Copyright 1997 by The Journal of Bone and Joint Surgery, Incorporated

Non-Operative Treatment of
Subacromial Impingement Syndrome*
BY DAVID S. MORRISON, M.D.t, ANTHONY D. FROGAMENI, M.D4,
AND PAUL WOODWORTH, P.T.f, LONG BEACH, CALIFORNIA

Investigation performed at the Southern California Center for Sports Medicine, Long Beach

ABSTRACT: We performed a retrospective study Thirty-two (91 per cent) of the thirty-five patients
of 616 patients (636 shoulders) who had subacromial who had a type-I acromion had a successful result,
impingement syndrome to assess the results of non- compared with 173 (68 per cent) of the 256 who had a
operative treatment. The diagnosis was made on the type-II acromion and with 208 (64 per cent) of the 325
basis of a positive impingement sign and the absence who had a type-Ill acromion.
of other abnormalities of the shoulder, such as full- Shoulder dominance, gender, and concomitant ten-
thickness tears of the rotator cuff, osteoarthrosis of derness of the acromioclavicular joint did not affect
the acromioclavicular joint, instability of the glenohu- the result significantly (p = 0.084, 0.555, and 0.365,
meral joint, or adhesive capsulitis. All patients were respectively).
managed with anti-inflammatory medication and a spe-
cific, supervised physical-therapy regimen consisting Subacromial impingement syndrome refers to en-
of isotonic exercises for strengthening of the rotator croachment of the coracoacromial arch on the under-
cuff. The average duration of follow-up was twenty- lying mechanism of the rotator cuff26. The disorder was
seven months (range, six to eighty-one months). first recognized by Jarjavay18 in 1867, and the term im-
Over-all, 413 patients (67 per cent) had a satisfac- pingement syndrome was popularized by Neer26 in the
tory result. One hundred and seventy-two patients (28 1970's. Many treatment alternatives, ranging from rest
per cent) had no improvement and went on to have to total acromionectomy, have been suggested in the
an arthroscopic subacromial decompression. Thirty- li t e r a ture 2 " 4 ' 6 ' 7 , 1 '"' 7 '' s-24-26.28-31 •33-34.37-:'9
one patients (5 per cent) had an unsatisfactory result The goals of non-operative treatment of subacro-
but declined additional treatment. Seventy-four (18 per mial impingement syndrome are to decrease subacro-
cent) of the 413 patients who had a successful result mial inflammation, to allow healing of the compromised
had a recurrence of the symptoms during the follow-up rotator cuff, and to restore satisfactory function to the
period; the symptoms resolved with rest or after re- painful shoulder. Anti-inflammatory medication, ice,
sumption of the exercise program. and ultrasound have been shown to be effective in
The patients were stratified according to age, the the treatment of impingement syndrome2730, but some
duration of symptoms, and acromial morphology. Pa- authors also have advocated the use of gentle range-of-
tients who were twenty years old or less and those who motion exercises16, stretching20, and exercises for mobi-
were forty-one to sixty years old fared better than lization of the joint37 as part of an early rehabilitation
those who were twenty-one to forty years old. Patients program.
who were more than sixty years old had the poorest The purpose of the present retrospective clinical
results. study was to review our experience with the non-
Sixty-seven (78 per cent) of the eighty-six patients operative treatment of subacromial impingement syn-
in whom the symptoms had been present for less than drome. The study also focused on the influence of
four weeks had a satisfactory result, compared with confounding variables such as gender, shoulder domi-
144 (63 per cent) of the 228 who had had the symptoms nance, acromial morphology, tenderness of the acromio-
for one to six months and with 202 (67 per cent) of the clavicular joint, age, and the duration of symptoms.
302 who had had the symptoms for more than six
months. Materials and Methods
Seven hundred and seventy patients were diagnosed
*No benefits in any form have been received or will be received as having subacromial impingement syndrome between
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study. 1985 and 1991. The diagnosis was made on the basis of
tSouthern California Center for Sports Medicine, 2760 Atlantic a history, a clinical examination, and a positive impinge-
Avenue, Long Beach, California 90866. ment sign. Neer described the impingement sign as the
^Division of Sports Medicine, Department of Orthopaedic Sur-
gery, Medical College of Ohio, 3000 Arlington Avenue, Toledo, Ohio production of pain in the lateral region of the deltoid
43699. when the affected extremity is forcibly elevated while

732 THE JOURNAL OF BONE AND JOINT SURGERY

 NON-OPERATIVE TREATMENT OF SUBACROMIAL IMPINGEMENT SYNDROME 733

the scapula is stabilized, causing the supraspinatus ten- per cent). In all of the patients who had bilateral in-
don to be pinched between the humeral head and the volvement, the acromial morphology was the same on
anterior-inferior aspect of the acromion27. Patients who both sides.
had concomitant adhesive capsulitis, cervical radiculop- The follow-up evaluations were performed by the
athy, or suprascapular nerve palsy were excluded, as senior one of us; the average duration of follow-up was
were patients who had major weakness on testing of twenty-seven months (range, six to eighty-one months).
the rotator cuff or a full-thickness tear of the rotator All patients responded to questions regarding pain, func-
cuff on magnetic resonance imaging. Fifty-one patients tion of the shoulder, work status, recurrence of symp-
were lost to follow-up and two died, leaving a final study toms, and over-all satisfaction. The results were analyzed
group of 616 patients (636 shoulders). with use of the shoulder-rating scale of the University of
The study group comprised 386 male patients and California at Los Angeles10 (Table I). This 35-point scale
230 female patients. The average age was forty-two combines scores for pain, function, the range of active
years (range, fifteen to eighty-one years). We divided the forward elevation, the strength in forward elevation, and
patients into four age-groups: those who were twenty patient satisfaction.
years old or less (thirty-three patients), those who were Statistical analysis was performed with use of the
twenty-one to forty years old (253 patients), those who chi-square test.
were forty-one to sixty years old (252 patients), and
those who were more than sixty years old (seventy- Treatment Protocol
eight patients). Four hundred and six patients (66 per Beginning at the time of the initial examination, all
cent) had involvement of the dominant shoulder, 190 patients were managed with a three-week course of in-
patients (31 per cent) had involvement of the non- domethacin that was administered in divided doses of
dominant shoulder, and twenty patients (3 per cent) had 150 milligrams per day.
bilateral involvement. The physical therapy program was closely super-
The average duration of the symptoms was sixteen vised at our institution. If the patient was seen at
months (range, one day to twenty years). We separated another physical-therapy center, a description of the
the patients into three categories on the basis of the specific program was sent to the physical therapist at
duration of the symptoms. In eighty-six patients (14 per our institution. After inflammation was under control
cent), the symptoms were classified as acute (lasting for and pain had been decreased to a level that allowed the
less than four weeks); in 228 (37 per cent), as non-acute initiation of the exercise program, soft-tissue stretch-
(lasting for one to six months); and in 302 (49 per cent), ing was begun. Stretching exercises were performed by
as chronic (lasting for more than six months). the patient at home and with a therapist until a normal
All shoulders were examined by the senior one of range of motion had been achieved. At that point, the
us (D. S. M.). The purpose of the examination was to strengthening program was begun. The mainstays of
determine the range of motion; the strength of the the strengthening program are internal and external ro-
shoulder in the planes of forward elevation, abduction, tation exercises, performed with the extremity at the
and external rotation; and the presence or absence of an side. It is important that strengthening of the deltoid be
impingement sign. Care was taken to differentiate pain avoided during these exercises; therefore, the patient is
in the region of the acromioclavicular joint from pain in instructed to hold a magazine between the extremity
the rotator cuff. For eighty-five patients, the diagnosis and the side while exercising. This forced adduction re-
on examination was not clear; these patients received a laxes the deltoid and isolates the oblique muscles of the
subacromial injection of ten milliliters of 1 per cent rotator cuff.
plain Xylocaine (lidocaine), and the diagnosis of sub- The patient is instructed to place one end of a
acromial impingement was confirmed if pain was absent segment of surgical tubing over a doorknob or the con-
during the impingement maneuver after the injection. tralateral wrist and to stretch the tubing until the symp-
Seventy-five (88 per cent) of the eighty-five patients had tomatic extremity is brought into a position of neutral
relief of the pain; the other ten patients were not en- rotation at the side. These exercises are continued until
tered into the study. the patient can tolerate three sets often repetitions, with
Anteroposterior, axillary, and supraspinatus outlet the affected extremity held in the neutral position for
radiographs of the shoulder were made for each pa- ten seconds after each repetition. As the cuff begins to
tient824, and the acromial morphology then was analyzed strengthen, the resistance can be increased by varying
according to the criteria described by Bigliani et al.5. A the stretch on the rubber tubing. The patient is advised
type-I acromion is flat, a type-II acromion is curved that conditioning of the cuff is a six-week process.
downward, and a type-Ill acromion has a hook on the The rationale behind the program was to strengthen
anterior-inferior surface and converges on the humeral the subscapularis, infraspinatus, and teres minor muscles
head. In the 616 patients (636 shoulders), there were in order to increase the depressor effect of this portion
thirty-nine type-I acromions (6 per cent), 270 type-II of the rotator cuff on the humeral head resulting from
acromions (42 per cent), and 327 type-III acromions (51 the oblique orientation of these muscles. We did not

VOL. 79-A, NO. 5, MAY 1997

734 D. S. MORRISON, A. D. FROGAMENI, AND PAUL WOODWORTH

initially recommend any exercises for the deltoid or TABLE I

SHOULDER-RATING SCALE OF
supraspinatus muscles because we sought to avoid an
THE UNIVERSITY OF CALIFORNIA AT LOS ANGELES 1 0
increase in the force of elevation on the humerus. Only
after the shoulder was totally painless and fully func- No. of Points*
tional was a generalized program for strengthening Pain
of the shoulder (including the deltoid and the supra- Present always and unbearable; 1
strong medication needed frequently
spinatus) initiated, and then only for patients who had Present always but bearable; strong 2
high functional demands. medication needed occasionally
The patient was supervised by a physical therapist None or little at rest, present during light 4
until he or she was able to perform the exercises inde- activities; salicylates needed frequently
Present during heavy or particular activities 6
pendently. The patient was then discharged to a home only; salicylates needed occasionally
program and was followed at three to four-week inter- Occasional and slight 8
vals. The patient was instructed to continue the exercises None 10
for at least four weeks after the shoulder became pain- Function
Unable to use limb 1
free and to resume the exercise program if the symp-
Only light activities possible 2
toms recurred. Able to do light housework and most 4
activities of daily living
Results Most housework, shopping, and driving 6
possible; able to brush hair and to dress
Fifty-six of the 616 patients had complete relief and undress, including to fasten brassiere
of the symptoms during the first six weeks of therapy Slight restriction only; able to work above 8
and canceled the follow-up appointment; all of these shoulder level
patients were contacted by telephone and remained Normal activities 10
symptom-free at a minimum of one year. Of the remain- Active forward elevation (degrees)
>150 5
ing 560 patients, 465 (83 per cent) were available for 121-150 4
physical examination at the time of the latest follow- 91-120 3
up evaluation. The other ninety-five patients were con- 46-90 2
tacted by telephone; although a physical examination 30-45 1
was not performed, these ninety-five patients provided <30 0
adequate information regarding pain, the level of ac- Strength in forward elevation
(on manual muscle-testing) (grade)
tivity, and work status. 5 (normal) 5
Four hundred and thirteen (67 per cent) of the 616 4 (good) 4
patients had a satisfactory result; specifically, 186 pa- 3 (fair) 3
2 (poor) 2
tients (30 per cent) had an excellent result and 227 (37 1 (muscle contraction) 1
per cent) had a good result. One hundred and seventy- 0(none) ' 0
two patients (28 per cent) had no improvement after Satisfaction of patient
the non-operative treatment and went on to have an Satisfied and better 5
arthroscopic subacromial decompression at an aver- Not satisfied 0
age of seven months after the initiation of treatment *The maximum score possible was 35 points, with 34 or 35 points
(an average of twenty-four months after the onset of indicating an excellent result; 28 to 33 points, a good result; 21 to 27
symptoms). Thirty-one patients (5 per cent) refused points, a fair result; and 0 to 20 points, a poor result.
additional treatment after the non-operative treatment
failed. male patients and 151 (66 per cent) of the 230 female
Of the 413 patients who had a satisfactory result, patients had a satisfactory result. With the numbers
seventy-four (18 per cent) had a recurrence of the symp- available, this difference was not significant (p = 0.555).
toms during the follow-up period. These symptoms re- Two hundred and eighty (69 per cent) of the 406
solved either spontaneously or after the resumption of dominant shoulders were treated successfully, com-
the exercise regimen. Forty-nine patients (12 per cent) pared with 121 (64 per cent) of the 190 non-dominant
responded to the initial non-operative program but shoulders and with twenty-four (60 per cent) of the forty
failed to respond to the resumption of exercises after shoulders in the patients who had bilateral involve-
the symptoms recurred. The results for these patients ment; these differences were not significant (p = 0.084).
were considered unsatisfactory. Surprisingly, none of the patients who had bilateral in-
The effects of gender, shoulder dominance, acromial volvement had a successful result on one side and a
morphology, tenderness of the acromioclavicular joint, failure on the contralateral side.
age, and the duration of symptoms were analyzed inde- Thirty-two (91 per cent) of the thirty-five patients
pendently with respect to the result at the time of the (thirty-five of thirty-nine shoulders) who had a type-I
latest follow-up evaluation. acromion had a satisfactory result, compared with 173
Two hundred and sixty-two (68 per cent) of the 386 (68 per cent) of the 256 patients (181 of 270 shoulders)

THE JOURNAL OF BONE AND JOINT SURGERY

 N O N - O P E R A T I V E T R E A T M E N T OF SUBACROMIAL IMPINGEMENT SYNDROME 735

who had a type-II acromion and with 208 (64 per cent) protect the underlying rotator cuff and tendinitis of the
of the 325 patients (209 of 327 shoulders) who had a cuff develops (stage II). This stage is characterized by
type-Ill acromion. The results for the patients who had inflammation of the rotator cuff, and partial-thickness
a type-I acromion were significantly better than those tears are possible. As the process continues, the wear of
for the patients who had a type-II or type-Ill acromion the anterior aspect of the acromion on the greater tu-
(p = 0.002 for both comparisons). The results for the berosity and the supraspinatus tendon eventually re-
patients who had a type-II acromion were not signifi- sults in a full-thickness tear of the rotator cuff (stage
cantly better than those for the patients who had a III). Neer26 and others121023243839 have demonstrated that
type-Ill acromion, with the numbers available. None of this progressive process can be interrupted with an
the patients who had bilateral involvement had a suc- acromioplasty.
cessful result on one side and a failure on the contralat- Previous investigators who have reported on non-
eral side. operative treatment of subacromial impingement syn-
Sixty-nine (58 per cent) of the 120 patients who had drome have documented successful results for patients
concomitant tenderness of the acromioclavicular joint managed in the early stages of the disease2731. Ellman
had satisfactory relief of the symptoms of impingement, stated that most of his patients who had stage-II impinge-
compared with 344 (69 per cent) of the 496 patients who ment had improvement with rest, anti-inflammatory
did not have such tenderness. With the numbers avail- medication, physical therapy, and strengthening exer-
able, this difference was not significant (p = 0.365). cises designed to balance the muscles of the rotator
Twenty-four (73 per cent) of the thirty-three pa- cuff". Hawkins and Abrams recommended modification
tients who were twenty years old or younger had a of activity, warm-up exercises, ultrasound, and a physical
satisfactory result, compared with 162 (64 per cent) of therapy program that included stretching and strength-
the 253 patients who were twenty-one to forty years old, ening exercises; however, the specific exercise regimen
184 (73 per cent) of the 252 who were forty-one to sixty was not described16.
years old, and forty-three (55 per cent) of the seventy- Our physical therapy protocol was designed to ad-
eight who were more than sixty years old. These differ- dress the extrinsic theory of subacromial impingement
ences were significant (p = 0.018 for all comparisons). syndrome. The exercises for the rotator cuff are per-
Sixty-seven (78 per cent) of the eighty-six patients formed with the extremity at the side, the intention
who had acute symptoms had a satisfactory result, com- being to strengthen the inferior portion of the rotator
pared with 144 (63 per cent) of the 228 patients who had cuff and to avoid strengthening the deltoid muscle. Dur-
non-acute symptoms and with 202 (67 per cent) of the ing elevation of the glenohumeral joint, a force couple
302 patients who had chronic symptoms. The differences develops between the rotator cuff, which stabilizes and
between the group that had acute symptoms and the depresses the humeral head, and the deltoid muscle,
other two groups were significant (p = 0.046 for both which elevates the humerus. The deltoid muscle is sub-
comparisons). stantially more massive than the muscles that form the
rotator cuff. Weakening of the rotator cuff causes an
Discussion imbalance of the force couple about the glenohumeral
The pathophysiology of impingement syndrome may joint and allows the deltoid to elevate the proximal
have both extrinsic and intrinsic components62425272836. part of the humerus in the absence of an adequate de-
The extrinsic theory is mechanical and is related to the pressor effect from the rotator cuff. This causes a de-
anatomy of the coracoacromial arch. We found that pa- crease in the subacromial space and impingement of
tients who had a flat (type-I) acromion had better re- the rotator cuff on the anterior aspect of the acromion.
sults than those who had either a curved (type-II) or a Physical therapy therefore should be directed at in-
hooked (type-Ill) acromion. As would be expected in a creasing the depressor effect of the rotator cuff while
population of patients who had lesions of the rotator avoiding any increase in the elevating effect of the del-
cuff, there was a decreased prevalence of type-I acromial toid. By strengthening the infraspinatus, teres minor,
morphology and an increased prevalence of type-Ill and subscapularis relative to the supraspinatus and the
acromial morphology. Despite this finding, the outcome deltoid, it may be possible to re-establish the normal
for the patients who had a type-II acromion was not balance and force couple during elevation of the gleno-
significantly different than that for the patients who had humeral joint. Perry also noted the depressor effect and
a type-Ill acromion. the downward shear component of the subscapularis,
infraspinatus, and teres minor muscles during active
Neer divided the impingement process into three
contraction32. Functional weakness in the external rota-
stages27. Stage I is characterized by acute bursitis with
tors of patients who have impingement syndrome also
subacromial edema and hemorrhage. This stage usually
has been described clinically24.
is observed in patients who are thirty years old or less.
As the irritation of the subacromial structures continues Patients who had concomitant cervical radiculop-
as a result of the abnormal contact with the acromion, athy were excluded from the current study because of
the subacromial bursa loses its ability to lubricate and the difficulty in differentiating patterns of pain and re-

VOL. 79-A, NO. 5, MAY 1997

736 D. S. MORRISON, A. D. F R O G A M E N I , A N D PAUL WOODWORTH

sponses to treatment. In addition to radicular pain, they account for the increased rate of failure observed
which can be referred to the shoulder area, there are among patients who had concomitant osteoarthrosis of
two associated lesions of the shoulder that can mimic the acromioclavicular joint.
the symptoms of impingement syndrome. Adhesive cap- It is difficult to explain the bimodal distribution of
sulitis can present concomitantly with tendinitis of the satisfactory results with regard to age. While poorer
rotator cuff. In addition, stiffness of the posterior aspect results may be expected among patients who are more
of the capsule can worsen the impingement process by than sixty years old because of the presence of undiag-
pushing the humeral head up into the acromion during nosed full-thickness tears of the rotator cuff, it is unclear
elevation of the shoulder7. It therefore is very important why the patients who were twenty-one to forty years old
for a patient to have a completely normal range of mo- had less satisfactory results.
tion before beginning a strengthening program such as We found it interesting that patients who had a type-
the one described in the present study. We believe that Ill acromion fared no worse than those who had a type-II
a diagnosis of impingement syndrome cannot be made acromion. Perhaps there is a non-anatomical mechanism
in the presence of a stiff shoulder as all of our provoc- for pain in the rotator cuff in addition to impingement at
ative tests produce pain, which does not distinguish be- the coracoacromial arch.
tween the two entities. Degenerative changes of the One shortcoming of our study may have been the
acromioclavicular joint, including narrowing of the joint use of the shoulder-rating system of the University of
space and the formation of inferior osteophytes, also California at Los Angeles'". Although this system is
can accompany impingement syndrome22-2729. If these widely accepted for the reporting of results after the
osteoarthrotic changes are not painful and do not con- treatment of lesions of the shoulder, the scoring does
tribute to the impingement process (by encroaching not account for the presence or absence of an impinge-
on the supraspinatus muscle), we prefer not to inter- ment sign, and 150 degrees or more is rated as full for-
fere with the acromioclavicular joint. In the current ward elevation. Typically, impingement is not apparent
study, painful osteoarthrosis of the acromioclavicular until the shoulder achieves a greater angle of forward
joint did not prevent a successful response to the exer- elevation. While these factors may appear to elevate the
cise protocol. However, in a small number of patients, results artificially, pain, function, and over-all patient
the acromioclavicular joint was irritated to the point at satisfaction are weighted more highly in this system and
which exercises could not be continued. These patients therefore are much more important criteria in evaluat-
were considered to have had a failure of treatment, and ing the results.

References
Altchek, D. W.; Warren, R. F.; Wickiewicz, T. L.; Skyhar, M. J.; Ortiz, G.; and Schwartz, E.: Arthroscopic acromioplasty. Technique and
results. J. Bone and Joint Surg., 72-A: 1198-1207, Sept. 1990.
Apoil, A.; Dautry, P.; Koechlin, P.; and Hardy, J.: The surgical treatment of rotator cuff impingement. In Shoulder Surgery, pp. 22-26.
Edited by K. Bayley. New York, Springer, 1982.
Armstrong, ,1. R.: Excision of the acromion in treatment of the supraspinatus syndrome. Report of ninety-five excisions. J. Bone and
Joint Surg., 31-B(3): 436-442,1949.
Berry, H.; Fernandes, L.; Bloom, B.; Clark, R. J.; and Hamilton, E. B.: Clinical study comparing acupuncture, physiotherapy, injection
and oral anti-inflammatory therapy in shoulder-cuff lesions. Curr. Med. Res. and Opin., 7:121-126,1980.
Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to rotator cuff tears. Orthop.
Trans., 10:228,1986.
Codman, E. A.: The Shoulder. Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston,
privately printed, 1934.
Cofield, R. H., and Simonet, W. T.: Symposium on sports medicine: part 2. The shoulder in sports. Mayo Clin. Proc., 59:157-164,1984.
Cone, R. O., Ill; Resnick, D.; and Danzig, L.: Shoulder impingement syndrome: radiographic evaluation. Radiology, 150: 29-33,1984.
Einhorn, A. R., and Jackson, D. W.: Rehabilitation of the shoulder. In Shoulder Surgery in the Athlete. Techniques in Orthopaedics. Vol.
4, pp. 103-118. Edited by D. W. Jackson. Rockville, Maryland, Aspen Systems, 1985.
10. Ellman, H.: Arthroscopic subacromial decompression: analysis of one- to three-year results. Arthroscopy, 3:173-181,1987.
11. Ellman, H.: Diagnosis and treatment of incomplete rotator cuff tears. Clin. Orthop., 254: 64-74,1990.
12. Fu, F. H.; Harner, C. D.; and Klein, A. H.: Shoulder impingement syndrome. A critical review. Clin. Orthop., 269:162-173,1991.
13. Ha'eri, G. B., and Wiley, A. M.: Shoulder impingement syndrome. Results of operative release. Clin. Orthop., 168:128-132,1982.
14. Hammond, G.: Complete acromionectomy in the treatment of chronic tendinitis of the shoulder. / Bone and Joint Surg., 44-A: 494-504,
April 1962.
15. Hammond. G.: Complete acromionectomy in the treatment of chronic tendinitis of the shoulder. A follow-up of ninety operations on
eighty-seven patients. J. Bone and Joint Surg., 53-A: 173-180, Jan. 1971.
16. Hawkins, R. J., and Abrams, J. S.: Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2). Orthop. Clin. North
America, 18:373-382,1987.
17. Hawkins, R. J., and Kennedy, J. C: Impingement syndrome in athletes. Am. J. Sports Med., 8:151-158,1980.
18. Jarjavay, J. F.: Sur la luxation du tendon de la longue portion du muscle biceps humeral; sur la luxation des tendons des muscles
peroniers latercux. Cat. hebd. med. chir., 21: 325,1867.
19. Jobe, F. W.: Impingement problems in the athlete. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons.
Vol. 38, pp. 205-209. Park Ridge, Illinois, The American Academy of Orthopaedic Surgeons, 1989.

T H E J O U R N A L O F BONE AND J O I N T S U R G E R Y
 NON-OPERATIVE TREATMENT OF SUBACROMIAL IMPINGEMENT SYNDROME 737

20. Jobe, F. W., and Moynes, D. R.: Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. Am. J. Sports
Med., 10:336-339,1982.
21. Johansson, J. E., and Barrington, T. W.: Coracoacromial ligament division. Am. J. Sports Med., 12:138-141,1984.
22. Kessei, L., and Watson, M.: The painful arc syndrome. Clinical classification as a guide to management. /. Bone and Joint Surg., 59-B(2):
166-172,1977.
23. Lirette, R.; Morin, E; and Kinnard, P.: The difficulties in assessment of results of anterior acromioplasty. Clin. Orthop., 278:14-16,1992.
24. Matsen, F. A., Ill, and Arntz, C. T.: Subacromial impingement. In The Shoulder, edited by C. A. Rockwood, Jr., F. A. Matsen, III, and C.
T. Arntz. Vol. 2, pp. 622-646. Philadelphia, W. B. Saunders, 1990.
25. Moseley, H. E, and Goldie, I.: The arterial pattern of the rotator cuff of the shoulder. J. Bone and Joint Surg., 45-B(4): 780-789,1963.
26. Neer, C. S., II: Anterior acromioplasty for the chronic impingement syndrome in the shoulder. A preliminary report. J. Bone and Joint
Surg., 54-A: 41-50, Jan. 1972.
27. Neer, C. S., II: Impingement lesions. Clin. Orthop., 173:70-77,1983.
28. Neer, C. S., II, and Welsh, R. P.: The shoulder in sports. Orthop. Clin. North America, 8: 583-591,1977.
29. Neer, C. S., II; Bigliani, L. U.; and Hawkins, R. J.: Rupture of the long head of the biceps related to subacromial impingement. Orthop.
Trans., 1:111,1977.
30. Neviaser, R. J., and Neviaser, T. J.: Observations on impingement. Clin. Orthop., 254: 60-63,1990.
31. Nirschl, R. P.: Rotator cuff tendinitis: basic concepts of pathoetiology. In Instructional Course Lectures, The American Academy of
Orthopaedic Surgeons. Vol. 38, pp. 439-445. Park Ridge, Illinois, The American Academy of Orthopaedic Surgeons, 1989.
32. Perry, J.: Biomechanics of the shoulder. In The Shoulder, pp. 1-15. Edited by C. R. Rowe. New York, Churchill Livingstone, 1988.
33. Pink, M., and Jobe, E: Shoulder injuries in athletes. Clin. Manage., 1: 31-47,1991.
34. Post, M., and Cohen, J.: Impingement syndrome. A review of late stage II and early stage III lesions. Clin. Orthop., 207:126-132,1986.
35. Richardson, A. B.; Jobe, F. W.; and Collins, H. R.: The shoulder in competitive swimming. Am. J. Sports Med., 8:159-163,1980.
36. Rothman, R. H., and Parke, W. W.: The vascular anatomy of the rotator cuff. Clin. Orthop., 41:176-186,1965.
37. Scheib, J. S.: Diagnosis and rehabilitation of the shoulder impingement syndrome in the overhand and throwing athlete. Rheumat. Dis.
Clin. North America, 16: 971-988,1990.
38. Thorling, J.; Bjerneld, H.; Hallin, G.; Hovelius, L.; and Hagg, O.: Acromioplasty for impingement syndrome. Acta Orthop. Scandinavica,
56:147-148,1985.
39. Tibone, J. E.; Jobe, F. W.; Kerlan, R. K.; Carter, V. S.; Shields, C. L.; Lombardo, S. J.; and Yocum, L. A.: Shoulder impingement syndrome
in athletes treated by an anterior acromioplasty. Clin. Orthop., 198:134-140,1985.

VOL. 79-A, NO. 5, MAY 1997