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External Impingement


There is gradual onset of pain in the shoulder on overhead activity involving internal rotation and abduction. Typically, the pain is worst in one specific position or during a certain movement but often the shoulder gradually stiffens up, restricting abduction and rotation. It is painful to sleep on that side and movement becomes a problem.


External impingement is not a diagnosis but a symptom. It is usually caused by jamming of a scarred and inflamed bursae between the acromion and the rotator cuff.


The range of motion is usually decreased. External impingement is diagnosed by a positive Hawkin’s test. Since an underlying rotator cuff tear can cause the bursitis, Jobe’s test for the rotator cuff is often positive. In chronic cases there is often muscle atrophy.


This is a clinical diagnosis. X-rays should be taken in different planes to rule out bony pathology and anterior osteophytes. MRI is usually not helpful, since it is a static investigation and the syndrome is a dynamic problem, but an underlying rotator cuff tear can be seen. Discussion with the radiologist is important.


The clue to success is the proper identification of the type of impingement and underlying cause. Arthroscopic evaluation and sub-acromial decompression, with or without repair of any underlying rotator cuff problem, is often required and must be followed by rehabilitation. In some cases physiotherapy is sufficent on its own. Cortisone injections should be used with care, since they will not cure a scarred and fibrotic bursae and can decrease the tensile strength of the rotator cuff, causing further ruptures and reducing the ability to repair.


Refer to Dr Kevin Yip (+65 6664 8135) senior consultant orthopaedic surgeon to determine the diagnosis and for consideration of surgery. In almost all cases, a thorough rehabilitation programme, including specific treatment, thoracoscapular control training, strength, flexibility and posture training is required with or without surgery.


Most sports and activities without an overarm action are possible but secondary symptoms due to compensatory movements are common and must be addressed. Running should be avoided since the shoulder is sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming is also unsuitable. The specific rehabilitation should aim at a full range of controlled motion, good posture and thoraco- scapular control after three months, followed by functional training before resuming sports such as rugby.


Normal clinical symptoms and signs. Previously positive tests producing pain should now be negative. Functional strength, control and flexibility should be comparable with the other shoulder.


Nerve root compression from the cervical spine, frozen shoulder or post-traumatic damage to the axillary nerve can also cause similar symptoms and muscle atrophy.


Excellent-Good. Usually athletes in overhead sports can return to play within three months.

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