March 3RD 2020

SUBACROMIAL IMPINGEMENT

Team II :
RO/KE/MZ/ZA
Mod : HP
Supervisor :
Dr. Andi Dhedie Prasatia Sam , M.Kes, SpOT(K)
 CASE REPORT
• The patient was a 54 y/o Caucasian female
who was throwing a ball for her dog when she
felt a pop in her right shoulder in April. She
was referred to physical therapy for right
shoulder pain. The patient participated in
conservative physical therapy treatment for
one month, which resulted in poor outcomes
due to high levels of pain.
 Introduction
• Subacromial impingement syndrome (SAIS) is
the most common disorder of shoulder,
accounting for 44-65% of all complaints of
shoulder pain
• SAIS is an encroachment of the subacromial
tissues as a result of narrowing of the
subacromial space.

Orthopedic Reviews 2012; volume 4:e18

 Introduction
• Subacromial space is defined by the humeral
head inferiorly, the anterior edge and under
surface of the anterior third of the acromion,
coracoacromial ligament and the
acromioclavicular joint superiorly. The height
of space between acromion and humeral head
ranges from 1.0 to 1.5 centimeters as seen on
radiographs.

Orthopedic Reviews 2012; volume 4:e18

 Introduction
Neer described three stages of impingement.
Stage-I
edema and hemorrhage of the subacromial bursa and cuff. It is
typically found in patients who are less than twenty-five years
old.
Stage-II
irreversible changes, such as fibrosis and tendinitis of the
rotator cuff, and is typically found in patients who are twenty-
five to forty years old.
Stage-III
more chronic changes, such as partial or complete tears of the
rotator cuff, and usually is seen in patients who are more than
forty years old.
Orthopedic Reviews 2012; volume 4:e18
 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 and narrowing of the subacromial space

• inflammatory process
– inflammation of the subacromial bursa due to abutement between
the humerus and rotator cuff, and acromion and associated
ligaments 

Orthobullet,2012
 Classification
• Bigliani classification of acromion
morphology (based on a supraspinatus outlet
view) classification types
– Type I - flat
– Type II - curved
– Type III - hooked

Orthobullet,2012
Campbell, 12 th edition
 Symptoms
• Pain
– insidious onset
– exacerbated by overhead activities and lifting
objects away from body
– night pain

Orthobullet,2012
impingement sign
positive if passive forward flexion >90° causes pain
positive Neer impingement test
if a subacromial injection relieves pain associated with passive forward flexion
>90°
Campbell, 12 th edition
Hawkins test
positive if internal rotation and passive forward flexion to 90° causes pain

Campbell, 12 th edition
Jobe test
pain with resisted pronation and forward flexion to 90° indicates supraspinatus
pathology

Campbell, 12 th edition
 Radiographs
• true AP of the shoulder 
• 30° caudal tilt view

Orthobullet,2012
Caudal tilt view
 Treatment
• Nonoperative
– physical therapy, oral anti-inflammatory
medication, subacromial injections
• Operative
– subacromial decompression / acromioplasty

Orthobullet,2012
 Complications
• Deltoid dysfunction
• Anterosuperior escape

Orthobullet,2012
Q&A
• Arthroscopic subacromial decompression with
acromioplasty has been shown to yield lower
subjective satisfaction scores in patients with
which of the following preoperative factors?
• 1 Dominant arm involvement
• 2 Males
• 3 Workers' compensation
• 4 Smokers
• 5 age < 60 yo
• PREFERRED RESPONSE 3 
• The first two referenced articles found that
patients with active worker’s compensation
claims reported significantly decreased
satisfaction postoperatively compared to the
rest of the cohort. The most recent article
reported similar scores, but longer time to
return to work.