Shoulder

Impingement
syndrome
 Objectives
• Shoulder impingement
- Definition
- Risk Factor
- Classification
• Diagnoses
- Clinical Picture
- Special test
• Treatment Recommendation : know what forms of treatment are suitable.
 Surgery
• Approximately 30% of patients undergo surgery after ineffective
conservative treatment .
• Surgery is indicated if the symptoms fail to improve after 3 or more
months of conservative treatment.
• Caution is advised if the diagnosis is unclear or in the setting of
marked restriction of glenohumeral movement, muscle atrophy,
mental illness, or a relevant underlying neurological disease.
 Surgery
• Subacromial decompression: This involves removal of the anterior
and lateral portions of the undersurface of the acromion (5–8 mm)
and detachment of the coracoacromial ligament.
• Bursectomy: As the bursa is usually affected by inflammatory
changes, this tissue is removed. A randomized trial showed no
difference in the functional outcome of bursectomy with and without
additional acromioplasty, but the acromion type and the nature of
symptoms did have an effect on the outcome
 Surgery
• Rotator cuff damage: Lesions of the rotator cuff can be partial—
affecting the articular part of the joint, the bursa, or the tendons—or
total (rupture). Complete ruptures are assessed in terms of their size,
the number and nature of the affected tendons, and retraction, fatty
degeneration, and atrophy of the corresponding muscles.
• These factors are of prognostic significance regardless of whether an
open or an arthroscopic technique is used
 Surgery
• Surgery is indicated if the patient is suffering from pain and a
disturbing loss of function; age plays a steadily less important role.
• Surgery is particularly favored for younger patients, those with high
functional requirements, and those whose impingement syndrome
was caused by trauma.
• All traumatic ruptures and all ruptures of the subscapularis tendon
are absolute indications for surgery
 Surgery
• Predictors of an unfavorable outcome after rotator cuff
reconstruction or of an unreconstructable rupture
● Severe muscle atrophy and fatty degeneration
● Involvement of more than two tendons
● Preoperative acromiohumeral distance (AHD) less than 7 mm
● Weak external rotation
● Positive external rotation lag sign
 AC injuries
• Acute AC modified classification system
by Rockwood describes six different types of AC joint injuries.
AC injuries
AC injuries
AC injuries
 AC injuries
Classification Description Notes
Type 1 Ac joint strain Normal radiograph
Localized tenderness
Pain with flexion
Type 2 Ac disruption , CC disrupted Mild vertical separation
Normal AC interval 5-8 mm
Small palpable step off
Type 3 AC and CC disrupted CC distance 25 – 100 of sound side
Marked step deformity
Type 4 Distal clavicle positioned posterior Marked step deformity
to acromion
Type 5 Distal clavicle positioned superior Marked step deformity
to acromion Greater soft tissue injuries
Type 6 Distal clavicle positioned inferior to Rare
coracoid
 AC injuries
• Conventional radiographic assessment of patients with clinically
suspected instability of the AC joint should include a bilateral, weight-
bearing Zanca view radiograph (10 kg, “water-bearer” radiograph,
• An axial radiograph and bilateral Alexander view radiographs (outlet
view with cross-body maneuver)
 AC injuries

Bilateral weight bearing zanca view

 AC injuries

Alexander view
 AC injuries
• Management is based on the general principles of management of
ligamentous injuries.
• Initially, ice is applied to minimise the degree of damage and the
injured part is immobilised in a sling for pain relief.
• This may be for 2-3 days in the case of type I injuries or up to 6 weeks
in severe type II or type III injuries.
• Isometric strengthening exercises should be commenced once pain
permits.
• Return to sport is possible when there is no further localised
tenderness and full range of pain-free movement has been regained
 AC injuries

Surgery : arthroscopic or open

reduction internal fixation
 AC injuries
• Chronic AC injuries : OA AC
• Osteoarthritis of the AC joint may occur as a result of recurrent
injuries. This is characterised by a typical radiographic appearance
with sclerosis and osteophyte formation.
• Seen especially in weight lifters
performing large number of chest press
• Treatment: mobilization, MWM and ex