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Differential Diagnosis of Shoulder Impingement. Charlie Cotterill Junior Physiotherapist Feb 2006. AIMS. Subacromial joint. Subacromial space 9-10mm Force couple to counteract downward pull of deltoid Thompson et al (1996) Jarjavay (1867)

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differential diagnosis of shoulder impingement

Differential Diagnosis of Shoulder Impingement

Charlie Cotterill

Junior Physiotherapist

Feb 2006

Charlie Cotterill


Charlie Cotterill

Subacromial joint.

Subacromial space 9-10mm

Force couple to counteract downward pull of deltoid Thompson et al (1996)

Jarjavay (1867)

Neer (1972), anatomical variations in build, strain and repetitive microtrauma.

Degeneration of the rotator cuff, oedema, bleeding, fibrosis and calcification → ruptures, osteophyte formation, and spur formation.


Charlie Cotterill

  • Primary/Secondary
  • Intrinsic/Extrinsic

Bigliani Classification (1991)

Charlie Cotterill


Aetiology of SIS is multifactoral (Lewis et al 2001).

  • Mechanical/Anatomical
      • Primary mechanical impingement (Neer 1972, 1983)
      • Acromial bone spurs (Neer 1972)
      • Os acromiale (Neer 1972, 1983)
      • Corocoacromial ligament (soslosky et al 1994)
      • Postereosuperior glenoid impingement (Jobe 1997, Riand et al 1998)
  • Rotator cuff
      • RC overuse (Jobe and Jobe 1983, Meister and Andrews 1993, Frost et al 1999)
      • Degenerative tendinopathy (Ozaki et al 1988)
  • Instability/hypermobility
      • Secondary tensile disease (Meister and Andrews 1993)
      • Secondary compressive impingement (Warner et al 1990)

Charlie Cotterill

  • Restrictive processes
      • Restricted glenhumeral capsule (Harryman et al 1990, Matsen and Arntz 1990)
  • Posture
      • Ayub 1991, Bowling et al 1986, Calliet 1991, Solem-Bertoft et al 1993)
  • Functional scapular instability
      • Kibler 1991, 1998, 2002, 2003, Warner et al 1992, Lukasiewicz 1999, Ludewig and Cook 2000, Wandsworth, Bullock Saxton 1997)
      • Lateral Kibler slide test

Charlie Cotterill


Charlie Cotterill

differential diagnosis
Differential Diagnosis?

Labrum tear Cervical/Thoracic spine RA Bursitis

Polymyalgia Rheumatica Rotator cuff tear #

Biceps tendon rupture/tendinopathy Calcific tendinitis

Adhesive capsulitis AC arthritis Glenohumeral arthritis

Septic arthritis Gout Lyme disease Long thoracic nerve injury

Visceral: PE, pleuritis, pericarditis, angina, MI, cholecystitis, pancreatitis, adnexitis.

Lupus erythematosus Spondylo-arthropathy AVN

Cervical radiculopathy Tumor/Malignancy Thoracic outlet Brachial plexus neuropathy Trigger points Post CVA Glenohumeral instability Humeral subluxation

Charlie Cotterill

  • Evidence suggests that the condition is not self-limiting.
  • Systematic review of manual and physical therapy treatment in SIS by Desmeules et al. revealed only 7 RCTs = Limited evidence to support the efficacy of physical therapy in SIS
  • Lack of uniformity in defining, evaluating, and treating SIS.
  • Supervised exercises appear to be preferable to arthroscopic surgery for patients with persistent shoulder impingement syndrome. Brox et al (1993)
  • A review of 8 RCTs evaluated the efficacy of corticosteroid injection in the rx of rotator cuff tendonitis (Koester et al). 2 of the 8 trials showed clinically relevant improvements in pain and range of motion in the injection groups as compared with placebo.
  • Two systematic reviews found ultrasound to be ineffective in the management of pain in the shoulder (Green and Heijden

Charlie Cotterill

scapula rehab
Scapula Rehab

“Living within a window”

Charlie Cotterill


Charlie Cotterill


Neer CS. Impingement lesions. Clin Orthop Rel Res. 1983;173:70 –77.

Neer, C. S. II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J. Bone Joint Surg. 54A:41–50, 1972; 22.

Neer, C. S. II and R. P. Welsh. The shoulder in sports. Orthop. Clin. North Am. 8:583–591, 1977.

Hawkins RJ, Brock RM, Abrams JS, Hobeika P. Acromioplasty for impingement with an intact Rotator cuff. J Bone Joint Surg Br. 1988; 70:795–797.

Michael C. Koester, MD, Michael S. George, MD, John E. Kuhn, MD Shoulder impingement syndromeThe American Journal of Medicine (2005) 118, 452–455

Brox JI et al Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome) BMJ 1993 Oct 9; 307:899-903.

Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD, Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am. 1996 Nov;78(11):1685-9. 

Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis. A double blind trial. Phys Ther1986;66:194–9.

Nykanen M. Pulsed ultrasound treatment of the shoulder. A randomised, double blind, placebo controlled trial. Scand J Rehabil Med1995;27:105–8.

Hasson S, Mundorf R, Barnes W, Williams J, Fujii M. Effect of pulsed ultrasound versus placebo on muscle soreness perception and muscular performance. Scand J Rehabil Med1990;22:199–205.

Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment and efficacy. Br Med J1998;316:354–60.

Charlie Cotterill


Kibler, W. Ben MD a; Uhl, Tim L. PhD, ATC, PT b; Maddux, Jackson W. Q. MD c; Brooks, Paul V. MD a; Zeller, Brian MS, ATC d; McMullen, John MS, ATC 2002. a Qualitative clinical evaluation of scapular dysfunction: A reliability study. Journal of Shoulder & Elbow Surgery. 11(6):550-556,

W. Ben Kibler, MD and John McMullen, ATC , 2003 Scapular Dyskinesis and Its Relation to Shoulder Pain, J Am Acad Orthop Surg, Vol 11, No 2,, 142-151.

Lewis. J, Green. A, Dekel. S, The Aetiology of subacromial impingement syndrome, Physiotherapy Sept 2001, vol 87, No 9, pg 453-468.

McKenna et al (2004) Inter-tester reliability of scapular pposition in junior elite swimmers, Physical therapy in sport 5, 146-155.

Van der Heijden GJMG, van der Windt DAWM, de Winter AF. Physiotherapy for patients with shoulder disorders: a systematic review of randomised controlled clinical trials. Br Med J1997;315:25–30.

C. A. Speed, Rheumatology 2001; 40: 1331-1336, Therapeutic ultrasound in soft tissue lesions

P Frost and JH Andersen, shoulder impingement syndrome in relation to Shoulder intensive workOccup. Environ. Med. 1999;56;494-498

Charlie Cotterill