This document discusses anatomical considerations related to impingement syndrome and rotator cuff tears. It describes four types of impingement syndromes, including subacromial impingement, which is the most common. Stages of subacromial impingement are outlined from stage I involving tendonitis to stage IV with cuff tear arthropathy. Diagnosis is mainly clinical through evaluation of range of motion and impingement tests. Imaging such as MRI can further assess tendon integrity and tear size. Treatment options include conservative measures, arthroscopic subacromial decompression, or open repair of torn rotator cuff tendons.

1. Anatomical considerations
of the shoulder girdle
IMPINGMENT SYNDROME
& ROTATOR CUFF TEAR
Mohamed Hamdi Elgawadi ,MD,FRCS (T&O)

2.  Definition:
 Abnormal Contact
Compression, Crushing
Encroachment, Entrapment
Of the Rotator Cuff

3.  Impingement" syndromes of the
shoulder includes 4 items ( Rossi,
1998):
 1-Subacromial impingement
syndrome
 2-Subcoracoid impingement syndrome
 3-Posterior superior glenoid rim
impingement syndrome
 4- Suprascapular nerve impingement
syndrome

4. Subcoracoid impingment
Decreased coracohumeral distance (less than 6 mm)
Normal 8.7 mm

5. Coracoplasty

6. Internal impingment
(GIRD)
caused by impingement of posterior under-
surface of supraspinatus tendon on
the posterosuperior glenoid rim
BENNETT LESION

7. INTERNAL VS EXTERNAL
Internal impingement refers to pathology on undersurface of rotator cuff
in contrast to
subacromial or "external" impingement which occurs on bursal side of rotator cuff

8. Anatomical considerations
of the shoulder girdle
Anatomical cosideration of
the shoulder girdle

9. Created wlth
TYPES OF ACROMION

10. Outlet is bounded by
CAarch
Strong arch resist upward thrust
(William and Worwick ,1980)
AC joint
Plane synovial diarthrodial
Stability by AC &CC ligaments

11. Vestigial (continuation of
pectoralis minor) (Batman ,1972)
Thickening of the
clavipectoral fascia (Iannotti et
al. ,1991)
Triangular to trapizoid
FUNCTIONS:
Humeral head guide
Prevent upward migration
of humeral head.

12.  The largest
 Roof is related to deltoid,
acromion and to CA
ligament
 Base is related to RC and
greater tuberosity of the
humerus

13.  SS
 IS
 Sb.S
• TMn
The critical zone
1 cm medial to SS attachment
 similar zone in IS & Sb.S
Area of anastomosis
Limits potentiality for healing

15.  Lindholm has described
an area of avascularity in
the supraspinatus tendon
proximal to its insertion
into the greater tuberosity.
 Dynamic reason
 Histological transition
that takes place from
tendon to calcified
fibrocartilage to bone

16. Pathological considerations
of subacromial
impingement syndrome

17.  Stage I lesion:
 Reversible oedema and haemorrhage in the tendon with bursal
irritation , below 25 years
 Stage II :
 Tendonitis and fibrosis with bursal thickening, superficial cuff
fibers dissociation , residual damage ,25-40 years
 Stage III :
 bony osteophytes appear, tendon wear and ruptures, partial
thickness &full thickness tear ,above 40 years
 Stage IV:
 Cuff tear arthropathy

18.  Jobe&Jobe in1983
 Stage I : tendonitis, of SS and LHB, with oedema
 Stage II : fibers dissociation
 Stage III : rotator cuff tears of less than 1cm
 Stage IV : the tear is more than 1 cm.
 Paulos et.al in 1996 stated that there are two distinct types
of impingement syndrome: primary and secondary.
1ry form is the classic form of Neer
Over 40 years
Treated by acromioplasty
2ry (normal subacromial anatomy)
Instability, trauma or overuse
Any age
Treated by managimg the cause

19.  1-Anatomical etiology. .
 2-Truamatic. Etiology
 3-Vascular. Etiology
 4-Degenerative etiology
 Impingement =
 4 factors interplay

20. Anatomical considerations
of the shoulder girdle
Diagnosis of subacromial
impingment syndrome

21. CLINICAL ISSUE
 Symptoms:
 Pain
 Limitation of motions
 Weakness
 Signs:
 Arc of pain
 Crepitus
 Weakness
 Impingement sign
 Impingement test

22.  Cuff tear:
 Dropping sign
 Shrugging sign
 Heamoarthrosis
 Cuff tear arthropathy:
 Advanced painful limitation of movement

23. 1. Forward elevation
(maximum arm-trunk angle)
2. Abduction (note classic
painful arc)
4. External r
(arm comfo
otation
rtably at side)
3. External rotation
(arm at 90 degree abduction

24.  The “lift-off” test can
help to assess
subscapularis
integrity

26.  Resisted ER
 Infraspinatus
 Teres Minor

27.  Neer sign for
impingement

28.  Hawkins Test

29.  Other causes of painful shoulder
 AC arthritis
 RC tear
 Frozen shoulder
 Calcific tendonitis
 LHB tendonitis
 GH instability ,arthritis
 AHSB (acute haemorrhagic subacromialbursitis)
 Snapping scapula
 Cervical radiculopathy C5-C6

30. Anatomical considerations
of the shoulder girdle
Radiological assessment of
subacromial impingment
syndrome

31. positive in late stage II and
 (A) Plain -X-ray:
stage III
 1-True AP view
 2-The 30˚ caudal tilt view
 3-supraspintus out let view
 4-Axillary view

32. 2-The 30˚ caudal tilt view

33. 4-Axillary view

34.  8 to 12
millimeters

37.  Squaring and or decalcification of
the greater tuberosity
 Anterior acromial spur and or
erosions
 Prominent under surface of
acromioclavicular joint
 Loss of acromiohumeral distance
(normal 7-13 mm.)
 GH instability
 RC tear arthropathy

38.  Dynamic and static
 Subjective
 Non invasive
 Cheap
Arthrography
Full thickness tear
CT scanning

39.  Magnetic resonance imaging is the most useful diagnostic
modality for shoulder disorders ( Rossi, 1998).
*SENETIVE AND SPECIFIC
*MORE OBJECTIVE (OPERATOR INDEPENDENT)
*NON INVASIVE
*HIGHER SOFT TISSIUE CONTRAST
*MULIPLANER(SAGITTAL,CORONAL&AXIAL)

40.  More accurate than X ray in evaluating acromion
 Can predict intra substance and partial thickness tear
 Assessment of bursa, LHB, labrum and CA ligament
MRI grade of RC evaluation
G 0 ……… normal
G I ………tendonitis increased signal
G II ……… increased signal and disturbed morphology
G III ……..subacromial subdeltoid fat plane disruption ”partialtear”
G IV………fluid in the bursa “complete tear”

42. Anatomical considerations
of the shoulder girdle
Treatment of subacromial
impingment syndrome

43. prophylactic curative
Conservative
-rest
-NSAID
-corticosteroid injection
-physical therapy
Surgical
-CA ligament release
-Ant.Acromioplasty
-lat. Clavicle excision
-repair of RC tear
-biceps tenodesis
-epsilon of calcified
deposit
-combination

44.  Above 40 years
 No rotator cuff tear
 Persistent disability
 Pain can be eliminated by impingement test.
 Under 40 years
 Stage II impingement lesions
 or any young active patient with his work requiring
an over head movement of the arm
 if conservative ttt fail.

45.  Good prognostic signs:
 (1)A well motivated patient over 40 years old.
 (2)Absence of posterior capsularstiffness.
 (3)Presence of subacromial crepitus.
 (4)Pain relieved by the subacromial injection of lidocaine.
 (5)A condition that is unrelated to the patient's occupation.
 Poor prognostic signs:
 (1)Age less than 40 years old.
 (2)Stiffness.
 (3)Absence of subacromial crepitus.
 (4)Lack of relieve by subacromial injection.
 (5)Attribution of problem to occupation.
 (6)Concomitant evidence of glenohumeral instability.
 (7)Neurogenic cuff muscle weakness.

47.  Arthroscope.
 Mini open repair.
 Open repair.

48.  Indication:
-Patient are unable to tolerate either the
surgery or post operative rehabilitation of
an open procedure.

49.  Procedure :-
1Glenohumeral inspection.
2 Bursectomy.
3Determination of cuff reliability.
4- Identification of tear geometry.
5- Resection of coracoacromial ligament.

50. 6Acromioplasty.
7Greater tuberosity preparation.
8- Anchor placement.
9 Suture placement.
10 Knot tying.

51.  Post operative management:
- 6 weeks passive ROM.
- Then active ROM.
- Strengthening excersise at 3 month.
- Rehabilitation continue for 6 - 12 month.

53.  The technique combines Arthroscopic
subacromial decompression with open
tendon repair through a small deltoid split.

54.  Advantages:-
- Lower preoperative morbidity.
- Short hospital stay.
- Cosmetic incision.
- Short rehabilitation period.
- Preservation of deltoid origin during repair.

55.  Patient selection:-
Mini open repair is usually reserved for
patient with small to medium sized tears
<3cm without significant retraction.

57. ROTATOR CUFF ARTHROPATHY

58. Reverse TSA
TSA
GLENOID LOOSENING BY ( ROCKING
HORSE PHENOMENON)

60.  Impingement syndrome, presents one of the most
common cause of a painful shoulder
 Diagnosis of impingement syndrome is mainly a
CLINICAL issue
 Arthroscopic subacromial decompression carry more
advantages over open acromioplasty

61. THANK YOU
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