impingement syndromes

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  • 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.

    www.shoulder.gr

  • 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

    www.shoulder.gr

    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

    www.shoulder.gr

    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

    www.shoulder.gr

    The Neer Classification of Impingement Syndrome was an important step in understanding shoulder pathology for its time,but it is now outdated.

    Type I: 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)

    www.shoulder.gr

  • Primary Subacromial Impingement

    Primary impingement or external-Subacromialimpingement is the closest thing to Neers 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

    www.shoulder.gr

  • Primary Subacromial Impingement

    www.shoulder.gr

    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

    www.shoulder.gr

    Subacromial spurring

    DJD AC joint

    Os Acromiale

    Increased thoracic kyphosis

  • www.shoulder.gr

    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

  • www.shoulder.gr

    Radiographic Evaluation

    Plain X-ray

    Outlet View

    MRI

    Ultrasound

    http://imaging.birjournals.org/content/vol15/issue4/images/large/IMJ35943-14.jpeghttp://imaging.birjournals.org/content/vol15/issue4/images/large/IMJ35943-14.jpeg

  • Subacromial external impingement Impingement

    www.shoulder.gr

    Neers 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

    www.shoulder.gr

  • Secondary Subacromial Impingement

    www.shoulder.gr

    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

    www.shoulder.gr

    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

  • Jobes 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).

    www.shoulder.gr

  • Clinical Examination

    Rule out neck pathology (cervical radiculitis / DJD)

    Test Rc muscle strength

    Test active passive ROM

    Neers 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

    www.shoulder.gr

  • Surgical Treatment

    Acromioplasty (primary impingement)

    DCE (primary impingement)

    Cuff debridement/repair (primary or secondary)

    Repair of anterior instability if present (secondary impingement)

    www.shoulder.gr

  • Surgical Treatment

    Acromioplasty

    Detachment of CA ligament

    Soft tissue removal

    www.shoulder.gr

  • Surgical Treatment

    Acromioplasty

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  • Surgical Treatment

    Distal Clavicle Excision

    www.shoulder.gr

  • 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)

    www.shoulder.gr

  • 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.

    www.shoulder.gr

    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.

    www.shoulder.gr

  • 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

    www.shoulder.gr

  • Internal Impingement

    Types:

    I. Anterior Superior Impingement (ASI)

    II. Posterior Superior GlenoidImpingement (PSGI)

    www.shoulder.gr

  • 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

    www.shoulder.gr

    J Shoulder Elbow Surg

    (2000) 9:483490

  • 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

    www.shoulder.gr

  • ASIHISTORY

    MORE COMMON IN SWIMMERS

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  • Anterior Superior Internal Impingement

    www.shoulder.gr

    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 13:512

  • Ant

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