Evaluation and Treatment of Shoulder Impingement in Overhead Athletes

Evaluation and Treatment of Shoulder Impingement in Overhead Athletes

Susie Williams

Overview

Throwing athletes need full, unrestricted arm function to perform optimally in their sport¹. The throwing shoulder in baseball players demands considerable attention in the orthopedic and sports medicine community because of the frequency with which it is injured. Professional baseball pitchers are at risk for a number of injuries, yet 28% of these occur within the shoulder^2,3. Upper extremity injuries in collegiate baseball players’ account for 75% of time lost from the sport as a result of injury, with the pitcher being the most often injured position^2,3. Common injuries include impingement syndrome, rotator cuff pathology, biceps tendonitis, shoulder instability, labral tear, or acromioclavicular joint disruption; however, the most common cause of shoulder injury in any overhead athlete is impingement syndrome¹.

For my capstone, I want to present an educational review of shoulder impingement, diagnosis, and treatment for entry-level PTs and experienced clinicians.  Personally, I am very interested and vested in this topic as I have just recently managed and controlled symptoms of subacromial impingement that have effected me for nearly 4 years due to weight lifting. I went to physical therapy multiple times and at two different clinics. At both clinics I was treated with light resistance bands to strengthen my rotator cuff and core exercises, but was not progressed properly to return me to weight lifting and was not taught proper progression of exercises, management nor stretching techniques that may have been useful. After learning about the shoulder joint and this pathology along with special tests in our Musculoskeletal I course, I observed the special tests in the clinic were often inconclusive and disregarded. Furthermore, when discussing with classmates, many of them agreed that while we learned the shoulder and special tests, a shoulder patient in the clinic is very intimidating as there are multiple pathologies with overlapping and inconsistent results from special tests and that treatment of all injuries typically looked the same. In our Evidence-Based Practice II course in the fall of our third year, I decided to delve deeper into shoulder impingement and look for potential causes and treatment for this pathology as it related to the overhead athlete, specifically elite baseball players, by asking and answering the PICO question: For collegiate and professional baseball players with subacromial impingement, will increasing strength training of the external rotation muscles at the shoulder and reducing posterior capsule tightness be more effective than rest at minimizing lost days of play? Even after compiling research and writing a Research Paper on this, I still wasn’t satisfied with what I found.

The research for this Capstone project was centered on understanding all the factors that play into the rehabilitation process for shoulder impingement: What factors have predisposed this patient to shoulder impingement? Which anatomical structures and joint arthrokinematics are most critical to analyze and how is this done? Which special tests provide the strongest psychometric properties when clustered together to most accurately diagnose shoulder impingement? Which rehab techniques, strengthening exercises, and stretches will be most useful to manage symptoms and reverse pathology for the patient? Which outcome measures are psychometrically appropriate for these athletes? What other patient-related and rehab factors must we consider for the resolution of the impingement and a safe return to activity or sport?

Literature Review

To help answer these questions, I continued to do a review of the current evidence and literature. I researched studies that addressed not only the cause of shoulder impingement in the overhead athlete, but those that also addressed different interventions and examination. The results of these studies that specifically addressed my PICO question can be found in my Evidence Table.

Through this research, I created a Power Point presentation I intend to present as an inservice at my future clinical site, Proaxis Therapy in Greer, SC.  After feedback was received (and is compiled here) I  also created a Voice Thread lecture (in the browse tool bar, search “Evaluation and Treatment of Shoulder Impingement in Overhead Athletes”) that will be available to UNC faculty and students to supplement the knowledge they gain through the present curriculum. In addition to feedback I received, I compiled a Handout for clinicians that reviews a CPR for identifying impingement and special test clusters for determining the severity of rotator cuff disease present in your patient. In order to maximize the effectiveness of my lecture, I reviewed resources on the effectiveness of instruction during presentations. What I really took from this is the importance of considering what my audience already knows and figuring out how to engage their attention. As I am presenting my powerpoint as an inservice to experience clinicians, some of whom do research on the very topic I am presenting on, I intend to focus less on the anatomy and background of the shoulder and glenohumeral complex, as much of this is a review to the audience.  I also wanted to ensure that my presentation required the listeners to actively integrate the information I am presenting with what they already know. To help them become more engaged, I added of reflective questions and summaries after each section.

Feedback and a Special Thanks

I would like to say thank you to all of those who served on my committee and gave me invaluable feedback throughout my evidence search, material development, and evaluation. I appreciated the guidance you all supplied throughout the semester and the time you devoted to help me with this process. Thank you to Mike Gross, Jon Hacke, Mike McMorris, Kristen Mason, Morven Ross, and Daniel Blackmon.

For those of you who would like to provide additional feedback for further development, please do so using this Feedback Form and the comments box below.

References

1. Kennedy DJ, Visco CJ, Press J. Current Concepts for Shoulder Training in the Overhead Athlete. Curr Sports Med Rep. 2009;8(3):154-160
2. Wilk K, Macrina L, Arrigo C. Passive Range of Motion Characteristics in the Overhead Baseball Pitcher and Their Implications for Rehabilitation. Clinical Orthopaedics and Related Research. 2012;470(6):1586-1594.
3. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329-335.