Shoulder impingement in an x-ray technician
A 50-year-old female x-ray technician presents with weakness on shoulder flexion and pain in her right A-C joint on 90 degrees flexion. After taking a complete history, you determine that this shoulder problem is of insidious onset.
On evaluation, you quickly rule out any serious problems indicated by red flags and diagnoses that simply must not be missed: radiculopathy of various etiologies, tumor, A-C tears, etc.
Resisted isometric muscle strength testing of the rotator cuff muscles show that she appears to be slightly weak only in the position of scaption, or the “empty can” test,’ suggesting that her supraspinatus muscle is weak. Active and passive range-of-motion demonstrate limitation in external rotation (tested with the arm abducted to 90 degrees, elbow flexed to 90 degrees and palm facing anteriorly), as well as pain at 90 degrees of forward flexion (also known as vertical or horizontal flexion).
You ask her to demonstrate some of her activities of daily living, whereupon she shows you how she reaches over her head and pulls and pushes the horizontal x-ray bucky while at work. The shoulder position moves from 160 degrees flexion with the elbow extended, to 90 degrees of abduction with the elbow bent at 90 degrees, in a position of external rotation-with her hand over her head and shoulder while she is pulling on a heavy apparatus. She explains that the machine weighs over 100 lbs. and is resistant to movement due to faulty lubrication and old metal parts. This demonstration of her daily movements makes it obvious to you that she is exacerbating her problem with this motion.
Your diagnosis is impingement syndrome of insidious onset with restricted shoulder movement in both forward flexion and external rotation. For the treatment of shoulder restrictions, the primary-if not exclusive-method many of us learned for adjusting the shoulder involved thrusting through the arm, from the elbow to the shoulder, by bracing the posterior aspect of the patient’s shoulder against the doctor’s chest or shoulder. If the fixation was in external rotation, then the patient’s arm was to be in external rotation during this adjustment procedure. Although there is certainly a time and a place for this procedure, I do not feel it appropriate to use it as something of a “one-size-fits-all” maneuver.
Impingement syndrome was once only thought to be a frictional irritation of the structures as they passed through the subacromial outlet. Current literature suggests that there is a tension overload in the shoulder joint that causes fatigue, injury, and weakness of the rotator cuff muscles. This, in turn, causes instability and an impingement by the humeral head against the roof of the glenohumeral joint. The above-described adjustive procedure can increase the symptoms of impingement.
The alternative chiropractic adjustive procedure that I have begun using with great success on this type of shoulder diagnosis is to apply a force that decreases the superior position of the humerus in the glenohumeral joint, while addressing any other restrictions. The treatment approach begins with putting the arm in 90 degrees of flexion with the elbow bent, so that the patient’s hand almost rests on her shoulder. I also place her arm in a position of external rotation in order to decrease her external rotation restrictions. I then put one hand under the elbow for stabilization (on the posterior aspect of the arm). The other hand is placed just inferior and anterior to the A-C joint (see Figure 1). The thrust is anterior to posterior, although because of the position of the patient’s arm, it looks as though it were superior to inferior. The thrust should be minimal, and need not be accompanied by an audible (osseous) release, or cavitation event. In any case, the thrust is just forceful enough to release any adhesions, but not so forceful as to cause any tears or create instability. The patient who should not receive this adjustive method is one with anterior or inferior shoulder instability.
I follow the adjustments with PNF (proprioceptive neuromuscular facilitation) or reciprocal inhibition, using a cycle of 20 percent resisted isometric or isokinetic contractions and stretches in all the ranges of motion (see Figure 2). It is important to always end with a contraction to avoid a reflex spasm. After completing a number of PNF contract-stretch cycles, I move the body part through a passive range of motion. Then, I have the patient accomplish active range-of-motion exercises in all physiological ranges to reset the muscles. This allows continued increased range of motion after the office visit. In the case of the shoulder, I find reciprocal inhibition to be the most effective. It involves PNF for both the agonist and the antagonist, followed by a stretch of the agonist. The patient is set up in the “howdy” position (arm abducted to 90 degrees, elbow flexed to 90 degrees, palm facing anteriorly). I have the patient contract (at 10 to 20 percent contraction) the agonists and the antagonists of external rotation. I grasp the elbow and place my hand on the patient’s. It is necessary to check at the elbow to make sure no other muscles are helping in the contraction of the external rotators. This means the patient will push gently against my hand with her palm (antagonist) for about 10 seconds, and then against my hand with the back of her hand (agonist) for about 10 seconds. I follow this with a passive stretch of the arm into external rotation. It is amazing to see a patient who had almost no external rotation, as shown by an inability to move her hand posterior to her ear from this “howdy” position, become able to move her hand 5″ to 10″ posterior to her ear. This is an increase in external rotation of about 10 to 25 degrees.
To best help patients, it is important to customize adjustments and ancillary techniques for the exact diagnostic entity with which they present. It is essential to incorporate specific myofascial release techniques to provide a whole approach in chiropractic care. Patients who are given this kind of situation-specific treatment will appreciate your care and ingenuity and will no doubt be a great referral base for your future practice.
1. Souza T. Sports Injuries of the shoulder. New York: Churchill Livingstone; 1994.
Dr. Lew is a part-time instructor at Palmer College of Chiropractic West, where she teaches chiropractic technique and rehabilitation methods. She may be reached at
This column is coordinated by Dr. Robert Cooperstein at Palmer College of Chiropractic West. Submissions for this column may be sent to firstname.lastname@example.org.
Copyright American Chiropractic Association May 2001
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