- Classic Neer Impingment Sign:
- is tested by having the patient place his hand on the unaffected shoulder and gradually forward flexing the shoulder;
- impingement sign is elicited w/ pt seated and the examiner standing;
- scapular rotation is prevented w/ one hand while other hand raises arm in forced foward elevation causing greater tuberosity to impinge against the acromion;
- raise the arm somewhere between flexion and abduction;
- this maneuver produces pain in pts w/ impingement lesions of all stages (as well as partial frozen shoulder, instability, arthritis ect.)
- if this motion is painful at 90 degrees of forward flexion it is a positive sign for impingement (primary impingement sign);
- pain during abduction of the arm to 80 deg and internal rotation is a secondary impingement sign;
-
Hawkins modification:
- looks for impingement in the plane of the scapula (which brings the greater tuberosity directly under the CA ligment);
- forward flex the humerus and forcefully internally rotate the humerus;
- this test may help determine whether the CA ligament is contributing to the impingement;
- Impingement Test:
- while the impignement sign will be positive in other shoulder conditions, injection of 10 cc of 1%
lidocaine beneath anterior acromion will relieve pain in the
case of an impingement syndrome;
- note that this injection can also give the surgeon an idea of the patient's pain tolerance;
- if there is excessive pain during the injection, then there may be excessive pain following surgery;
-
steroids:
- consider adding steroids to the injection to provide the patient w/ long term relief as well as to better confirm the diagnosis;
- most patients w/ primary subacromial impingement will receive several months of good pain relief w/ steroid injection;
- if patients do not recieve relief, then consider another diagnosis such as
AC joint arthrosis or secondary impingment;
- consider adding 1 ml of
triamcinolone
- hexacetonide is used for large joints, may cause hypopigmentation but has long lasting effect
- acetonide is for small and medium sized joints;
-
cautions: steroid injection may be contraindicated in brittle diabetic patients;
The accuracy of subacromial injections: a prospective randomized magnetic resonance imaging study.
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