textbook impingement syndrome

By:Gopinath

A Mutmainna RAyustia Risvani Akbar

Nurul MuchlizaHastuti

Fitra Yahya

Advisors:dr. Chaniagodr. Mervin

dr. Ricodr. Arif

Orthopaedic and Traumatology DepartmentFaculty of Medicine

Hasanuddin University2013

a painful disorder which is thought to arise from repetitive compression or rubbing of the tendons (mainly supraspinatus) under the coracoacromial arch

Apley’s System Of Orthopaedics And Fractures 9th Edition

Prevalence: 5% to 10% of the population

Predominant sex: Males more than females

Predominan Age: >40 yr

,Kennedy, John F. Ferri’s Clinical Advisor 2013. Philadelphia: Elsevier.

A combination of: Tendon overload Microvascular compromise Compression by surrounding structures


Netter

Repetitive overhead activity Advanced Aged Trauma


Repetitive compression/ stress / rubbing of tendon compressed and irritated slightly swollen impinging on the acromioclavicular arch

osteophytes on the anterior edge of the acromion


Friction minor tears can develop scaring, fibrocartilaginous metaplasia or calcification in the tendon vascular reaction and local congestion further impingement


Shoulder pain , with subsequent progress depends on age, stage of the disorder, and vigour of healing response.

Three Stages Stage 1:acute

inflammation,edema,hemorrhage Stage 2:fibrosis and tendinitis Stage 3:mechanical disruption of the rotator

cuff tendonsApley’s System Of Orthopaedics And Fractures 9th Edition

Due to vascular congestion, microscopic haemorrhage and oedema

Pain after vigorous or unaccustomed activity ( swimming)

Shoulder looks normal but acutely tender along the anterior edge of acromion


Pain worse at night, the patient cannot lie on the affected side, comfortable to sit up out of bed.

May restrict even simple activities ( hair grooming or dressing) Age 40-50 History of recurrent attacks of subacute tendinitis


Pain settling down with rest or anti inflammatory treatment and recur when more demanding activities resumed

Crepitation over the rotator cuff when shoulder is passively rotated

Small, unsuspected tears are quite often found during arthroscopy or operation


The most advanced stage Resulting in either partial or full

thickness tear Aged over 45 History of refractory shoulder pain with

increasing stifness and weakness


The painful arc sign :


On active abduction scapulo- humeral rhythm is disturbed and pain is aggravated

as the arm traverses an arc between 60 and 120 degrees

Neer’s impingement sign


the scapula is stabilized with

one hand while with the other

hand the examiner raises the

affected arm to the full extent

in pas- sive flexion, abduction

and internal rotation, thus

bringing the greater tuberosity

directly under the

coracoacromial arch. The test

is positive when pain, located

to the subacromial space or

anterior edge of acromion, is

elicited by this manoeuvre.

Neer’s test for impingement

If the previous manoeuvre is positive, it may be repeated after injecting 10 mL of 1 per cent lignocaine into the subacromial space; if the pain is abolished (or sig- nificantly reduced), this will help to confirm the diagnosis.


Hawkins-Kennedy testThe patient’s arm is placed

in 90 degrees forward

flexion with the elbow also

flexed to 90 degrees. The

examiner then stabilizes

the upper arm with one

hand while using the other

hand to internally rotate the

arm fully. Pain around the

anterolateral aspect of the

shoulder is noted as a

positive test.

The patient is asked to raise his or her arms to a position of 90 degrees abduction, 30 degrees of forward flexion and internal rotation. The examiner stands behind the patient and applies downward pressure on both arms, with the patient resisting this force. The result is positive when the affected side is weaker than the unaffected side


the patient stands holding his or her arms close to the body and the elbows flexed to 90 degrees. He or she is instructed to externally rotate both arms while the examiner applies resistance; lack of power on one side signifies weakness of infraspinatus.



the patient is asked to stand and place one arm behind his or her back with the dorsum of the hand resting against the mid- lumbar spine. The examiner then lifts the patient’s hand off the back and the patient is told to hold it there. Inability to do this signifies subscapularis

X-ray Usually normal in early stages Chronic tendiitis : there may be erosion,

sclerosis or cyst formation In chronic cases: roughening or overgrowht

of anterior edge at the caudal tilt view Older patient and late cases: osteoarthritis

of the acromioclavicular joint


USGIDENTIFYING AND MEASURING THE SIZE OF FULL THICKNESS AND PARTIAL THICKNESS ROTATOR CUFF TEARS


Non-operative Operative


Rest without overhead activity Physical Therapy NSAIDs for 7-10 days Subacromial glucocorticoid injections

Open AcromioplastyThrough an anterior incision the deltoid muscle is split and the part arising from the anterior edge of the acromion is dissected free, exposing the coracoacromial ligament, the acromion and the acromioclavicular joint.The coracoacromial ligament is excised and the anteroinferior portion of the acromion is removed by an undercutting osteotomy.


Excres- cences on the undersurface of the a cromioclavicular joint are pared down.

If the joint is hypertrophic, the outer 1cm of clavicle is removed; this last step exposes even more of the cuff and permits recon- struction of larger defects.

An important step is care- ful reattachment of the deltoid to the acromion, if necessary by suturing through drill holes in the acromion; failure to obtain secure attachment may lead to postoperative pain and weakness. After the operation, shoulder movements are commenced as soon as pain subsides.



Arthroscopic SurgeryThe underside of the acromion must be trimmed and the coracoacromial ligament divided or removed. This procedure has now become the gold standard and allows earlier rehabilitation than open acromioplasty because detachment of the deltoid is not per- formed. Arthroscopic acromioplasty should achieve the same basic objectives as open acromioplasty Arthroscopy allows good visualization inside the gleno-humeral joint and therefore the detection of other abnormalities which may cause pain


THANK YOU

textbook impingement syndrome

Documents