions for improving pain and function.  Specific, targeted exercises were more valuable than generic exercises highlighting the importance of matching an exercise intervention with a patient's condition and examination.  The authors concluded exercise should be utilized in patients with shoulder impingement and manual therapy may also be considered to help reduce short term pain.  In our practice, manual therapy allows patients to transition to an exercise program sooner than exercise alone. 

To learn more about how Physical Therapy can improve your shoulder condition contact your local Physical Therapist. 

Shoulder Impingement and Boulder Physical Therapy Treatments
Shoulder impingement, pain and physical therapy treatments

Shoulder Pain and Impingement Background

Shoulder pain is a common source of peripheral joint pain occurring at a prevalence rate of up to 47% across all age groups and is second most common cause of musculoskeletal pain(7,9).

Symptoms of shoulder pain account for 33.2% of physician visits in the U.S. and are most frequently associated with SAIS(13). Only 50% of new shoulder problems show resolution of patient symptoms at 6 months(12) 

Physical Therapy Interventions

Physical Therapy treatments for shoulder pain and impingement

Evidence in the medical literature supports the utilization of manual therapy to the spine and shoulder girdle in the management of shoulder pain disorders(1, 2, 3, 5, 6, 8, 10, 11).

Patients with SAIS who received thoracic spine thrust manipulations demonstrated significant decreases in pain and disability scores at 48 hours(3).

A combined program of manual therapy and upper quarter strengthening has demonstrated improved symptoms and disability in patients with SAIS(9).

Systematic reviews support the utilization of rotator cuff and scapular strengthening, in combination with manual therapy, for patients with SAIS(6,8). 

Physical Therapy Evidence for Shoulder Pain Treatments

Physical Therapy Solutions and Shoulder Pain Treatments

Multiple articles in the research literature describe the effectiveness of a multimodal approach to treating shoulder pain utilizing manual therapy to the upper quarter and therapeutic exercise(1, 2, 5, 6, 8, 10).

Bang et al. reported significantly greater improvements in motion, strength, pain and function in a group treated with manual therapy and exercise compared with exercise alone(1).

Manipulative physical therapy when combined with supervised exercise has been shown to produce faster improvements in pain, ROM and function in patients with SAIS compared to patients who just performed exercise or received self care alone(1, 5, 10).

The addition of manual therapy to patients receiving usual care for their shoulder complaints accelerated their recovery to previous functional levels(2).

Specifically, the usual care group took 52 weeks to demonstrate the functional improvement noted in the manual therapy group at 12 weeks (see graph)(2).

Brox et al. has demonstrated a physical therapy program was as effective as surgical sub-acromial decompression in the treatment of stage II primary impingement(4).

When to seek Physical Therapy Care

Physicians should consider referral of patients with symptoms of shoulder pain and dysfunction associated with reaching, lifting, repetitive upper extremity activities, or over head activities.

Research supports the utilization of manual therapy and exercise in this patient population for reduction of pain and disability associated with shoulder pain. Physical Therapy combined with primary care management can accelerate recovery associated with these symptoms(1,2,5).

References

1. Bang, M. et al. Comparison of supervised exercise with and without manual physical therapy for patients with subacromial impingement syndrome. JOSPT. 2000. 30(3):126-137.

2. Bergman, G. et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain. A RCT. Ann Int Med. 2004. 141:432-439.

3 Boyles R, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009. 14:375-380

4. Brox, J. et al. Arthroscopic surgery compared with supervised exercise in patients with rotator cuff disease (stage II impingement syndrome). BMJ. 1993. 307(6909):899-903.

5. Kachingwe A, Phillip B, Sletten E, Plunkett S. Comparison of manual therapy techniques with therapeutic exercise in the treatment of shoulder impingement: a randomized controlled pilot clinical trial. J Man Manip Ther. 2008. 16:238-247.

6. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009. 18:138-160

7. Luime J. et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004. 33:73–81.

8. Michener, L. et al. Effectiveness of Rehabilitation for Patients with Subacromial Impingement Syndrome: A Systematic Review. J Hand Ther. 2004. 17:152–164.

9. Picavet H. et al. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study. Pain. 2003. 102:167-178 

10. Senbursa G. et al. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthro. 2007. 15:915-921

11. Tate A, et al. Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: a case series. JOSPT. 2010. 40:474-491.

12. Winters J. et al. The long-term course of shoulder complaints: a prospective study in general practice. Rheumatology. 1999. 38:160–3

13. Wofford J. et al. Patient characteristics and clinical management of patients with shoulder pain in U.S. primary care settings: secondary data analysis of the National Ambulatory Medical Care Survey. BMC Musculoskelet Disord 2005. 6:4.