Author: Mike Connors, PT, DPT, OCS
Subacromial Impingement Syndrome (SAIS) is defined as an encroachment of soft tissue structures, such as the supraspinatus tendon, under the coracoacromial arch of the shoulder in the subacomial space. With shoulder impingement, a multitude of factors contribute to the pinching of the supraspinatus tendon when the arm is elevated overhead. The main limitation associated with SAIS is pain that ultimately leads to loss of function over time.
In addition to pain, damage can also occur to the supraspinatus tendon from chronic encroachment against the undersurface of the acromion. Alterations in rotator cuff muscle biomechanics and function diminishes their ability to provide the appropriate level of stability required in the shoulder to prevent impingement from occurring. The common pain presentation associated with SAIS is a radiation of pain from the acromion down the lateral aspect of the upper arm. In some acute and highly irritable circumstances, the pain can radiate into the forearm as a result of the impingement in the shoulder. Aside from the supraspinatus muscle, the infraspinatus muscle can also be a source of pain generation with impingement syndrome. With variations in the function of the rotator cuff muscles, the infraspinatus becomes involved as a pain generator not resulting from the encroachment but rather the alterations in the function of the musculature.
Along with the contributions of the rotator cuff musculature to shoulder impingement, the scapulothoracic articulation also has causative factors that predispose a patient to subacromial encroachment. With SAIS, a commonly observed finding is a shoulder girdle that is pulled inferiorly, anteriorly, and into scapular protraction due to a shortening of the pectoralis muscle. When the shoulder girdle, including the scapulothoracic joint, is pulled into this new position, the resulting effect is a decrease of the subacromial space thus putting the supraspinatus tendon at an increased risk for impingement. Alterations in the position of the scapula and the shoulder girdle lead to changes in the function of the scapular stabilizer muscles which further results in aberrant shoulder biomechanics.
How can dry needling be utilized as an adjunctive intervention?
The current evidence based standard of care for the clinical management of SAIS includes therapeutic exercise and manual therapy. There have been a multitude of studies that have examined the most efficacious exercises to manage SAIS, with a consensus on directly addressing the shoulder muscle length and strength deficits typically resulting from the impingement. The manual therapy interventions noted to be effective in managing SAIS are techniques aimed at improving mobility of the glenohumeral joint and the cervicothoracic junction.
Dry needling as a manual therapy technique can be very effective when utilized as an adjunctive intervention in managing impingement syndrome. I see a fair amount of shoulder patients in my clinical practice and have focused on studying the efficacy of certain exercise and spinal manipulation in the management of SAIS in my doctoral dissertation work. With such a strong interest in managing shoulder dysfunction, I am constantly challenging the current standard of care for SAIS to decrease the morbidity and recurrence rate of the condition. After taking the Functional Dry Needling® course series through KinetaCore®, I felt confident incorporating dry needling into my standard of care in the management of SAIS.
Utilizing the knowledge attained from the courses as well as some clinical logic, I began to address impingement syndrome as a more comprehensive chain that includes the shoulder, cervicothoracic junction, and scapula. It is obvious that all of these structures are linked through an anatomical connection but so often they are treated in isolation of one another as the patient presenting with shoulder pain is treated in the primary area of complaint. By addressing SAIS with a multiregional approach, I have reduced the incidence of morbidity as well as the recurrence rate in my patients with impingement syndrome.
With this approach, I now treat patients with SAIS with a slightly different approach using a combination of dry needling, spinal manipulation, and therapeutic exercise. I begin by dry needling the paraspinals of the CT junction, followed by the supraspinatus, infraspinatus, upper trapezius, and lateral deltoid. By addressing this soft tissue dysfunction with the goal of facilitating the activity of the rotator cuff musculature, I have noted an increase in muscle activation post needling that has contributed to the success in managing this difficult pathology. Following the dry needling, I manipulate the CT junction and the upper thoracic spine, which results in improved spinal mobility as well as an increase in enhancement of the neuromusculoskeletal system. Lastly, I utilize a comprehensive exercise program aimed at normalizing shoulder biomechanics. I have noted both improvements in range of motion as well as strength at the shoulder in a more expedited pace than without using dry needling.
I do not want to advocate for a one size fits all cookie cutter approach but feel that when you have a good system that works, it is totally appropriate to develop care pathways to manage that clinical condition. This expedited outcome provides evidence that we can realize an enhancement to our treatment effect when utilizing dry needling as an adjunctive intervention in the clinical management of SAIS.
Keep challenging the status quo!
- Ardic F, Kahraman Y, Kacar M, Kahraman MC, Findikoglu G. (2006). Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. American Journal of Physical Medicine & Rehabilitation, 85(1), 53-60.
- Bang MD, Deyle GD. (2000). Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients with Shoulder Impingement Syndrome. Journal of Orthopaedic & Sports Physical Therapy, 30(3), 126-137.
- liani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. (1991). The relationship of acromial archicture to rotator cuff disease. Clin Sports Med, 10, 823-838.
- Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JF, Koppenhaver SL, Wainner RS. (2009). The short-term effect of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy, 14, 375-380.
- Brossmann J, Preidler KW, Pedowitz RA, White LM, Trudell D, Resnick D. (1996). Shoulder impingement syndrome: influence of shoulder position on rotator cuff impingement–an anatomic study. American Journal of Roentgenology, 167(6), 1511-1515.
- Chester R, Smith TO, Hooper L, Dixon J. (2010). The impact of subacromial impingement syndrome on muscle activity patterns of the shoudler complex: a systematic review of electromyographic studies. BMC Musculoskeletal Disorders, 11, 1-12.
- Conroy, DE., and Hayes KW. (1998). The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy, 28(1), 3-14.
- Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. (2003). Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. American Journal of Sports Medicine, 31(4), 542-549.
- Desmeules F , Côté CH, and Frémont P. (2003). Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Clinical journal of sport medicine, 13(3), 176-182.
- Ellenbecker, TS., and Cools A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. British journal of sports medicine, 44(5), 319-327.