Impingement syndrome is a complex of interrelated and interdependent dysfunctions of the muscular and tendon-muscular apparatus of the shoulder joint.
Impingement syndrome is a complex of interrelated and interdependent dysfunctions of the muscular and tendon-muscular apparatus of the shoulder joint. The leading cause of such disorders is disease and damage to the rotator cuffs. The term “impingement syndrome” belongs to the American surgeon CS Neer and dates back to 1972.
External impingement syndrome is pathological changes in the soft tissue structures surrounding the shoulder joint. Some orthopedists distinguish “internal impingement syndrome” - a posterosuperior version of the syndrome associated with a rupture of the articular labrum; it often develops in athletes.
Inflammation of the bursa and its hypertrophy lead to a decrease in the subacromial space and pain when moving the arms above the head. Hypertrophy of the coracoacromial ligament is also a cause of decreased subacromial space and subsequent impingement .
Impingement syndrome is a common cause of shoulder that limits daily activities and sports activities. The pain resulting from impingement is localized in the area of the anterior outer part of the acromion process.
Patient complaints
Patients often note a gradual increase in pathological manifestations in the shoulder joint , which appear when actively working above the head or threading an arm through a coat. Weakness and limitation of movements in the shoulder joint often occur due to pain. A number of patients complain of sudden pain when exposed to trauma or learning a new sport. Patients often report pain at night and experience discomfort if they try to sleep on their sore shoulder. The range of motion sometimes decreases until a “frozen” shoulder forms.
Diagnosis F12.0 Acute intoxication
A condition caused by the use of a psychoactive substance, manifested by disturbances in consciousness, cognition, perception, emotions and behavior, or other psychophysiological functions and reactions. These disturbances are directly related to the acute pharmacological action of the substance and after some time completely disappear, except in cases where tissue damage and other complications occur. Complications may include trauma, aspiration of vomit, delirium, coma, and convulsions. The nature of complications depends on the pharmacological class of the substance and the method of its administration. Acute intoxication during alcoholism Bad trips (drug intoxication) Alcohol intoxication NOS Pathological intoxication Disorders in the form of trance and obsession during intoxication caused by psychoactive substances
Clinical examination
In order for the clinical examination to be comprehensive, the patient must be wearing a shirt, which will allow the neck and shoulders to be examined and the condition of the muscles to be assessed. The examination begins with the cervical spine and the upper extremity girdle. Restriction of movements in the cervical spine, pain that occurs during provoking tests and radiates to the shoulder region may be signs of pathological changes in the tissues of the neck and should not be mistakenly regarded as manifestations of impingement syndrome . The contours of the shoulder joint and the condition of the muscles should be compared with the opposite side, noting signs of atrophy and changes in the contours of the shoulder girdle. These signs, determined at rest, may indicate the neurological nature of the movement disorder in the shoulder joint, which leads to the development of secondary impingement syndrome . Against the background of pain, there is a limitation of active anterior flexion and abduction of the shoulder.
Diagnostics
Impingement syndrome of the shoulder joint is diagnosed by an orthopedic traumatologist. After a detailed interview with the patient, a clinical examination is carried out using special stress tests. In this case, X-rays are not very informative, since they only show the condition of the bone tissue, and the muscles and tendons are not visible in the image. X-rays reveal calcifications and osteophytes, which suggests damage to the rotator cuff.
Computed tomography accurately assesses the condition of the bone. Magnetic resonance imaging helps to evaluate soft tissue formations, identify partial tears, signs of inflammation and other defects. MRI is the most informative method for diagnosing impingement syndrome.
Shoulder impingement syndrome often develops in athletes and people who regularly raise their arms due to professional duties. Shoulder injuries cause the development of this syndrome. Symptoms are pain and inability to function normally in the arm. Treatment is predominantly conservative; modern medicine uses shock wave therapy. In extreme cases, surgery is indicated. MRI, CT and radiography are used for diagnosis. Treatment with an orthopedic traumatologist is long-term, with a positive prognosis if you seek medical help in a timely manner.
Diagnostic tests
Neer test
It is considered positive if pain at the anterior and outer edge of the acromion occurs when the examiner stabilizes the scapula and performs passive anterior flexion of the shoulder during internal rotation.
The Hawkins-Kennedy test
is considered positive if pain occurs with anterior flexion of the shoulder to 90° and slight internal rotation.
Test "Painful arc"
considered positive when pain occurs between 60° and 120° during shoulder abduction.
Infraspinatus muscle test
is considered positive if, due to weakness and pain, the patient cannot resist or there is a symptom of lag in external rotation. When performing the test, the arm is located along the body and bent at the elbow joint. The patient is asked to resist the internal rotation force.
Yergason test
– increased pain in the area of the intertubercular groove with resistance to supination of the forearm.
Positive "anxiety" test
performed by passive abduction and external rotation of the arm.
If pain occurs and intensifies, the patient seeks to stop the study. Characteristic of internal impingement syndrome .
Gerber-Krushell test
– the patient places both arms behind his back in a position of internal rotation, and then raises them along the back. Informative in case of rupture of the subscapularis tendon.
With positive Hawkins-Kennedy, painful arch, and infraspinatus tests, the likelihood of impingement syndrome is greater than 95%. If these tests are negative, the probability is less than 24%.
Diagnostic confidence can be increased using the lidocaine test. A decrease in the severity of symptoms when performing provocative tests after an injection of lidocaine is confirmation of impingement syndrome .
The leading method is MRI, radiography of joints, ultrasound.
The mechanism of formation of impingement syndrome
The shoulder joint connects 3 bones – the humerus, the clavicle and the scapula. At the same time, on the upper edge of the scapula there is a small bone process - the acromion - which hangs like a visor over the joint. There is a gap between it and the head of the humerus (called the subacromial space). There are tendons of the muscles responsible for mobility in the shoulder - the so-called rotator cuff.
Normally, all elements of the joint are clearly adjusted to each other, but with age this harmony can be disrupted. One of the possible consequences of this is impingement syndrome, in which there is a narrowing of the subacromial space. As a result, when moving the arm, the tendons become pinched between the head of the humerus and the acromion, causing an attack of pain.
Theoretically, anyone can encounter a similar phenomenon, but some have a higher chance. Firstly, there is a congenital predisposition - a position or shape of the acromion that is different from the norm. Secondly, glenohumeral periarthritis can develop as a result of joint injury. The biggest risk group is those whose activities involve regular loads on the shoulder in a raised arm position. Humeral periarthritis is an occupational disease not only of painters or plasterers, but also of tennis players, volleyball players, etc.
Regular compression of the rotator cuff over many years leads to tendon injury. Inflammation develops, which stimulates the appearance on the surface of the acromion of bone growths (osteophytes), calcium deposits in the passing tendons. This, in turn, further narrows the subacromial space...
Treatment of impingement syndrome
The treatment complex includes: competent therapeutic exercises (mainly exercises aimed at stretching muscles), mandatory night splints with shoulder abduction, physiotherapeutic treatment, blockades with steroids.
Surgical treatment, arthroscopy (three main options): only treatment, consisting of sanitation of the tendon and attachment site; treatment in combination with acromioplasty and restoration of tendon integrity in combination with acromioplasty. Repair of collateral damage.
According to Azar, the concept of acromioplasty includes:
- resection of the acromiocoracoid ligament;
- removal of the anterior lip of the acromion;
- removal of the anterior part of the acromion to the anterior edge of the clavicle;
- resection of 1-1.5 cm of the acromial end of the clavicle in the presence of pronounced arthrosis changes in the acromial clavicular joint.
Postoperative rehabilitation takes up to 3 months and depends on the presence of concomitant pathology in the joint and the extent of surgical intervention.
Treatment
The initial course of the disease involves conservative treatment. Loads that cause pain should be avoided. Excellent results are shown by physiotherapeutic treatment, selection of anti-inflammatory and hormonal drugs in the subacromial zone. If this treatment does not help, pain and limited movement persist, then surgery with skin punctures (arthroscopy) is indicated. During surgery, resection and correction of bone growths are performed.
The duration of rehabilitation after surgery takes about a month. For the first 7 days after surgery, the patient uses a scarf orthosis. Sutures are removed two weeks after surgery. The treatment program is tailored to each patient; you should contact a doctor after the first symptoms or pain. In the past, the main methods of treatment were: spinal traction, manual therapy, physiotherapy, acupuncture, massage, and medication. Today, shock wave therapy is increasingly used.
Diagnosis F12.7 Residual and delayed psychotic disorders
A disorder in which disturbances in cognition, emotion, personality, or behavior caused by alcohol or a psychoactive substance may persist beyond the period during which the direct influence of the psychoactive substance is evident. The onset of the disorder must be directly related to the use of a psychoactive substance. Cases in which impairment occurs after an episode(s) of substance use should be coded with the above fourth character only when there is compelling evidence that residual effects of the substance are involved in the disorder. Residual phenomena can be distinguished from a psychotic state partly by their episodic nature, mostly of a very short duration, duplication of previous alcoholic or drug manifestations. Alcohol-induced dementia NOS Chronic alcoholic cerebral syndrome Dementia and other mild forms of persistent cognitive impairment Flashback Delayed-onset psychotic substance use disorder Perceptual impairment after hallucinogen use Residual: . emotional [affective] disorder. personality and behavior disorder Excluded: alcohol or drug use: . Korsakov's syndrome (F10-F19 with a common fourth sign of .6). psychotic state (F10-F19 with common fourth character .5)
Diagnosis F12.5 Psychotic disorder
A complex of psychotic symptoms that occur during or after the use of a psychoactive substance, which, however, cannot be explained solely by acute intoxication and which are not part of the withdrawal state. The disorder is characterized by hallucinations (usually auditory, but often of several types), perceptual disturbances, delusions (often paranoid or persecutory), psychomotor disturbances (excitement or stupor), and abnormal affect, ranging from intense fear to ecstasy. Consciousness is usually clear, but there may be some degree of clouding, but without severe confusion. Alcoholic: . hallucinosis. delirium of jealousy. paranoia. psychosis NOS Excludes: alcohol or other substance-induced residual and delayed psychotic disorders (F10-F19 with common fourth digit .7)
Diagnosis F12.2 Dependency syndrome
A complex of behavioral, cognitive and physiological symptoms that occurs after repeated use of a substance and usually includes a strong desire to take it; difficulties in controlling its use; persistent continuation of its use despite harmful consequences; preference for the use of psychoactive substances to the detriment of other activities and duties; an increase in permissible limits of use and sometimes a state of withdrawal. The dependence syndrome may be to a specific substance (eg, tobacco, alcohol, or diazepam), a class of substances (eg, opioid drugs), or to a wide range of pharmacologically distinct psychoactive substances. Chronic alcoholism Dipsomania Drug addiction
