Unresolved Whiplash? – Look for Shoulder Impingment.

11/220 cases of whiplash, examined medico-legally for non-resolution, had comorbid subacromial impingment, many of which had been missed. This adds to the growing legion of real problems missed in whiplash cases.

J Orthop Surg. 2008 Jun 27;3(1):25. [Epub ahead of print]
Subacromial Impingement in patients with whiplash injury to the cervical spine.
Abbassian A, Giddins GE.

abstract here

Sealbelt injury is common in whiplash cases and 85% of the shoulder injury cases gave history of such.

Comment – the neck – shoulder post whiplash condition present an important diagnotic concern. How to distinguish it has been suggested by:

J Bone Joint Surg Am. 2003 Apr;85-A(4):635-8.
Shoulder impingement presenting as neck pain.
Gorski JM, Schwartz LH.

abstract here

they were tested the following way:

“The arm was moved through forward elevation to the full overhead position, both actively and passively, with the hand pronated. The patient was asked if pain was present in the shoulder or neck with the arm in the full overhead position. If the patient reported no pain in the shoulder, he or she was deemed to have a negative shoulder impingement sign. If pain in the neck was reported, the patient was deemed to have a positive “referred” shoulder impingement sign. The test was performed bilaterally, with both active and passive forward elevation of the shoulder up to 180°”

I found pain on passive elevation end range a very useful test. They followed up with subacromial injection done such:

“4 mL of lidocaine (2% plain) with 1 mL of methylprednisolone (40 mg/mL) was injected into the subacromial space of the shoulder through a posterior portal. This portal is identified by palpation of a “soft spot,” 1 cm inferior and 1 cm medial to the posterolateral corner of the acromion. ”

This doesn’t always get subacromial though:

The targeting accuracy of subacromial injection to the shoulder: An arthrographic evaluation . Arthroscopy: The Journal of Arthroscopic & Related Surgery , Volume 18 , Issue 8 , Pages 887 – 891K . Yamakado
his technique:
With the patient sitting in a chair, the injection point was 1 cm anteroinferior to the posterolateral
angle of the acromion. A 32-mm long, 22- gauge needle was used. This length is thought to be
sufficient to reach the subacromial bursa. The needle was angled 45° upward and inward in a direction lateral to the anterior edge of the acromioclavicle joint. A mixture of 0.5 mL (2.5 mg) betamethasone acetate, 3 mL radiographic contrast material (iotrolan), and 7 mL of 1% lidocaine was injected.

“were randomized to receive a subacromial injection of corticosteroids, local anesthetic, and contrast dye from 1 of 3 locations: anterolateral, lateral, or posterior…The overall accuracy was 70%, with no difference
among the 3 portals.Accuracy was not related to body mass index. Furthermore, accurate injections did not significantly improve the UCLA score, pain scale, or patient satisfaction at 3 months.”

This above seeming lack of efficacy was subject to a review:

Subacromial corticosteroid injections
Journal of Shoulder and Elbow Surgery, Volume 17, Issue 1, Supplement 1, January-February 2008, Pages S118-S130
Konrad I. Gruson, David E. Ruchelsman, Joseph D. Zuckerman”The disparity in the literature regarding the efficacy of subacromial corticosteroid injections appears
to be a product of study design variability. Duration of impingement symptoms before subacromial injection, the number of injections administered, the amount of medication injected, and use of adjunct NSAIDs and physiotherapy regimens vary among studies and thus limit the strength of conclusions.”

Lots of one shot MORON studies out there – the subscapularis and deltoid muslces are very strong perpetuators of the impingment. I can remember one case where the patient had a calcification in her supraspinatus that would catch on elevation. After I worked out the knots in the Deltoid – I was amazed to find there no longer was a catch. If there is not considerable work done on these and the Infraspinatus/Pect muscles then they desire to fail. The scapula is also held down and muslces about it need work too.

By the way, I massage out subscapularis muscles in the axilla and I have NEVER achieved a full release under 120 rubs. If you have a therapist rub let say ten times – they are wasting their and your time.

Another issue is whether there is rotator cuff injury as well. I have a case now that has suprspinatus tendonitis as well (with cervical radiculopathy) that is being deep frictioned (why do I have to spend 20 minutes twice a week doing what physios should be doing?)

Clinical or subclinical C5 radiculopathy is also associated with this and if you have a shoulder complaint associated with catching pain on neck rotation I would be very suspicious of such. Finding neck traction or Mackenzie techniques help the arm would help confirm that. Then you will achieve little with the shoulder without steroid epidurals or Enbrel shots cooling the radiculitis.
Often there is a double crunch issue with neck radiculopathy – there is usually some scalene spasm and that too causes enrapement, nerve root symptoms, (and spasm of muslces like deltoid that aggravate impingement) .

Having the big picture seen in whiplash is often missed because internal disc derangements (often multilevel) and facets syndromes image poorly or not at all.
I would be interested in others perspectives of this very difficult situation.