Stage I Impingement Of Rotator Cuff

Stage I Impingement

Stage I impingement is characterized by edema and hemorrhage (inflammation) of the rotator cuff and suprahumeral tissue. The patient is usually under the age of 25 and usually has a trigger for shoulder overuse. Clinical symptoms include pain along the anterior and lateral aspect of the shoulder, which when acute or reactive extends below the elbow. The pain is usually described as a deep, dull pain, with acute subacromial pain during elevation of the limb. The patient has active full range of motion (AROM) and passive ROM (PROM), a painful arch (pain between 60-90-120 limb elevation), and a sign of abnormal impingement. Muscle strength is usually normal for the abductors and external rotators of the glenohumeral joint, but muscles can be painful and weak in an acute state. Palpation causes subacromial tenderness, usually along the greater tubercle and bicipital sulcus. Muscle spasms are usually present along the ipsilateral superior trapezius, levator scapula and subscapular muscles. Many of these patients have scapular postural changes, including excessive downward rotation and anterior tilt of the scapular.

Principles of Treatment

The principles of treatment for stage I are based on the stage of clinical reactivity and associated abnormalities. Because primary stage I shock is usually acute, treatment goals are to reduce and eliminate inflammation, increase patient awareness of shock syndrome, improve proximal (parascapular) muscle control, and prevent atrophy or weakness. muscle caused by the lack of use of the glenohumeral joint. The patient should be instructed to rest from activity, but not to function, and to perform all activities in front of the shoulder and below shoulder level. A complete (but understandable)


An explanation of the locking process is helpful for many patients to understand harmful positions. Active, forced elevation above the shoulder level can produce a painful arch and impingement and can perpetuate the inflammatory response. The patient would be well advised to take an oral non-steroidal anti-inflammatory drug, along with anti-inflammatory modalities including ice, interferential


pulsed or low-intensity stimulation or ultrasound. Soft tissues need to be worked and stretched to relieve muscle spasms.

Exercise, including manual resistance, can be used early to facilitate scapular parascapular muscle control without further aggravation of the suprahumeral tissue As reactivity diminishes with elimination of rest pain and pain below the elbow, and with elimination of painful arc and subacromial tenderness, the patient progresses into a dynamic strengthening program that emphasizes reestablishment of the force couple mechanisms at both the scapulothoracic junction and the glenohumeral joint. The emphasis should be on high repetitions (3 to 5 sets of 15 repetitions for each exercise), multiple sessions of 3 to 4 daily, working initially in a pain-free range, and using both concentric and eccentric muscle contraction. Exercises are slowly increased to 7 to 10 different movement patterns to isolate different muscle

groups. The proper use of these exercises with a low-weight (never greater than 5 lb) and high-repetition format is recommended to enhance local muscle endurance of the rotator cuff muscle and parascapular muscles. Moncrief et al studied the effects of a 5 times per week training program of rotator cuff

exercises with 2 sets of 15 repetitions for 1 month in healthy, uninjured subjects. Subjects were pretested and post-tested on an isokinetic dynamometer to quantify internal and external rotation strength objectively. Results of the 1-month rotator cuff training program showed an 8% to 10% gain in isokinetically measured internal and external rotation strength in the training arms of the study and no significant improvement in strength in a control group. Neer suggested that a patient should continue this

conservative approach for several months before considering surgical treatment. If the patient is an athlete, as signs and symptoms permit, an additional program of sport-specific exercises and functional training should be incorporated into the program. More recent studies showed the effectiveness of

a structured and supervised exercise program for patients with shoulder impingement that was  comparable to surgical acromioplasties.

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