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Impingement syndromes

  1. 1. Impingement Syndromes in Shoulder pathology Manos Antonogiannakis Director 2nd Orthopaedic Department Center for Shoulder Arthroscopy IASO General Hospital
  2. 2. Introduction Subacromial Space a 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.
  3. 3. By definition “shoulder impingement syndrome” was considered the Subacromial outlet obstruction resulting in trauma to the supraspinatus tendon. In other words the supraspinatus tendon 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
  4. 4. The History of Impingement Syndrome Neer classified and named the disorder as shoulder impingement. More over he classified the diagnostic process. Neer, JBJS(A) 1972
  5. 5. The History of Impingement Syndrome However, the process itself was first described but not named by Meyer as early as 1931. Meyer AW JBJS 1931;13:341-360
  6. 6. The History of Impingement Syndrome 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of Impingement Syndrome was an important step in understanding shoulder pathology for its time, but it is now outdated.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
  7. 7. Current classification of shoulder impingement syndromes • Primary and secondary Subacromial Impingement • Coracohumeral Impingement • Glenoid (Internal) Impingement • ASI (AnteroSuperior Impingement) • PSGI (PosteroSuperior Glenoid Impingement)
  8. 8. Primary Subacromial Impingement Primary impingement or external-Subacromial impingement 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
  9. 9. Primary Subacromial Impingement  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.
  10. 10. Primary Subacromial Impingement  Subacromial spurring  DJD AC joint  Os Acromiale  Increased thoracic kyphosis
  11. 11. 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
  12. 12. Radiographic Evaluation  Plain X-ray Outlet View  MRI  Ultrasound
  13. 13. Subacromial external impingement Impingement Neer’s test positive Hawkins test positive
  14. 14. Primary subacromial Impingement Why partial rot cuf tears are usually at the articular side?  Fewer arteriolars  Greater stiffness  Less favorable stress- strain curve
  15. 15. Secondary Subacromial Impingement •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.
  16. 16. Secondary Subacromial Impingement •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
  17. 17. 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).
  18. 18. Clinical Examination  Rule out neck pathology (cervical radiculitis / DJD)  Test Rc muscle strength  Test active – passive ROM  Neer’s test  Hawkins Test
  19. 19. Conservative Treatment  Duration up to 6 months depending on patients demands  Modification of activity  NSAIDs  Steroid Injections  Physiotherapy
  20. 20. Surgical Treatment  Acromioplasty (primary impingement)  DCE (primary impingement)  Cuff debridement/repair (primary or secondary)  Repair of anterior instability if present (secondary impingement)
  21. 21. Surgical Treatment Acromioplasty  Detachment of CA ligament  Soft tissue removal
  22. 22. Surgical Treatment Acromioplasty
  23. 23. Surgical Treatment Distal Clavicle Excision
  24. 24. Subcoracoid impingement Impingement of the coracoid process against the humerus (usually the lesser tuberosity) in a coracoid impingement position (humerus is flexed, adducted and internally rotated)
  25. 25. Subcoracoid Impingement  Subcoracoid space: Interval between the tip of the coracoid and the humeral head (the coracohumeral interval).  Normal coracohumeral interval: 8.4- 11.0mm  Subcoracoid stenosis: Narrowing of the Subcoracoid space with a coracohumeral interval of less than 6mm. Bigliani, JBJS 1997 Current Concepts Review - Subacromial Impingement Syndrome
  26. 26. 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.
  27. 27. 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
  28. 28. Internal Impingement Types: I. Anterior Superior Impingement (ASI) II. Posterior Superior Glenoid Impingement (PSGI)
  29. 29. 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 defind concept  Gerber and Sebesta first described ASI as a form of intra-articular impingement responsible for unexplained anterior shoulder pain and managed to reproduce the impingement mechanism during arthroscopy J Shoulder Elbow Surg (2000) 9:483–490
  30. 30. Anterior Superior Internal Impingement  While the articular side of the posterior-superior rotator cuff is involved in PSGI, the articular side 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
  32. 32. Anterior Superior Internal Impingement 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 subscapularis tendon Habermeyer (2004)J Shoulder Elbow Surg 13:5–12
  33. 33. Anterior Superior Internal Impingement Clinical Examination  Hawkins with forward elevation >90 positive
  34. 34. Internal Impingement – Clinical Examination O’Brien’s test = positive 66.7%
  35. 35. Anterior Superior Internal Impingement Imaging •Ultrasound •MRI •MRI Arthro No specific findings LHB tendon instability in u/s Clinical tests and imaging are not specific for ASI. ASI is best determined by dynamic evaluation in arthroscopy
  36. 36. Anterior Superior Internal Impingement Treatment •there are no published guidelines or treatment protocols for the 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
  37. 37. 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
  38. 38. Some contact between these structures is physiologic, but repetitive contact with altered shoulder mechanics may be pathologic Posterior Superior Glenoid Internal Impingement - Definition
  39. 39. For undefined reasons this contact in some athletes become pathologic and produces symptoms Posterior Superior Glenoid Internal Impingement
  40. 40. Normally in abduction and external rotation (ABER) there is obligate posterior & inferior translation of the humerus that allows for more motion and less contact between the greater tuberosity and the posterosuperior glenoid rim Posterior Superior Glenoid Impingement
  41. 41. Mechanism of PSGI Two major theories:  Andrew  Burkhart & Morgan May co-exist
  42. 42. Mechanism of PSGI Andrew 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
  43. 43. Mechanism of PSGI Burkhart & Morgan Theory: Repeated ABER Tight posterior capsule Superior translation of Humeral Head Torsional stress to biceps anchor Peel-off Mechanism SLAP II and Pseudolaxity Increased contact of undersurface of RC and posterosuperior glenoid Internal Impingement
  44. 44. It is essentially an overuse injury associated with overhead athletes Posterior Superior Glenoid Impingement
  45. 45.  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 Posterior Superior Glenoid Impingement
  46. 46. Internal impingement
  47. 47. Structures involved:  Humeral head  Anterior capsule  Inferior GHL  Posterior capsule  Rot cuff muscles Posterior Superior Glenoid Impingement
  48. 48. PSGI History  Chronicity of pain  Posterior pain  Abduction + external rotation aggravates pain
  49. 49. PSGI History  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
  50. 50. 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.
  51. 51. 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
  52. 52. PSGI Clinical Examination Provocative tests:  Neer’s test = negative
  53. 53. PSGI Clinical Examination Provocative tests: O’Brien’s test = negative (unless SLAP lesion)
  54. 54. 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)
  55. 55. 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
  56. 56. PSGI MRI findings
  57. 57. 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
  58. 58. PSG Internal Impingement – Arthroscopic findings
  59. 59. PSG Impingement – Treatment  Conservative  Surgical
  60. 60. 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
  61. 61. 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
  62. 62. 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 ?
  63. 63. PSG Impingement – Surgical Treatment  Open/Arthroscopic Capsulolabral Reconstruction  Arthrolysis of posterior capsule tightness  Repair of SLAP lesions  Repair of the rot cuff  Address anterior capsule laxity (50 - 81% pre-injury level)
  64. 64. PSG Impingement – Surgical Treatment
  65. 65. PSG Impingement – Surgical Treatment
  66. 66. PSG Impingement – Surgical Treatment
  67. 67. Internal impingement – Surgical Treatments Infrequently Used Today  Arthroscopic Thermal Capsulorraphy Another method to reduce the anterior capsular laxity At the same time debridement + arthroscopic fixation of labral tears 86% return to pre-injury level  Rotational Osteotomy Derotation osteotomy of humerous => increase of retroversion + shortening of subscapularis => less impingement 55% return to pre-injury level
  68. 68. Subacromial decompression  22% of throwing athletes returned to the same level of participation after subacromial decompression Tibone ,Jobe. CORR 1985 PSG Impingement – Surgical Treatment
  69. 69. 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
  70. 70.  Initial treatment:  Complete REST + PHYSIOTHERAPY  If symptoms persist:  Multiple surgical techniques  Repair all lesions if possible Take home messages
  71. 71.  Subacromial impingement was the first concept developed  Valid especially in older non- athletic popullation but partiall  Subacromial decompression very effective Take home messages
  72. 72.  Secondary subacromial impingement 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
  73. 73.  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
  74. 74.  Subcoracoid impingement an other cause to keep in mind and repair when treating anterosuperior RC tears (subscapularis LHB anterior supraspinatus Take home messages
  75. 75. Thank you for your attention
  76. 76. Case-1  Female, 23years  Gym Academy, Volley player  Loose joints  4 months Pain at ABD+EXT ROT  Suprasipatus test +, Relocation Test +
  77. 77. Case-1 MRI Partial RC tear
  78. 78. Case-1
  79. 79. Case-1
  80. 80. Case-1
  81. 81. Case-1 6 months post OP
  82. 82. Internal Impingement Throwing phases:
  83. 83. Internal impingement Throwing phases:
  84. 84. PSG Impingement – Arthroscopic findings
  85. 85. PSG Impingement – Arthroscopic findings