Impingement Syndromes in Shoulder pathology Manos Antonogiannakis Director 2 nd Orthopaedic Department Center for Shoulder Arthroscopy IASO General Hospital www.shoulder.gr
Impingement Syndromesin Shoulder pathology
Manos AntonogiannakisDirector
2nd Orthopaedic Department
Center for Shoulder Arthroscopy
IASO General Hospital
www.shoulder.gr
Introduction
Subacromial Spacea number of soft-tissue structures are
situated between two rigid structures . The superior border (the roof) of the
space is the coracoacromial arch, which consists of the acromion, the coracoacromial ligament, and the coracoid process.
The acromioclavicular joint is directly superior and posterior to the coracoacromial ligament.
The inferior border (the floor) consists of the greater tuberosity of the humerus and the superior aspect of the humeral head.
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By definition “shoulder
impingement syndrome” was considered the Subacromial outlet obstruction resulting in trauma to the supraspinatus tendon.
In other words the supraspinatustendon was pinched against the
undersurface of the acromion
during elevation of the arm
The History of Impingement Syndrome
The concept was attributed to Charles Neer, MD, in 1972 www.shoulder.gr
The History of Impingement Syndrome
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Neer classified and named the disorder as shoulder impingement.
More over he classified the diagnostic process.
Neer, JBJS(A) 1972
The History of Impingement Syndrome
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However, the process itself was first described but not named by Meyer as early as 1931.
Meyer AW JBJS 1931;13:341-360
The History of Impingement Syndrome
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The Neer Classification of Impingement Syndrome was an important step in understanding shoulder pathology for its time,but it is now outdated.
Type I: <25 years old, Reversible, swelling, tendonitis, no tears, conservative treatment
Type II: 25-40 years old, Permanent scarring, tendonitis, no tears, SAD
Type III: >40 years old, Small RTC tear, SAD with debridement/repair
Type IV: >40 years old, Large RTC tear, SAD with repair
Current classification of shoulder impingement syndromes
• Primary and secondary Subacromial Impingement
• Coracohumeral Impingement
• Glenoid (Internal) Impingement
• ASI (AnteroSuperior Impingement)
• PSGI (PosteroSuperior Glenoid Impingement)
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Primary Subacromial Impingement
Primary impingement or external-Subacromialimpingement is the closest thing to Neer’s original description of shoulder impingement syndrome.
The area of the RC that is torn or irritated in primary impingement is typically the bursal side of the RC.
This means that the source of pathology is confined to the Subacromial space.
Andrews, 1994
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Primary Subacromial Impingement
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Usually in patients >40 yo
pain in the anterior or front of the shoulder during overhead activities.
pain at night.
pathologic changes of the coracoacromial arch.
most common in the industrial population.
Primary Subacromial Impingement
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Subacromial spurring
DJD AC joint
Os Acromiale
Increased thoracic kyphosis
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Acromial Morphology
Type I: Flat acromion low incidence of impingement
Type II: Curved acromion higher incidence of impingement
Type III: Beaked acromion very high incidence of impingement
Bigliani, 1986
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Radiographic Evaluation
Plain X-ray
Outlet View
MRI
Ultrasound
Subacromial external impingement Impingement
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Neer’s test positive
Hawkins test positive
Primary subacromial Impingement
Why partial rot cuf tears are usually at the articular side?
Fewer arteriolars
Greater stiffness
Less favorable stress-strain curve
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Secondary Subacromial Impingement
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•Secondary Impingement by definition implies that there is a problem with the functional ability of the shoulder to keep the humeral head centered in the glenoid fossa during movement of the arm.
•Generally is caused by weakness in the RC muscles (functional instability) combined with a glenohumeral joint capsule and ligaments that are to loose (micro-instability). The combination allows a superior motion of the humeral head and as a consequence narrowing of the subacromial space
•Tearing of the RC is the primary event due to fatigue and the subacromial impingement is secondary due to loss of the ability to center the humeral head worsening the condition .
•Intra-articular partial tearing is seen in these patients.
Secondary Subacromial Impingement
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•Patients are typically younger and the pain is located in the anterior or anterolateral aspect of the shoulder. The symptoms are usually activity specific and involve overhead activities.
•It is important to search for and treat the underlying “micro-instability” in patients with secondary impingement if it exists.
Arroyo et al, Orth Cl North Am 1997
Jobe’s Instability Continuum
RC
weakness
generally
occurs
first
Functional
instability
follows
prolonged
RTC
weakness
Capsular laxity, develops
(acquired) or becomes
prominent (preexisting
congenital laxity).
Subluxation
(inability of the
humeral head to
center in the
glenoid during
motion).
RC/Labral tearing (late stage
disease of secondary
impingement).
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Clinical Examination
Rule out neck pathology (cervical radiculitis / DJD)
Test Rc muscle strength
Test active – passive ROM
Neer’s test
Hawkins Test
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Conservative Treatment
Duration up to 6 months depending on patients demands
Modification of activity
NSAIDs
Steroid Injections
Physiotherapy
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Surgical Treatment
Acromioplasty (primary impingement)
DCE (primary impingement)
Cuff debridement/repair (primary or secondary)
Repair of anterior instability if present (secondary impingement)
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Surgical Treatment
Acromioplasty
Detachment of CA ligament
Soft tissue removal
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Surgical Treatment
Acromioplasty
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Surgical Treatment
Distal Clavicle Excision
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Subcoracoid impingement
Impingement of the coracoid process against the humerus (usually the lesser tuberosity) in a coracoidimpingement position (humerus is flexed, adducted and internally rotated)
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Subcoracoid Impingement
Subcoracoid space: Interval between the tip of the coracoid and the humeral head (the coracohumeralinterval).
Normal coracohumeral interval: 8.4-11.0mm
Subcoracoid stenosis: Narrowing of the Subcoracoid space with a coracohumeral interval of less than 6mm.
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Bigliani, JBJS 1997 Current Concepts Review -
Subacromial Impingement Syndrome
Coracohumeral Impingement
Usually resistant to conservative
Surgical treatment is usually warranted.
Surgical treatment involves a coracoplasty(removing a portion of the coracoid process) with debridement or repair of the subscapularis tear.
Lo and Burkhart, Arthroscopy, 19;2003:1142-1150.
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Internal Impingement
Backround Knowledge
Overhead athletes subject their shoulder to tremendous forces during competition
During the late cocking phase of throwing the arm may achieve 170 to 180 degrees of ext. rotation to generate the torque required
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Internal Impingement
Types:
I. Anterior Superior Impingement (ASI)
II. Posterior Superior GlenoidImpingement (PSGI)
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Anterior Superior Internal Impingement
Pain is generated during the followthrough movement, with the arm in position of internal rotation, flexion and adduction
Exact etiology unknown ill defindconcept
Gerber and Sebesta first described ASI as a form of intra-articularimpingement responsible for unexplained anterior shoulder pain and managed to reproduce the impingement mechanism during arthroscopy
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J Shoulder Elbow Surg
(2000) 9:483–490
Anterior Superior Internal Impingement
While the articular side of the posterior-superior rotator cuff is involved in PSGI, the articularside of the subscapularis tendon and the pulley system of the long head of the bicepts are affected in ASI
LHB instability combined with macrotrauma or repetitive microtrauma are involved in the acquisition of ASI
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ASI–HISTORY
MORE COMMON IN SWIMMERS
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Anterior Superior Internal Impingement
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Classification of Pulley Lesions
type I with an isolated lesion of the SGHL
type II with a lesion of the SGHL associated with a
partial articular side supraspinatus tendon tear
type III with a lesion of the SGHL associated with a partial subscapularis tendon tear
type IV with a lesion of the SGHL associated with a partial tear of the supraspinatus and subscapularistendon
Habermeyer (2004)J Shoulder Elbow Surg 13:5–12
Anterior Superior Internal Impingement
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Clinical Examination
Hawkins with forward elevation >90 positive
Internal Impingement –Clinical Examination
O’Brien’s test = positive 66.7%
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Anterior Superior Internal Impingement
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Imaging
•Ultrasound•MRI•MRI Arthro
No specific findingsLHB tendon instability in u/s
Clinical tests and imaging are not specific for ASI.
ASI is best determined by dynamic evaluation in arthroscopy
Anterior Superior Internal Impingement
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Treatment•there are no published guidelines or treatment protocols forthe conservative management of ASI•surgical treatment guidelinesare are not well established• It is usually treated as part of other associated injuries
in patients with a pulley lesion, there is some evidence that early surgical management, when minor soft injury lesions are present, produces better clinical outcomes
Posterior Superior Glenoid Internal Impingement - Definition
Injury and dysfunction due to repeated contact
between the undersurface of the rot cuff tendons and the posterosuperior glenoid
Walch JSES 1992
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Some contact between these structures is physiologic,
but repetitive contact with altered shoulder mechanics
may be pathologic
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Posterior Superior Glenoid Internal Impingement - Definition
For undefined reasons this contact in some athletes become pathologic and
produces symptoms
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Posterior Superior Glenoid Internal Impingement
Normally
in abduction and external rotation (ABER) there is
obligate posterior & inferiortranslation
of the humerus that allows for
more motion and less contact
between the greater tuberosity and
the posterosuperior glenoid rim
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Posterior Superior Glenoid Impingement
Mechanism of PSGI
Two major theories:
Andrew
Burkhart & Morgan
May co-exist
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Mechanism of PSGIAndrew Theory:
Repeated ABER
Dynamic stabilizers
fatigue
Increase stress to anterior & IGHL
Anterior capsule laxity
to allow max ABER
Reduction of posterior & inferior translation of HH
Increased contact of undersurface of RC and posterosuperior glenoid
Internal Impingement
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Mechanism of PSGIBurkhart & Morgan Theory:
Repeated ABER
Tight posterior capsule
Superior translation of Humeral Head
Torsional stress to biceps anchor
Peel-off
MechanismSLAP II and
Pseudolaxity
Increased contact of undersurface of RC and posterosuperior glenoid Internal
Impingement
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It is essentially an
overuse injury associated
with overhead athletes
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Posterior Superior Glenoid Impingement
Typically symptoms are present only while playing
No symptoms with activities of daily living
Represents about 80% of the problems seen in the overhead athletes
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Posterior Superior Glenoid Impingement
Internal impingement
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Structures involved:
Humeral head
Anterior capsule
Inferior GHL
Posterior capsule
Rot cuff muscles
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Posterior Superior Glenoid Impingement
PSGIHistory
Chronicity of pain
Posterior pain
Abduction + externalrotation aggravates pain
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PSGIHistory
Insidious onset
Increases as the season progresses
Dull posterior pain
Worse at late cocking phase
Rarely can remember any traumatic episode
Loss of control and velocity
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PSGI Clinical Examination
Palpation:
pain can be elicited over the infraspinatous
pain worse posteriorly than on GT, (vice versa on rot cuff tendonitis)
Anterior part of the shoulder, biceps groove and tendon are not painful.
No bony abnormalities.
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PSGI Clinical Examination
ROM: usually full range of motion
dominant arm tends to have 10-15 deg more ext rotation and
10-15 deg less internal rotation at 90 deg abduction
The most common for an overhead athlete is: 2+ anterior laxity,
up to 1+ posterior laxity,
some inferior laxity,
but a firm endpoint
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PSGI Clinical Examination
Provocative tests:
Neer’s test = negative
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PSGI Clinical Examination
Provocative tests:
O’Brien’s test = negative (unless SLAP lesion)
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PSGI Clinical Examination
Provocative tests:
Internal Impingement test = positive
(patient supine, 90 deg abduction and max external rotation. If pain experienced at the posterior part of the joint = positive, 90% sensitive)
Relocation test = positive,
(different from relocation test for anterior translation)
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Relocation test of
Jobe:
Pain in the posterior joint line
when the arm is brought in abduction external rotation with the patient supine that is relieved when a posterior directed force is applied to the shoulder
Internal Impingement –
Clinical Examination
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PSGIMRI findings
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Internal Impingement –Differential Diagnosis
SLAP lesions ASI Pain more anterior than Internal Impingement.
Positive O’Brien test and SLAPrehension test. These tests are negative for internal impingement.
Isolated posterior labrum tear The most difficult to differentiate from internal imp.
Both posterior pain in the abducted and ext rotated position
Posterior instability.
Arthroscopy can help
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PSG Internal Impingement –Arthroscopic findings
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PSG Impingement –Treatment
Conservative
Surgical
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PSG Impingement –Conservative Treatment
Two main requirements for a good throw:
Large arc of motion
Adequate stability
Thrower’s paradox
some laxity to static restrains
=> some degree of instability
=> muscles compensate
Fine balance is needed
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PSG Impingement –Conservative Treatment
Rest (complete stop of throwing is critical)
Rehabilitation (physical therapy as soon as possible) to
improve posterior flexibility
improve dynamic stabilization
increase strength of rot cuff muscles
Then gradual return to throwing
Improvement of throwing technique
+/- NSAID
Most athletes return to sport
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PSG Impingement –Surgical Treatment
Diagnostic arthroscopy
(other pathology found…SLAP, biceps tendonitis, rot cuff tears etc)
Arthroscopic Debridement
25-85% return to pre-injury activity => effective ?
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PSG Impingement –Surgical Treatment
Open/Arthroscopic CapsulolabralReconstruction
Arthrolysis of posterior capsule tightness
Repair of SLAP lesions Repair of the rot cuff Address anterior capsule laxity
(50 - 81% pre-injury level)
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PSG Impingement –Surgical Treatment
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PSG Impingement –Surgical Treatment
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PSG Impingement –Surgical Treatment
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Internal impingement –Surgical Treatments
Infrequently Used Today
Arthroscopic Thermal CapsulorraphyAnother method to reduce the anterior capsular laxity At the same time debridement + arthroscopic fixation of labral tears86% return to pre-injury level
Rotational OsteotomyDerotation osteotomy of humerous
=> increase of retroversion + shortening of subscapularis=> less impingement
55% return to pre-injury level
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Subacromialdecompression
22% of throwing athletes returned to the same level of participation after subacromial decompression
Tibone ,Jobe. CORR 1985
PSG Impingement –Surgical Treatment
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Take home messages
Internal Impingement is a relatively common problem in overhead athletes
Difficult to treat
Caused by repetitive contact between the undersurface of the rot cuff and posterosuperior glenoid
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Initial treatment: Complete REST + PHYSIOTHERAPY
If symptoms persist: Multiple surgical techniques
Repair all lesions if possible
Take home messages
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Subacromial impingement was the first concept developed
Valid especially in older non-athletic popullation but partiall
Subacromial decompression very effective
Take home messages
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Secondary subacromialimpingement the next concept to explain RC tears especially in younger more athletically oriented patients
Repair of the cuff very effective
Search and repair anterior instability if pressent
Acromioplasty +/-
Take home messages
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Posterior internal impingement the concept to explain posterior shoulder pain and RC tears in throwers
Anterior internal impingement explaining more anterior pain in young athletes (especially swimmers)
Repair the cuff and co existing pathology
Take home messages
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Subcoracoid impingement an other cause to keep in mind and repair when treating anterosuperior RC tears (subscapularis LHB anterior supraspinatus
Take home messages
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Thank you for your attention
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Case-1
Female, 23years
Gym Academy, Volley player
Loose joints
4 months Pain at ABD+EXT ROT
Suprasipatus test +, Relocation Test +
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Case-1
MRI
Partial RC tear
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Case-1
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Case-1
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Case-1
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Case-1
6 months post OP
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Internal Impingement
Throwing phases:
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Internal impingement
Throwing phases:
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PSG Impingement –Arthroscopic findings
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PSG Impingement –Arthroscopic findings
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