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Intrinsic Factors

Intrinsic factors, such as degenerative changes within the rotator cuff tendons, are likely to cause problems because of subsequent weakness causing superior migration of the humerus, thus producing a secondary mechanical impingement.


– Grade 1: pretear condition with subacromial bursitis and/or tendinitis.
– Grade 2: impingement with partial rotator cuff tears.

Symptoms and diagnosis

– When the arm is used for overhead activities and is lifted above the horizontal plane, pain is located at the lateral and upper part of the shoulder.
– When the arm is above 90° of abduction (elevated to the side), the athlete will often substitute scapulothoracic motion for glenohumeral motion—i.e. will use the shoulder blade more than normally.
This can be seen to hunch the affected shoulder up during abduction of the arm. The pain is often worse after the arm is lowered than when it is raised.
– Pain occurs at night, especially if there is involvement of the rotator cuff.
– Tenderness can be felt in the upper aspect of the head of the humerus, and also over the biceps tendon.
– Active range of motion can be limited in abduction and forward flexion secondary to pain, especially above shoulder level. There may be a subtle loss of internal rotation.
– Crepitus can be palpable in the subacromial region.
– Hypotrophy of the deltoid and the spine muscles may be present.
– Impingement tests will, if positive, verify the diagnosis.

Plain X-rays, including an anteroposterior view of the glenohumeral joint (that is, an internal rotation view of the humerus with 20° upward angulation to show the acromioclavicular joint), an axillary lateral view,
and the supraspinatus outlet or arch view, will show the subacromial morphology well.

Preventive measures

– Perform warm-up exercises and flexibility training.
– Exercise the whole kinetic chain, including strength training.
– Avoid abuse (pain-causing situations).


The athlete should:
– carry out active movements of the shoulder and maintain range of motion;
– keep up conditioning exercises;
– apply local heat and use a heat retainer after the acute phase;
– resume sports training gradually when the pain has resolved.

The doctor may:
– give instructions for specific strengthening and stretching programs. A maintenance program to prevent loss of motion and stiffness is important;
– prescribe anti-inflammatory medication;
– use steroid injections selectively (when local steroids are justified, the injection should be followed by a few days of rest);
– operate if conservative therapy fails.

As long as the patient is making progress and other significant lesions do not exist, conservative treatment should be continued. If a plateau is reached, surgery may be indicated. A subacromial decompression
includes removal of the bursa and the undersurface of the acromion which can create more space for the soft tissues. The surgery can be performed with the aid of an arthroscope. In the elderly, more extensive
measures may be necessary. After surgery, early mobilization with active strength training is recommended. A return to overhead sports is often possible 2–3 months after surgery.

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