Impingement & Rotator Cuff

IMPINGEMENT &
ROTATOR CUFF
SUBACROMIAL
IMPINGEMENT
Subacromial Impingement
Introduction
the first stage of rotator cuff disease which is a continuum of disease from
 impingement and bursitis
 partial to full-thickness tear
 massive rotator cuff tears
 rotator cuff tear arthropathy
Epidemiology
incidence
• subacromial impingement is the most common cause of shoulder pain
• accounts for 44-65% of shoulder disorders
Pathophysiology
subacromial impingement is thought to be a combination of
• extrinsic compression of the rotator cuff between the humeral head and
• anterior acromion
• coracoacromial ligaments
• acromioclavicular joint
• intrinsic degeneration
• Supraspinatus
attrition of the supraspinatus leads to inability to balance the humeral head on the glenoid causing
superior migration, impinging the subacromial space
inflammatory process
• inflammation of the subacromial bursa due to abutement between the humerus and rotator cuff,
and acromion and associated ligaments
Associated conditions
• hook-shaped acromion
• os acromiale
• posterior capsular contracture
• scapular dyskinesia
Anatomy
Acromion
• 3 ossification centers unite to form the acromion
• meta-acromion (base)
• meso-acromion (mid)
• pre-acromion (tip)
• failure of the ossification centers to fuse results in
an os acromiale
Classification
Bigliani classification of acromion morphology (based on a supraspinatus outlet
view)
classification types
• Type I - flat
• Type II - curved
• Type III - hooked
studies have shown classification system has poor inter observer reliability
Presentation
Symptoms
- pain
• insidious onset
• exacerbated by overhead activities
• night pain
• poor indicator of successful nonoperative management
Presentation
Physical exam
• Strength
• positive Hawkins test
usually normal
positive if internal rotation and passive forward flexion to 90° causes
• impingement tests pain
• positive Neer impingement sign
• Jobe test
positive if passive forward flexion >90° causes pain
• positive Neer impingement test pain with resisted pronation and forward flexion to 90° indicates
if a subacromial injection relieves pain associated with passive forward flexion supraspinatus pathology
>90°
• internal impingement test
positive if pain is elicited with abduction and external rotation of the
shoulder
Imaging: Radiographs
recommended views
true AP of the shoulder
 useful in evaluating the acromiohumeral interval
 normal distance is 7-14 mm
30° caudal tilt view

 useful in identifying subacromial spurring
supraspinatus outlet view

 useful in defining acromial morphology
findings
common radiographic findings associated with impingement
 proximal migration of the humerus as seen in rotator cuff tear arthropathy
 traction osteophytes
 calcification of the coracoacromial ligament
 cystic changes within the greater tuberosity
 Type III-hooked acromion

 associated with impingment
 os acromiale
best seen on axillary lateral
Imaging
MRI
• useful in evaluating the degree of rotator cuff pathology
• subacromial and subdeltoid bursisits often seen
CT arthography
• can also accurately image the rotator cuff tendons and muscle bellies
Ultrasound
• o can also accurately image the rotator cuff tendons and muscle bellies
supraspinatus outlet view showing os
acromiale
Studies: histology
Tendinopathy histology shows:
• disorganized collagen fibers
• mucoid degeneration
• inflammatory cells
inflammation of the subacromial bursa:
• high levels of metalloproteases and other inflammatory cytokines
Treatment
Nonoperative
physical therapy, oral anti-inflammatory medication, subacromial

injections
Operative
subacromial decompression / acromioplasty

Treatment: Non Operative
physical therapy, oral anti-inflammatory medication, subacromial injections
• Indications: first line and mainstay of treatment of subacromial impingement
alone without rotator cuff tear
• techniques
• aggressive rotator cuff strengthening and periscapular stabilizing exercises
• an integrated rehabilitation program is indicated in the presence of scapular dyskinesia
which aims to regain full shoulder range of motion and coordinate the scapula with
trunk and hip motions
• platelet-rich plasma injections: data is controversial at this point
Treatment: Operative
subacromial decompression / acromioplasty
• indications
• subacromial impingement syndrome that has failed a minimum of 4-6 months of
nonoperative treatment
• outcomes
• poor subjective outcomes have been observed after acromioplasty in patients with
workers' compensation claims
Technique
Subacromial decompression and • an anteroinferior acromioplasty to
acromioplasty smooth the undersurface of the
acromion follows as the second step of
• acromioplasty the procedure
• two-step procedure performed open or • a bone rasp is used if performed open
arthroscopically • a shaver or burr is used if performed
• an anterior acromionectomy is performed arthroscopically
first
• the anterior deltoid origin determines the • the deltoid is meticulously repaired to
extent of the acromionectomy when bone in open procedures
performed arthroscopically and must
remain intact
Treatment
Treatment of an os acromiale
• a two-stage procedure may be required with the presence of an os acromiale to
avoid deltoid dysfunction caused by direct excision
• the os acromiale is first fused with bone graft and allowed to heal
• an acromioplasty is then performed as a separate second procedure
I:9 Os acromiale fixed by cannulated
screws and tension band
Complications
Deltoid dysfunction
• resulting from a failed deltoid repair following an open acromioplasty or an
excessive acromionectomy during an arthroscopic procedure
• secondary to direct excision of an os acromiale
Anterosuperior escape
• avoid acromioplasty and CA ligament release to preserve the coracoacromial arch
in patients with massive, irreparable rotator cuff tears
SUBCORACOID
IMPINGEMENT
Introduction
Subcoracoid impingement is defined as impingement of the subscapularis between
the coracoid and lesser tuberosity
Pathoanatomy
• mechanism
• position of maximal impingement is arm adduction,flexion, and internal rotation
• risk factors
• patients with a long or excessively lateral coracoid process
• prior surgery that caused posterior capsular tightening and loss of internal rotation
• Associated conditions
• Combined subscapularis, supraspinatus, and infraspinatus tears
Anatomy
• Glenohumeral joint anatomy and biomechanics
• Coracoid
• muscle attachments
• coracobrachialis, pectoralis minor, and short head of the biceps attach to the coracoid
• ligamentous attachments
• coracohumeral ligament, coracoacromial ligament attach to coracoid
• coracoclavicular ligament which is composed of the conoid and the trapezium
• subscapularis tendon
• inserts onto lesser tuberosity
Presentation
• Symptoms • tenderness over anterior coracoid
• pain in anterior shoulder worsened by • position of maximal pain is 120-130° of
various degrees of flexion, adduction, arm flexion and internal rotation
and rotation
• Physical exam
Imaging
Radiographs • normal is 8.7 mm in the adducted arm 6.7 mm in the flexed arm
• recommended MRI
• findings • indications
• may show a decreased coracohumeral distance • used to evaluate degree of rotator cuff pathology
CT scan • findings
• increased signal in subscapularis
• views • increased signal in lesser tuberosity
• obtained with the arms crossed on chest is helpful to make the diagnosis
• views
• findings • axial view also effective to look for a decreased coracohumeral distance
• a coracohumeral distance of < 6 mm is considered abnormal
Studies
Diagnostic injection
• local corticosteroid injections
should eliminate symptoms and
can be diagnostic
Treatment
• Nonoperative
rest, ice, activity modification, NSAIDS, corticosteroid injections
• Operative
arthroscopic coracoplasty ± subscapularis repair
open coracoplasty
Treatment
rest, ice, activity modification, NSAIDS, corticosteroid injections
• indications : first line of treatment
• techniques
• local corticosteroid injections can be diagnostic and therapeutic
• PT focuses on stretching
Treatment
Arthroscopic coracoplasty ± subscapularis repair
• indications
• symptoms refractory to conservative treatment
• subscapularis tearing secondary to impingement
• technique
• resect posterolateral coracoid to create 7 mm clearance between coracoid and
subscapularis
• if significant subscapularis tendon tear then repair
Treatment
open coracoplasty
• indications
• symptoms refractory to conservative treatment
• subscapularis tearing secondary to impingement
• technique
• resect lateral aspect of coracoid process and reattach the conjoined tendon to the
remaining coracoid

Impingement & Rotator Cuff

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Impingement & Rotator Cuff

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IMPINGEMENT &

30° caudal tilt view

supraspinatus outlet view

 calcification of the coracoacromial ligament

 cystic changes within the greater tuberosity

 Type III-hooked acromion

physical therapy, oral anti-inflammatory medication, subacromial

subacromial decompression / acromioplasty

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