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Teori Impingement Syndrome

• Definition
Impingement syndrome also called painful arc
syndrome, supraspinatus syndrome, swimmer`
shoulder and thrower`s shoulder, is a clinical
syndrome which occurs when the tendons of the
rotator cuff muscles become irritates and inflamed as
they pass through the subacromial space, the
passage beneath the acromion.
 The rotator cuff muscle tendons pass through a narrow
space between the acromion process of the scapula and the
head of the humerus. Anything which causes further
narrowing of this space can result in impingement
syndrome. This can be caused by bony structures such as
subacromial spurs (bony projections from the acromion),
osteoarthritic spurs on the acromioclavicular joint, and
variations in the shape of the acromion. Thickening or
calcification of the coracoacromial ligament can also cause
impingement. Loss of function of the rotator cuff muscles,
due to injury or loss of strength, may cause the humerus to
move superiorly, resulting in impingement. Inflammation
and subsequent thickening of the subacromial bursa may
also cause impingement.[
• Impingement of the tendon, most commonly the
supraspinatus, under the acromion and the
greater tuberosity occurs with arm abduction and
internal rotation
• Impingement syndrome may progress to a
rotator cuff tear (complete or partial)
• Stages of subacromial impingement syndrome
Stage 1: Edema or hemorrhage—reversible (age
< 25)
Stage 2: Fibrosis and tendonitis (ages 25–40)
Stage 3: Acromioclavicular spur and rotator cuff
tear (Age > 40) (Miller, 2000)

1. Gleno – Humeral joint

2. Suprahumeral joint
3. Acromio – Clavicular joint
4. Scapulo – Costal joint
5. Sternal – Claviculo joint
6. Costo – Sternal joint
7. Costo – Vertebral joint
8. Biceps mechanism
Impingement Shoulder Syndrome
 •Pain during range of motion, specifically in repetitive overhead activities,
such as:
– Throwing a baseball
– Swimming (occurs at the catch phase of the overhead swimming stroke)
 Patients may feel crepitus, clicking, catching on overhead activities
 Pain may be referred anywhere along the deltoid musculature
 Weakness in forward flexion, abduction, and internal rotation indicating
impingement(Hawkins sign)
 inability to initiate abduction may indicate a rotator cuff tear
 Pain may be nocturnal. Patients often report having difficulty sleeping on
the affected side
 Tenderness over the greater tuberosity or inferior to the acromion on
 Atrophy of the involved muscle resulting in a gross deformity at the
respective area,
 usually seen in chronic tears
Provocative Tests
 Supraspinatus isolation test/empty can test: The
supraspinatus may be isolated by having the
patient rotate the upper extremity so that the
thumbs are pointing to the floor and apply
resistance with the arms in 30° of forward flexion
and 90° of abduction (assimilates emptying of a
 Neer’s impingement sign (Figure 4–21)
-Stabilize the scapula and passively flex the arm
forward greater than 90° eliciting pain
- Pain indicates the supraspinatus tendon is
compressing between the acromion and greater
Hawkins Impingement Sign (Figure 4–22)
• Stabilize the scapula and passively forward
flex (to 90°) the internally rotated arm eliciting
• A positive test indicates the supraspinatus
tendon is compressing against the
coracoacromial ligament
 Rotator cuff tests
Supraspinatus test
 Pain and weakness with arm flexion abduction and internal
rotation (thumbpointed down)
 With abduction the humerus will naturally externally
rotate. In assessing the integrity of the supraspinatus, the
patient should internally rotate the humerus, forcing the
greater tuberosity under the acromion. In this position, the
maximum amount of abduction is to 120°
Drop arm test
 The arm is passively abducted to 90° and internally rotated
 The patient is unable to maintain the arm in abduction with
or without a force applied Initially the deltoid will assist in
abduction but fails quickly
 This indicates a complete tear of the
Apley Scratch test
•To test the Active
ROM of the
a. Add-Endo
b. Abd-Exo
c. Add-Exo
Impingement, chronic-partial and full tears
Conservative: Rehabilitation
• Acute phase (up to 4 weeks)
- Relative rest: Avoid any activity that aggravates the
-Reduce pain and inflammation
- Modalities: Ultrasound iontophoresis
- Reestablish nonpainful and scapulohumeral range of
- Retard muscle atrophy of the entire upper extremity
- full pain-free ROM
• Recovery phase (months) (up to 6 months)
- Improve upper extremity range of motion and proprioception
-Full pain-free ROM
-Improve rotator cuff (supraspinatus) and scapular stabilizers
-Assess single planes of motion in activity related exercises
• Functional phase
- Continue strengthening increasing power and endurance
-Activity-specific training
• Corticosteroid injection: Only up to three yearly
• May weaken the collagen tissue leading to more microtrauma
-Activity-specific training
-Corticosteroid injection: Only up to three yearly
- May weaken the collagen tissue leading to more
• Indications
- Full thickness or partial tears that fail
conservative treatment
- Reduction or elimination of impingement pain is
the primary indication for surgical repair in
chronic rotator cuff tears. The patient should be
made aware that restoration of abduction is less
predictable than relief of pain
Shoulder Exercise –
Towel Exercise
Finger Ladder Exercise