Stage II & III Impingement

Stage II Impingement

Stage II impingement is characterized by fibrosis of the glenohumeral capsule and subacromial bursa and tendonitis of the affected tendons. The condition is typically seen in patients between the ages of 20 and 40. The clinical presentation may be similar to stage I, except that the patient has loss of AROM and PROM due to capsular fibrosis. Loss of ROM normally appears in the capsular pattern, described by Cyriax as a significant loss of external rotation and abduction, with less loss of internal rotation.

Principles of Treatment

The principles of treatment are similar to those for stage I clamping, except that the primary goal is to restore full AROM and PROM to prevent further clamping and tissue damage. Cofield and Simonet described how patients with adhesive capsulitis of the glenohumeral joint developed subacromial impingement. In particular, the tension of the posterior capsule caused the humeral head to move forward and superiorly in the subacromial arch and in the anteroinferior acromion. Subsequent treatment should be aimed at restoring capsular extensibility, to allow the humeral head to reach its normal center of rotation. Several manual techniques are effective in mobilizing the glenohumeral joint capsule. The force and direction of the mobilization force should be based on the stage of the clinical trials of mobility and reactivity. Treatment time in patients with stage II disease is longer than stage I, and the prognosis and functional outcome may be more limited.

Stage III Impingement

Stage III impingement is the most difficult to treat conservatively and is characterized by disruption of the rotator cuff tendons. The patient is normally more than 40 years old. Clinically, muscle testing yields weakness, usually for external rotation and abduction. Visual observation indicates a “squaring” of the acromion, a finding that indicates atrophy of both the rotator cuff and deltoid muscles. Patients with

significant tendon disruption have a positive “drop-arm” or supraspinatus test result.

Principles of Treatment

The principles of treatment are based in part on the size and location of the lesion. Tears are classified by size, diameter, location or topography. Small to medium-sized tears can work relatively well for limited functional purposes. The patient progresses similarly to the previous principles of treatment. If treatment is ineffective and the patient continues to experience pain and an inability to raise the arm above the head, options include rotator cuff debridement and anterior acromioplasty or mini-open repair. For those with large, massive tears, surgery is usually the most effective option, followed by an extensive rehabilitation program that incorporates the basic principles of treatment for impingement syndrome and adherence to guidelines for soft tissue healing.

Physical Therapy Evaluation

Based on presenting signs and symptoms, onset, and patient’s age, the physical therapist classifies a stage I primary impingement. The stage of clinical reactivity is acute. The patient has pain to the elbow, is unable to sleep on the involved side, has a painful arc, pain with manual resistance, and a positive impingement sign. Resisted testing and palpation seem to indicate primary involvement of the supraspinatus muscle tendon and the long head of the biceps tendon (empty can and Speed’s tests). A secondary problem of tingling in the right hand is likely related to cervical radiculopathy from long-term cervical arthritis (degenerative disk disease). This condition was also most likely exacerbated by painting.

Primary impairments (extrinsic) factors related to pathology include the following:

Scapular downward rotation and anterior tilting syndromes

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