This document discusses painful arc syndrome, also known as impingement syndrome. It begins with a brief history, noting early descriptions in the 1800s and contributions in the 1970s by Neer, who characterized it as impingement of the rotator cuff tendons against the acromion. It then describes the four main types of impingement and their causes. Treatment options discussed include non-operative treatments like anti-inflammatories and physiotherapy, as well as surgical options like arthroscopic acromioplasty to remove bone and relieve impingement. Potential complications of surgery are also outlined.

1. PAINFUL ARC SYNDROME
PRESENTOR- DR.SHARAN HONGAL

2. ALSO LNOWN AS
IMPINGEMENT SYNDROME
SUBACROMIAL IMPINGEMENT
SUPRASPINITUS SYNDROME
SWIMMER’S SHOULDER
THROWER’S SHOULDER

3. • 1867 FIRST JARJAVAY’S
DESCRIBED AS SUBACROMIAL
BURSITIS
• 1931 CODMAN NOTED THAT
PATIENTS WITH INABILITY TO
ABDUCT THE ARM HAD
INCOMPLETE OR COMPLETE
RUPTURES OF THE
SUPRASPINATUS TENDON

4. • 1972 NEER CHARACTERIZED IT BY
RIDGE OF PROLIFERATIVE SPURS
AND EXCRESCENCES ON THE
UNDERSURFACE OF THE ANTERIOR
PROCESS OF ACROMION
APPARENTLY CAUSED BY REPEATED
IMPINGEMENT OF ROTATORY CUFF
AND HUMERAL HEAD WITH TRACTION
OF THE CORACOACROMIAL
LIGAMENT.

5. • LATER NEER INTRODUCED
IMPINGEMENT SYNDROME
THE SUPRASPINITUS INSERTION
INTO GREATER TUBIROSITY
THAT PASSS BENEATH THE
CORACOACROMIAL ARCH
DURING FORWARD FLEXION OF
SHOULDER IS SUSCEPTIBLE TO
IMPINGEMENT.

6. • NEER IMPINGEMENT SIGN
WITH THE PATIENT SEATED, THE
EXAMINER RAISES THE AFFECTED
ARM IN FORCED FORWARD
ELEVATION WHILE STABILIZING
THE SCAPULA, CAUSING THE
GREATER TUBEROSITY TO
IMPINGE AGAINST THE
ACROMION.
• NEER IMPINGEMENT TEST
SUBACROMIAL INJECTION OF 10
ML OF 1% XYLOCAINE. PAIN
CAUSED BY IMPINGEMENT
USUALLY IS SIGNIFICANTLY
REDUCED OR ELIMINATED, BUT
PAIN CAUSED BY OTHER
CONDITIONS (WITH THE
EXCEPTION PERHAPS OF CALCIFIC
TENDINITIS) IS NOT RELIEVED

8. • Acromial morphology has been implicated as contributing to
impingement.

9. • SOME INVESTIGATION HAVE SUGGESTED THAT ACROMION SHAPE
AND CORACOACROMIAL LIGAMENT ARE NOT PRIMARY PROBLEMS
• AGE-RELATED DEGENERATIVE CHANGES, INCLUDING DECREASED
CELLULARITY, FASCICULAR THINNING AND DISRUPTION,
ACCUMULATION OF GRANULATION TISSUE, AND DYSTROPHIC
CALCIFICATION, ALL HAVE BEEN NOTED AND ARE LIKELY IRREVERSIBLE
• SOME HAVE SUGGESTED THAT THE ROTATOR CUFF TENDONS MAY
FAIL IN TENSION AS A RESULT OF THROWING A BASEBALL OR OTHER
OVERHEAD SPORTS.

10. THERE ARE FOUR TYPES
• PRIMARY IMPINGEMENT
• SECONDARY IMPINGEMENT
• SUBCOROCHOID IMPINGEMENT
• INTERNAL IMPINGEMENT

11. • PRIMARY
IT IS CLASSIC VERSION AND OCCURS WITHOUT ANY OTHER
CONTRIBUTING PATHOLOGY
DIVIDED INTO
INTRINSIC
EXTRINSIC

12. • SECONDARY
IT OCCURS WEN THERE IS INSTABILITY OF THE GLENOHUMERAL JOINT
ALLOWING TRANSLATION OF HUMERAL HEAD TYPICALLY ANTERIORLY
RESULTING IN CONTACT OF ROTATORY CUFF AGAINST
CORACOACROMIAL ARCH
INRINSIC
EXTRINSIC

13. • INTRINSIC
STRUCTURES PASSING BENEATH THE CORACOACROMIAL ARCH
BECOME ENLARGED RESULTING IN ABUTMENT AGAINST THE ARCH
THICKINING OF ROTATOR CUFF
CALCIUM DEPOSITS WITHIN ROTATOR CUFF
THICKENING OF SUBACROMIAL BURSA

14. • EXTRINSIC
WHEN THE SPACE AVAILABLE FOR THE ROTATOR CUFF IS DIMINISHED
SUBACROMIAL SPURRING
ACROMIAL FRACTURE
OSTEOPHYTES OFF ACROMIOCLAVICULAR JOINT
EXOSTOSES OF GREATER TUBEROSITY

15. SUBCORACOID IMPINGEMENT
PAIN CAUSED BY CONTACT
BETWEEN THE ROTATOR CUFF
AND THE CORACOID PROCESS
MAINLY DUE TO PROMINENT
CORACOID
WHICH MAY BE
IDIOPATHIC (MOST COMMON)
IATROGENIC

16. INTERNAL IMPINGEMENT
• INTERNAL CONTACT OF THE
ROTATOR CUFF OCCURS WITH THE
POSTEROSUPERIOR ASPECT OF
GLENOID WHEN THE ARM IS
ABDUCTED, EXTENDED AND
EXTERNALLY ROTATED AS IN THE
COCKED POSITION OF THE
THROWING MOTION

17. • OFTEN SEEN IN THROWERS WHO HAVE LOST INTERNAL ROTATION OF
SHOULDER
• THIS LOSS CAUSES THE CENTER OF ROTATION OF HUMERAL HEAD TO
MOVE UPWARD SO THAT THE CONTACT BETWEEN ROTATORY CUFF
AND BICEPS TENDON ATTACHMENTS INCREASES

18. ARTHROSCOPIC FINDINGS
• PARTIAL ROTATORY CUFF
TEAR
• POSTERIOR AND SUPERIOR
LABRAL TEARS
• ANTERIOR SHOULDER LAXITY

19. DIFFERENTIAL DIAGNOSIS
• ACROMIOCLAVICULAR ARTHRITIS
• GLENOHUMERAL ARTHRITIS
• SHOULDER INSTABILITY IN THROWING ATHLETES
• ADHESIVE CAPSULITIS
• FIBROMYALGIA
• CERVICAL SPONDYLOSIS
• SUPRASCAPULAR NERVE INJURY

20. TREATMENT
• NON OPERATIVE REGIMEN
ANTIINFLAMMATORY MEDICATION
½ SUBACROMIAL CORTISONE
INJECTION
PHYSIOTHERAPY ON
STRENGTHNING THE ROTATORY
CUFF & FULL RANGE OF
MOVEMENTS

21. • OPERATIVE
ARTHROSCOPIC OR
ANTERIOR ACROMIOPLASTY

23. • ADEQUATE BONE MUST BE REMOVED TO ALLEVIATE OUTLET
STENOSIS.
• IN ADDITION TO THE ANTERIOR LIP, THE PORTION OF THE ACROMION
ANTERIOR TO THE ANTERIOR CLAVICULAR BORDER MUST BE
REMOVED TO OBTAIN OPTIMAL RESULT
• OUR CURRENT PRACTICE IS TO RELEASE THE LIGAMENT. WE BELIEVE
THAT THE LIGAMENT CAN BE PART OF THE PATHOLOGICAL PROCESS
AND ANTICIPATE THAT IT WOULD HEAL BACK TO THE ACROMION,
RESTORING THE CORACOACROMIAL ARCH AND PREVENTING
ANTEROSUPERIOR SUBLUXATION OF THE HUMERAL HEAD.

25. • RELEASE OF THE CORACOACROMIAL LIGAMENT
• REMOVAL OF THE ANTERIOR LIP AND LATERAL EDGE OF THE
ACROMION
• REMOVAL OF PART OF THE ACROMION ANTERIOR TO THE ANTERIOR
BODER OF CLAVICLE
• REMOVAL OF THE DISTAL 1 TO 1.5 cm OF CLAVICLE IF SIGNIFICANT
DEGENRATIVE CHANGES ARE FOUND

26. • COMPLICATIONS AFTER ACROMIOPLASTY INCLUDE, BUT ARE NOT
LIMITED TO, INFECTION, SEROMA FORMATION, HEMATOMA,
SYNOVIAL FISTULA, BICEPS RUPTURE, PULMONARY EMBOLUS,
ACROMIAL FRACTURE, AND COMPLEX REGIONAL PAIN SYNDROME.
POOR PATIENT MOTIVATION, POOR REHABILITATION COMPLIANCE,
OR A POORLY DESIGNED REHABILITATION PROGRAM ALSO CAN LEAD
TO FAILURE BECAUSE OF CONTINUED PAIN AND STIFFNESS.
• WITHOUT QUESTION, THE WORST COMMON COMPLICATION IS LOSS
OF ANTERIOR DELTOID FUNCTION, WHICH IS CAUSED BY EITHER
AXILLARY NERVE INJURY OR DETACHMENT OF THE DELTOID FROM
THE ACROMION

27. REFERANCE
• CAMPBELL’S OPERATIVE ORTHOPAEDICS
• MCRAE’S

28. THANK YOU