Shoulder on Dr. Asadul Al Galib

Impingement Syndrome

Thu, 07 May 2026 00:00:00 +0000

repetitive compression or rubbing of the tendons (mainly supraspinatus) under coraco-acromial arch i.e. subacromial space
during abduction -> conjoint tendon slides under coraco-acromial arch
abduction approaches 90 deg -> subacromial space narrows
internal rotation -> narrower, external rotation -> wider
naturally, at 90 deg abduction -> arm externally rotates to increase the space
activities with repeated int. and ext. rotation (window cleaning, wall painting) -> compression, rubbing, friction of the tendon -> impingement syndrome
Impingement Position -> abduction, slight flexion, internal rotation
Site of impingment -> critical area of diminished vascularity in the supraspinatus tendon about 1 cm proximal to its insertion into the greater tuberosity

Intrinsic factors

degeneration of the tendon (age-related, cell-mediated)
changes in the presence of highly sulphated glycosaminoglycans
changes in the collagen composition with loading.
Changes in vascularity
All these changes -> rotator cuff dysfunction -> upward displacement of the humeral head -> subsequent extrinsic compression.

Extrinsic factors

spurs growing down the coracoacromial ligament
a laterally sloping acromion
osteoarthritic thickening of the acromioclavicular joint

Effects

friction -> tendinitis (edema, swelling) -> usually self-limiting
prolonged / repetitive -> minute tears -> scarring, fibrocartilaginous metaplasia, calcification in the tendon
healing -> vascular reaction -> local congestion -> narrowing of the space -> further impingement
slow healing / sudden strain -> microscopic tear extends -> partial / full thickness tear -> loss of abduction
large tears -> disturbed shoulder mechanics -> osteoarthritis of the glenohumeral joint

Clinical features

typically those of a Rotator Cuff Syndrome
Subsequent progress depends on the
- stage of the disorder,
- the age of the patient and
- the vigour of the healing response
3 patterns
- subacute tendinitis
- chronic tendinitis
- cuff disruption

Subacute tendinitis (painful arc syndrome)

anterior shoulder pain after vigorous/unaccustomed activity
tenderness along the anterior edge of acromion (easily elicited on extension)
often reversible, relieves spontaneously by activity modification

Chronic tendinitis

recurrent attacks of subacute tendinitis
pain relieves with rest, anti-inflammatory treatment
recurs with more demanding activity
pain is worse at night, patient cannot lie on the affected side
pain restricts even simple activities like hair grooming, dressing
signs of bicipital tendinitis (tenderness in the bicipital groove, crepitus on moving tendon)

Most advanced stage is progressive fibrosis and cuff disruption. Patient gives history of refractory shoulder pain, increasing stiffness and weakness.

Rehabilitation Protocol for Rotator Cuff Tendinitis

Thu, 07 May 2026 00:00:00 +0000

Phase I (1-2 weeks)

passive of active-assisted ROM exercises in pain-free ranges
- improve or maintain motion
- provide gentle stress for healing collagen tissue
- optimize subacromial gliding mechanism
phase I ROM -> forward elevation and external rotation, hold for 10 seconds, 10 times each, 2 times daily. both exercises should be pain free
phase II ROM -> extension, internal rotation, cross-body adduction, hold for 10 seconds, 10 times each, 2-4 times daily
phase I strengthening exercises (using elastic bands / free weights) -> external rotation, internal rotation, flexion, extension

Phase II (2-4 weeks)

pain and inflammation has resolved, ROM & strength improved
sleeper stretch -> hold for 10 seconds, 5 times
wall stretch & stretch behind the head
phase II strengthening (after reaching level 3 resistance in all phase I strengthening exercises) -> abduction and forward elevation to 45 degrees & external rotation at 45 degrees
total arm strengthening with biceps and triceps exercises
scapular strengthening exercises -> horizontal abduction with scapular retraction, external rotation with elastic resistance

Phase III

ROM should be full and pain-free
athletes will progress to higher-level exercises involving functional combination movements in more provocative positions

Phase IV

Athletes should continue with the rotator cuff, deltoid, and scapular exercises with a bias toward sport-specific positions

Rotator Cuff Syndrome

Thu, 07 May 2026 00:00:00 +0000

This comprises of at least four conditions

supraspinatus impingement and tendinitis
tears of the rotator cuff
acute calcific tendinitis
biceps tendinitis and/or rupture.

Symptoms

pain and/or weakness during certain movements of the shoulder.
Pain may have started recently, sometimes quite suddenly, after a particular type of exertion; the patient may know precisely which movements now reignite the pain and which to avoid.

Rotator cuff pain

over the front and lateral aspect of the shoulder
during activities with the arm abducted and medially rotated
may be present even with the arm at rest
tenderness is felt at the anterior edge of the acromion.

site	association
in front along the delto-pectoral boundary	biceps tendon
over the top of the shoulder	acromio-clavicular pathology
at the back along the scapular border	cervical spine

Rotator Cuff Anatomy

The rotator cuff comprises the lateral portions of the infraspinatus, teres minor, supraspinatus and subscapularis muscles and their conjoint tendon which is inserted into the greater and lesser tuberosity of the humerus.