Impingement Syndrome and Adhesive Capsulitis

by Sheldon C. Yao, DO

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    00:01 Impingement syndromes are syndromes where the rotator cuff tendon becomes inflamed, or the subacromial bursa or other soft tissues are trapped or impinged in that suprahumeral joint.

    00:14 So, right above the humerus, you have many different structures that pass in that area including the supraspinatus tendon.

    00:22 So, if you have an inflammation of the bursa there, if you have irritation or thickening of the capsule, if you have that tendon thickened or calcifications that occur at the humerus, that could potentially compress with certain motions of the shoulder.

    00:38 Sometimes if you have a recent fall or trauma, that could also irritate the region.

    00:46 Special tests include the Neer’s Test or Hawkins' Test.

    00:49 Both of these tests induce internal rotation and abduction or flexion which compresses that suprahumeral space.

    00:58 So, a positive test would recreate pain.

    01:01 Usually if someone has an impingement syndrome, medical management includes taking anti-inflammatories, rest.

    01:08 Ice could sometimes decrease some of the inflammation.

    01:11 Osteopathic treatment could be used to help decrease some of the muscles in the area.

    01:16 Certain treatments can help improve drainage and help with decreasing any sort of edema that might be in the region, and trying to remove restrictions to try to improve range of motion of the shoulder.

    01:29 So, one of the tests that we could perform to check for impingement syndrome is the Neer’s Test.

    01:36 The mnemonic to kind of remember Neer is that you're moving the shoulder joint near to the ear.

    01:41 So here, what we're going to do is going to internally rotate the patient's arm and then passively flex the arm until the hand is above the head.

    01:52 The suprahumeral space when you internally rotate and add flexion to the joint will be compressed.

    01:58 So, you're mimicking the impingement there.

    02:02 If there is impingement of the structures or the rotator cuff muscle there, the patient will have pain with the test.

    02:09 So, positive test is complaints of pain or really being unable to do the test secondary to pain.

    02:15 The Hawkins' test is a test for impingement of the rotator cuff.

    02:20 Here, we're going to start with flexion of the elbow to 90 degrees and then add internal rotation of the shoulder.

    02:27 When you add internal rotation to an already flexed shoulder, you're actually compressing the humerus and closing that suprahumeral space.

    02:35 So, a positive test is if a patient complains of pain or is unable to perform that motion in the region.

    02:43 Adhesive capsulitis is also known as frozen shoulder.

    02:46 This is an inflammatory process that results from immobilization.

    02:51 So, our shoulder joint has a lot of freedom of motion.

    02:55 Due to that freedom of motion, there is a lot of excessive tissue and fascia in the region.

    03:00 If we immobilize the shoulder for a prolonged period of time, all that tissue becomes bundled up.

    03:05 It could start to kind of stick together.

    03:09 So, it is important to try to mobilize the shoulder when we can especially after any sort of immobilization like a patient being in a sling, or being bedridden, or in a hospital bed for a while and not really moving their joints.

    03:22 Diabetic patients have an increased risk of developing adhesive capsulitis.

    03:27 If you do have it, it has a real significant effect on your activities of daily living and really prevention is the key.

    03:34 So, after any sort of immobilization, we want to get the shoulder moving and going through different exercises or therapies as soon as we can.

    03:43 One way to screen for this is to have the patient perform what's called the Apley’s scratch test.

    03:50 It is an active range of motion test where you're taking the shoulder do different motions and movements to quickly screen and compare sides to see if the patient has a decrease in range of motion.

    04:00 Osteopathic manipulation could help with freeing up some of that tissue, getting the shoulder moving better through the range of motion.

    04:09 So, a special test that we could perform to screen for range of motion of the shoulder is the Apley’s scratch test.

    04:17 What this will screen for is if the patient has any problem with moving their shoulder in a certain plane or direction.

    04:24 So, what we ask the patient to do is to do three different steps.

    04:29 First, we ask them to reach across their chest over their shoulder and try to touch their opposite scapula.

    04:34 Then we ask them to reach behind their back and touch the opposite scapula.

    04:39 Then they reach behind their head and try to touch the scapula on the opposite side of the arm.

    04:46 As you're doing these different motions, you're comparing the motion and mobility on both sides and how far can they reach in terms of touching the scapula.

    04:55 A positive test would be if they're unable to reach equal levels on each side.

    04:59 Osteopathic considerations in adhesive capsulitis: One of the techniques that we could potentially use to treat patients with adhesive capsulitis is muscle energy.

    05:10 Muscle energy technique could be applied to a wide range of issues and complaints.

    05:14 But what we could do here is to try to restore the muscle’s normal length and remove any restrictions in motions.

    05:20 How we perform muscle energy is that we localize the joint and we want to try to engage the muscle that is spasmed.

    05:28 We have to take that joint and put it into its barrier of motion in all planes.

    05:32 Let's say my shoulder is restricted in abduction.

    05:35 The physician will place the shoulder first into the joint barrier.

    05:41 Then we're going to ask the patient to move that joint towards its relative freedom.

    05:46 So, if my barrier was abduction, my freedom would be adduction.

    05:49 So then, I would contract my muscles isometrically, meaning that my joint doesn't move for three to five seconds.

    05:58 After that, the patient relaxes and then you should be able to move that joint a little bit further into its new barrier.

    06:05 Then you repeat the steps three to five times.

    06:08 This is using the Golgi tendon reflex.

    06:10 It pretty much almost like exhausts the muscle so that you could stretch the muscle a little bit further.

    06:15 At the end, you want to add a little bit of a passive stretch in order to increase the range of motion at that joint.

    06:24 Another technique that could be used for adhesive capsulitis is Spencer's technique.

    06:30 This is an articulatory technique to increase range of motion of the shoulder.

    06:34 I remember that articulatory techniques are techniques that just repetitively take the joint gently into the barrier.

    06:39 So, what we're going to do is we're going to gently spring the joint into the barrier similar to where you would put the joint to when you're putting somebody into the barrier for muscle energy technique.

    06:52 In fact, you could actually add muscle energy technique to the end of each of these motions to help enhance this technique.

    06:59 So, adhesive capsulitis has a restriction of motion of the shoulder joint.

    07:05 Spencer’s technique, what it does is really moves the joint into every possible plane of motion to try to increase the range of motion of the shoulder joint.

    07:15 The motions include extension, flexion, circumduction, circumduction with traction, abduction, internal rotation, and then glenohumeral traction.

    07:24 What you're going to do is you're going to gently engage the barrier of motion each time for seven times. Then you're going to perform this technique in this sequence.

    07:34 So usually, you could utilize Spencer's technique for any sort of issue with the shoulder where there's a restriction of motion.

    07:41 Not only adhesive capsulitis but you could also treat it and use this technique to treat any other issues going around the glenohumeral joints.

    07:48 It actually will help treat issues with the rib cage, the clavicle, and thoracic spine because of the muscles that attach through the shoulder joint also.

    About the Lecture

    The lecture Impingement Syndrome and Adhesive Capsulitis by Sheldon C. Yao, DO is from the course Osteopathic Diagnosis of the Shoulder Region. It contains the following chapters:

    • Impingement Syndrome
    • Neer Sign and Hawkin`s Test
    • Adhesive Capsulitis (Frozen Shoulder)
    • Apley`s Scratch Test

    Included Quiz Questions

    1. Flexion then internal rotation
    2. Adduction then internal rotation
    3. Flexion then external rotation
    4. Extension then external rotation
    5. Flexion
    1. Subacromial space or suprahumeral space
    2. Coracoid process
    3. Axillary pouch
    4. Costoclavicular space
    5. Glenoid labrum
    1. 90 degrees
    2. 45 degrees
    3. 120 degrees
    4. 130 degrees
    5. 180 degrees
    1. Diabetes
    2. Hypertension
    3. Rheumatoid arthritis
    4. Systemic lupus erythematosus
    5. Osteomyelitis

    Author of lecture Impingement Syndrome and Adhesive Capsulitis

     Sheldon C. Yao, DO

    Sheldon C. Yao, DO

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