Impingement Syndrome

Mohammad Ali Tahririan

Department of Orthopedics

Kashani Hospital

History

Jarjavavy 1867 Subacromial bursitis

Codman 1931 Supraspinatus rupture

Neer 1972 Impingement syndrome

Pain, weakness and loss of motion are the most common symptoms reported.

Minor pain that is present both with activity and at rest

Pain radiating from the front of the shoulder to the side of the arm

Pain is exacerbated by overhead or above-the-shoulder activities.

A frequent complaint is night pain, often disturbing sleep, particularly when the patient lies on the affected shoulder.

The onset of symptoms may be acute, following an injury, or insidious, particularly in older patients, where no specific injury occurs.

History

Impingement Syndrome

1) Primary impingement

2) Secondary impingement

3) Internal impingement

4) Subcoracoid

impingement

Primary impingement

• Usually older than 40 years, • complain of anterior shoulder and upper lateral arm

pain, with an inability to sleep on the affected side.• They have complaints of “shoulder weakness,” and

difficulty performing overhead activities.

Primary impingement

• On physical examination, patients may exhibit a loss of motion or weakness of rotator cuff strength secondary to pain.

• They will usually have a positive Hawkins sign and a positive impingement sign as described by Neer.

• The impingement test is performed by injecting 10 ml of 1% lidocaine into the subacromial space

Primary impingement

• Intrinsic type

• Extrinsic type

• Tendinopathy(thickening of the RC)

• Calcific tendinitis• Subacromial bursitis

.Subacromial spur

.Acromial fracture

.Os acromiale

.ACJ arthritis

.Exostoses of the GT

Calcific tendinitis

Calcific tendinitis is a painful, largely self-limited disorder of the rotator cuff in which the tendons are infiltrated with calcium deposits.

This condition most frequently affects the rotator cuff of the shoulder.

supraspinatus - 80% infraspinatus - 15% subscapularis - 5% periarticular soft tissues in addition to tendons ligaments capsule bursae

Calcific tendinitis

Location

Calcific tendinitis

Mostly asymptomaticOlder than 30 y10% of population10% bilaterallyF ˃ M

Calcific tendinitis

Phase I—precalcification stage

Phase II—calcification stage

Phase III—postcalcification phase

phase of formation

resting phase

resorptive phase Painful

Calcific tendinitis

Nonoperative management is the initial treatment of choice.

Nonoperative treatment usually includes physical therapy, exercises, anti inflammatory medications, and steroid injections.

The efficacy of any of these treatment methods has not been proved,however. Corticosteroids have been suggested to abort theresorptive phase, returning the lesion to dormancy and settinginto motion the factors necessary for recurrence.

Nonoperative treatment

indications:

(1)symptom progression(2)constant pain that interferes with activities of daily

living(3) absence of improvement after conservative

therapy.

Operative treatment

Calcific tendinitis

ultrasound-guided percutaneous needling + subacromial corticosteroid injection

successful in approximately 70% of patients.

In a cadaver study of 140 shoulders, one third had full-thickness tears of the rotator cuff, 73% of which were in shoulders with type III acromions.

AC joint Arthrosis

Os Acromiale

• The acromion forms from 4 ossification centers that normally fuse by age 18 years, and acromion fuses to the spine at 20-25 y.

Os Acromiale

• 1-15% of nl population

• M˃F• B˃W• 30-60% Bilat.• Mean age: 50 y

• The os acromiale may cause impingement because if it is unstable, it may be pulled inferiorly during abduction by the deltoid, which attaches here.

Os Acromiale

• Optimal surgical treatment for symptomatic os acromiale is unclear.

The most common type treated

mesoacromiale (94%)

The most common surgical technique:

IF (60%)

Excision (27%)

Acromioplasty (13%)

The most common concurrent surgical technique: RC RepairAll techniques Improve clinical outcome

Subacromial Impingement

Subacromial bursitis

Treatment

• NSAID,s

• 1-2 subacromial cortisone injections

• Physical therapy program focusing on stretching for full shoulder motion and strengthening the rotator cuff

• Operative intervention may

be indicated

No response after 3-4 months

We use arthroscopic and occasionally open techniques.

Principles:

■ Release (but not resection) of the coracoacromialligament■ Removal of the anterior lip and lateral edge of theacromion■ Removal of part of the acromion anterior to the anteriorborder of the clavicle■ Removal of the distal 1 to 1.5 cm of clavicle if significantdegenerative changes are found

Treatment

infection

seroma formation

hematoma

synovial fistulabiceps rupture

pulmonary embolus

acromial fracture

Complication

the worst common complication is loss of anterior deltoid function, which is caused by either axillary nerve injury or

detachment of the deltoid from the acromion.

Complication

Secondary impingement

• GH instability

• Scapulothoracic instability

Secondary impingement is a clinical phenomenon that results in a “relative narrowing” of the subacromial space.

Secondary impingement

• Patients with secondary impingement are usually younger and often participate in overhead sporting activities such as baseball, swimming, volleyball, or tennis.

• They complain of pain and weakness with

overhead motions and may even describe a feeling of the arm going “dead.”

Secondary impingement

• On physical examination, the examiner should look for possible associated pathology, including GH joint instability with a positive apprehension and relocation test or abnormal scapular function such as scapular winging or asymmetrical scapular motion.

physical examination

Secondary impingement

• Translation of the humeral head, typically anteriorly, resulting contact of the rotator cuff against the coracoacromial arch.

GH instability

Secondary impingement

• The loss of the stabilizing function of the rotator cuff muscles also leads to an abnormal superior translation of the humeral head (decreased depression of the humeral head during throwing and less “clearance”) and mechanical impingement of the rotator cuff on the coracoacromial arch .

Secondary impingement

• In patients who have scapular instability, impingement results from improper positioning of the scapula with relation to the humerus. The instability leads to insufficient retraction of the scapula, which allows for earlier abutment of the coracoacromial arch on the underlying rotator cuff.

Scapulothoracic instability

Secondary impingement

• In patients with secondary impingement, treatment of the underlying problem should result in resolution of the “secondary impingement” symptoms.

• A subacromial decompression here worsens the symptoms because the shoulder is rendered even more “unstable.”

Subcoracoid impingement

• Gerber et al. suggested that this painful contact might be caused by a prominent coracoid, for which there may be numerous reasons, including idiopathic and iatrogenic conditions.

• The iatrogenic form was most common in their

series, and it was found in patients who had undergone a Trillat osteotomy of the coracoid for the treatment of anterior instability.

Gerber Test

-Tenderness over the coracoid -Positive coracoid impingement test.-Subcoracoid injection similar to the Neer impingement test

Physical findings

Internal impingement

• In this condition, internal contact of the rotator cuff occurs with the posterosuperior aspect of the glenoid when the arm is abducted, extended, and externally rotated as in the position of the throwing motion.

Internal impingement

• It often occurs in throwers who have lost internal rotation of the shoulder.

• This loss causes the center of rotation of the humeral head to move upward so that the contact between the rotator cuff and the biceps tendon attachments increases.

• Arthroscopic findings include partial rotator cuff tears, posterior and superior labral tears, and anterior shoulder laxity.

Internal impingement

• Early in the course of the condition, aggressive physical therapy with attention to regaining internal rotation and rotator cuff strengthening often is successful.