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Anterior Acromioplasty for the Chronic Impingement Syndrome in the

Shoulder: A PRELIMINARY REPORT
CHARLES S. NEER, II
J Bone Joint Surg Am. 1972;54:41-50.

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The Journal of Bone and Joint Surgery

20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org

Anterior

Acromioplasty

I mpingement

for the Chronic

Syndrome

in the Shoulder

A PRELIMINARY
BY

CHARLES

S.

the Departtnent

Fron
Surgeons,

II,

M.D.t,

Orthopaedie

of

Columbia

NEER

REPORT

University,

Surgery,

and

The

Columbia-Presbyterian

Impingement
recognized

of

as one

the

of the

NEW

rotator

cuff

causes

York

the

Y.

of Physicians

Orthopaedic

Center,

beneath

of chronic

N.

College

New

Medical

YORK,

New

and

Hospital,

York

coraco-acromial

disability

of the

arch

shoulder

1.5,6

has

7,9,

been
Corn-

10

plete
acromionectonly
1,5,10
and lateral
acromionectomy
6.9
at various
levels
have
been advocated
for the condition.
Disappointment
with the results
of these
procedunes,
because
of weakening
of the leverage
of the deltoid
muscle,
displacement
of
the attachments
of the origin
of the deltoid,
fluid draining
through
the skin,
deep scars,
tomy,
the persistence
of symptoms
because

to a new
acrom

study

of the

role,

in the

impingement

relevant

anatomical

This

paper

describes

the technique,

been

and the preliminary

a procedure

revealed

performed

Inspection
of
alterations

the cadavera
characteristic

in

our

the

anterior

of the

ment,

and

erosion

of

process

was

rotator
cuff
it was quite
the acromion

three
specimens
surface
of the
erosion,

100 dissected
attributable

clinic

(Fig.
anterior

undersurface

of the

My

acrom

ion

observations
area for
tendon,

degenerative
extending

but

massive
the

tendon

and

long

head

insertion

Read

21, 1971.
161 Fort Washington

Virginia,

at the Annual

apparently

caused

cuff

posterior

have

it was
In one
tear,

third

sixth
on

has

the acromion
The ages of

decade
the

by

or older.
undersurface

repeated

consistently

of the

of the
Meeting

biceps

(Fig.

the anterior
scapula,
the

extended
was

impinge-

of The

lies just
American

underand

further

the

toward

it has

that

the

in the suprainfraspinatus
not

been

ade-

position,
all of these structhe position
in which
the
With external
rotation,
the

lateral

Orthopaedic

hypothesis

is centered
part of the

However,

arm in the anatomical

With
internal
rotation,
even more anterior.

supraspinatus

somewhat

rupture
anterior
2).

lip and
eburnation

spared.

supported

tendinitis
and tendon
at times
to include
the

quately
emphasized
that, with the
tures
lie anterior
to the acromion.
arni is often
used,
they are brought
facet for the

indica-

which

attention
to
in eleven.

majority
were
in the
spurs
and excrescences

Without
exception,
that was involved.

at surgery

critical
spinatus

the

the

I 965.

since

frequently,

by an old

of the

rationale,

Considerations

the

seen

the

acromioplasty,

and humeral
head,
with traction
on the coracoacromial
ligaprominent
in eight
specimens
(Fig.
1 -A). Eburnation
with
was thought
to be a later manifestation,
and was found
in
1-B).
third

accompanied

center

and

ofanterior

scapulae
with special
to mechanical
impingement

were unknown
but
ridge
of proliferative

ment

VOL.

of the

findings

results

Anatomical

the

syndrome,

ion.

tions,

of

formation
of sinuses
with bursal
or joint
and, in the case of lateral
acroniionecof residual
impingement,
stimulated
us

to the

anterior

Association,

third
Hot

of

Springs,

June

54-A,

NO.

1, JANUARY

Avenue,
1972

New

York,

N. Y. 10032.
41

42

C.

II

1-A

FI;.

Figs.
Fig.
thought
Spatial
Fig.

S. NEER,

1-B

FIG.

1-A and I -B: Photographs

of the undersurface
of the acromion
of elderly
cadavera.
1-A: Showing
a large
anterior
acromial
spur and excrescences
of the anterior
third,
characteristic
of chronic
impingement
with traction
on the coraco-acromial
ligament.
relations
can be determined
by the location
of the articular
facet for the clavicle.
1-B: Another
specimen
showing
erosion
of this area and eburnation,
which
appeared
to

be a later manifestation.

the

acromion

tomical

acromial

3). Thus,

(Fig.

position

of

external

ligament

elevation

of the arm in internal

rotation
or in the anathe critical
area to pass under
the coracoprocess
of the acromion.
The critical
area does not

rotation

or the

causes

anterior

touch
the posterior
two-thirds
of the acromion.
With scapular
rotation
the
is tilted
backwards,
leaving
the anterior
process
as the leading
edge.
At about
80 degrees
of abduction,
the critical
area of the supraspinatus

acromion

passes

beneath

elevation

of the

arm.

the

With

the undersurface
Arthrograms
One
deltoid
also

acroniioclavicularjoint

the joint

thesis

of

removes

an

pathological

this
innocent

supraspinatus

is that
part

the

a lateral

of

the

is rubbing

be

when

acromion,

the

that
that
One

anterior

coraco-acrornial
ligament.
If other
pathological
that is, a hypertrophic
acromioclavicular
joint,
head of the biceps
or greater
tuberosity,
they
ments

of the deltoid

should

be minimally

the

excrescences

impinge
not

rotator
part

the

therefore
along

cuff.

weakens
to

surface

should

on

the

the

is deficient,

posterior

process

on

only

cuff

rough

tendon

overhead

that

may

acromionectomy
bad

removed.
of

with

to assume

acromion

important

undersurface

tilts

it is logical

is especially
It seems

tendon
and

thisjoint

margin
of the
this point.

study
which

involvement.

edge

position,

of the anterior
seem to substantiate

unnecessarily,

terior

in this

and

the

on

areas
are discovered
or spurs
and adhesions
too should
be removed.

site

which

remove
with

but

the

the

of
the
an-

attached

at operation,
at the long
The attach-

disturbed.
Material

During
ated
tendon
twenty,

on

the years

by the
consisted
and

method

1965

of tendinitis

evidences

to 1970,

to be described.
of

shoulders

The

or partial
residual

fifty

tears

of

pathological
in nineteen

impingement

following
THE

JOURNAL

forty-six

findings

patients

were

shoulders,

complete

lateral

acromionectomy

OF BONE

oper-

in the supraspinatus

AND

JOINT

tears

in
in

SURGERY

ANTERIOR

43

ACROMIOPLASTY

cw

AIc

Fu.

2: Illustrating
the relationships
of the critical
is held in the anatomical
position.
Note the

Fig.

the

arm

and the proximity

Fig.

3:

at the

FI(;.

of the bicipital

Drawing

to

supraspinatus

Patients

niatoid

arthritis,

was

with

with

the

anterior

ages

the

was

patients

shoulder
Forty-seven

surgery,
Three

involved

twice

shoulders

were

twenty-nine
shoulders
had

genograms
and

was

were

one-half

cuff

procedure

to be

rotator

cuff.

lesions

did

described

not

The

first

comprise

the

necessarily

garded

as chemical

simple
patients

treatment
in this

rheu-

this

study,

years

and

tears and 58. 1 years

for
and eighteen
were women.

av-

those
The

left.

nine

nionths

average

to five years

questionnaire
period.

duration

at the

critical

Patients

following

and
Follow-up

of follow-up

complete.

and

tenderness

VOL.

54-A,

NO.

over
I, JANUARY

The

the

physical

supraspinatus
1972

tears

as an

area

with

tendons,

signs

with

records.
roentwas

long-term
tendon,

of varying

early
Calcific

of

such

either
supraspinatus

with

not considered
for
a history
of having

supraspinatus

the

syndrome.

which,
when present,
were inapparent
Since
the physical
and roentgenographic
were indistinguishable,
arthrograms
were

torn

of

is regarded

scarred

or

in patients

associated
lesion

occur

were
had

used
tears

impingement

irritants.

and
series

was
partial

have

tears

tendon,
for

two

for Surgery

cium
tients

zone

years.

The

two

in the
suitable

seventy-three

and eighteen
by
for the minimum
The

critical

part.

impingement.
to

as the

from

arch when
infraspinatus

the

posterior

considered

or partial
were men

six.

arcs,

the

of calcification
not

as frequently

in all but

coraco-acromial
insertion
of the

to the acromion.

not

forty-two

evaluated

functional

mechanical

from

tendinitis
patients

bility
froni
chronic
bursitis
and
complete
tears
of the supraspinatus
the

of the

acromion,

were

Indications

adjacent

the

considered

by examination
not been followed

obtained

any

evidence
tears

ranged

eraged
S I .5 years
for those with
with complete
tears.
Twenty-eight
right

of

the

area is anterior

into

third

or acute

to what

of

The critical

elevation

roentgenographic

fractures,

restricted

The

groove.

that

engages

eleven.
which

show

area with
overlapping

ELEVTIOP1fl

stage

were

degree

of the

deposits

ililpingement,

deposits

disaor

second
in the

and
usually

with

of the

they

and
rotator

were

re-

responsive

to

the procedure
under
discussion.
Nine
had such deposits
and were found
to

with

or without

minute

amounts

of cal-

roentgenographically.
findings
in the two categories
of pawere required
to demonstrate
whether
the
for

tendon,

both

groups

a good

of patients

range

included

of assisted

motion

crepitus
but

44

C.

S. NEER,

II

Fu. 4-A

Fic. 4-B

Figs. 4-A and 4-B: Roentgenognams

A three-centimeter
complete
tear ofthe
FIg. 4-A: Anteroposterlor
roentgenogram
ing

excrescence
FIg. 4-B:

anterior

at the

greater

Axillary

third

of an anterior
supraspinatus

tuberosity

showing

the

bicipital

groove.

and

roentgenogram

of the

of the acromion.

same

painful

arc of active
edge

more

prone

finding

was

inspection

the

edge

for

the
at

from

of cysts

stiffness

least

the

months

suspected
This suggests

the

cuff

were

vulnerable

the

acute

reaction

was

the

I 20

of the

and

degrees,

The
became
pected

not

the

patient

pain

greater

tuberosity,
of

tears

were

advised

and

the

performed.

and

In this

in this

more

intense

was

there

no

If the

patient

who

who

The

a few

was

advised.

occasional

series

years.

had

months

response

all

not

Many

had

patients

with

tears

had

sometimes

was

suspected

A special

indication

disability

patients

were

to use

the old

following
decompressed

skin

incision

for

anterior
partial

had

anteriorly

as much

close
at the

When

positive,

tears

The

weeks,

surgery

was

recommended.

cuff

avulsion,

was

residual

acromionectomy.
according

to

and,

of the central
part of the origin
of the deltoid.
This procedure
has also been used at the time
rheumatoid
and degenerative
arthritis.
These
cases
THE

for
tear

six

the

same

at times,

OF

BONE

sus-

arthrog-

In

the arm,
we
was perma-

principle.

we did

from

often

because

shoulders

of glenohunieral
are not included

JOURNAL

was

impingement

The

had

effects
of
joint
was

and

a complete

in

trauma,

symptonis

for

persist

included

a massive

acromioplasty

as possible

surgery
to

minor

intermittent

treatment

of having

lateral

an-

to conservachanges

of a history
of niinor
trauma
followed
by complete
inability
to raise
tried to make the arthrogram
and to do the repair
promptly
before
there
nent shortening
of the cuff muscles.
chronic

on

not

incomplete

were

to surgery.

to conservative

arthrogram
was

the

to have

following

patients

complete

prior

at

but

disability

inflammation

series,

symptoms

evi-

appears

4-B).

was

to swelling

at the

always

proliferation

of having
impingement
but responded
well
that while
such
patients
had pathological

reversible.

to twelve

and

raphy
the

patients

weeks

located

is

had symptoms
for from ten months
to ten years,
averaging
four years.
a xylocaine
injection
beneath
the acromion
or into the acromioclavicular
a useful
guide
as to what the procedure
would
accomplish.
six

a correspond-

are

and

years.

with partial
tears
seemed
common
roentgenographic
areas

disappeared,

surgery

the spur

although

Patients
The only

fifty-six

and

acromion

function

to

aged

acromion

that
the

corresponding

4-A
had

before

were

degrees

incomplete

shoulder

in the series
tive treatment.
that

(Figs.

at

normal

or sclerosis

of having

of

nine

70

showed

acromion

suspected

with

on

showing

findings

on forced
elevation.
range
of motion.

roentgenogranis

of the

Patients
until

presence

many

anterior

elevation

the acromion
to have a lesser

of

spur

patient

Roentgenographic

dent and, when present,

may be compatible
to be more vulnerable
to minor trauma.

tenor

acromial
spun in a man
was found at surgery.

and
of those
We

tried

a reconstruction
arthroplasty
for
in this study.
It

AND

JOINT

SURGERY

ANTERIOR

45

ACROMIOPLASTY

A.

B.
FIG. 5
Illustrating
downwards
oclavicular

five
joint

detachment
centimeters
capsule.

and
repair
of the deltoid
origin.
and
is detached
from
the anterior
The
tendinous
origin
on the anterior

dorsally
prior
to removing
bone,
rim of tissue for repair.
B: Secure
flap to the rim of tendinous
tissue
capsule
of the acromioclavicular
muscle.

was

The

split

that

thought

disease

is closed

would

the

inclusion

patient

affected

was

shoulder

free,
were

avoiding
anesthesiologist

could
placed

about

anterior

edge

was

incised

and

of its fibers,
jeopardizes

the

on

over

acromial

nine

Postoperative

the

the

table,

corner

other

of the

types

of

subacroniial

Regimen

positioned

of

the

so that

table.

The

the

deltoid

long,

acromion

was

to just

muscle

was

made

lateral

split

from

obliquely

to the
above

ligament.
was

The

divided

the

the

and
repair

of

acromion

was

elevated

NO.

JANUARY

the

deltoid

capsule
a wide

of
and

deltoid,
upward
1972

was
(Fig.

fascia,

placing

undersurface

osteophytes

facilitate

the

joint

claviculopectoral

to permit

arm

edges

artery,

acromioclavicular

the

to
the

anterior

stump

exposing

the
of

the

from

exposed

its
front

laterally
was

thickness
tendinous
of

the

the

origin
acromion

splitting
acromial

front

of the

the

coracothis

ion.

palpated
of

fascia

direction

from

acrom

lines

deep

in the

detached

process

determine

The

joint.
Further
cutting
the

the

The

in Langers

5).
under

was

position.
anesthesia.

downward,

This

of the

which

table.
Folded
an armboard,

coracoid.

extending

elevator

point

shoulder,

without
interference
from
the
The head was supported
with

centimeters

of the

thoraco-acromial

and

54-A.

for

analysis

five centimeters
distal
to the acromioclavicular
the axillary
nerve.
By sharp
dissection,
anticipating

of the

acromion

VOL..

an

hyperextension.
The table was adjusted
to the beach
chair
was draped
from the field; we preferred
intratracheal
incision,

on

procedures

to permit

and

high

be fully extended
under
the scapula.

the

sharp

of combined

variables

Technique

protruded

An

tion

edge of the acromion

and providing
a
is accomplished
by suturing
the lateral
as shown.
The medial
flap is sutured
to the
the joint
has been excised,
to the trapezius

on the acromion
joint
or, when

many

placed

from

ment,

anterior

of the deltoid

of results

too

Operative

branch

from
above
and acromiis elevated

syndrome.

The
draped
towels

the

closure

muscle
is split
of the acromion
of the acromion

third
third

last.

introduce

impingement

exposing

The

A:

With

ligatrac-

manually

the

for

acromion.
on
and

the
the

To
anterior
attach-

46
ment

C. S. NEER,

of the

osteotome

coraco-acroniial
was

the anterior
wedge-shaped

directed

ligament

(Fig.

horizontally

edge and lateral

piece of bone,

II

5).

A thin,

in a posterolateral

portion
which

of the undersurface
was usually
about

and 2.0 centimeters

long and which
included
the
acromial
ligament,
was removed
and the ligament
coracoid.
With the aid of an elevator
the undersurface
fragments
of bone or prom inences.
The undersurface
was next palpated
and if excrescences
were present,
symptomatic,
the distal
inences
on the acromial

2.5
side

centimeters
of this joint

sharp,

nineteen-millimeter

direction

(Fig.

6) to remove

of the anterior
process.
This
0.9 centimeter
thick anteriorly
entire
attachment
of the coracowas cut across
proximal
to the
was inspected
for any residual
of the acroniioclavicular
joint
or if an arthritic
joint
had been

of the clavicle
were removed.

was

excised

and

the

prom-

FIG. 6

To depict
removal
of the anterior
lip and undersurface
A: A thin nineteen-millimeter
osteotome
is seen
directed
edge
with
the attached
coraco-acromial
directed
just
lateral
to the articular
fragment,
the
deep
margins
of the

more

exposure
This

of the supraspinatus
approach

a wider
exposure
with
hyperextension
internal

nal

notation

rotation

placed

than
the

the

the

teres

minor

process
of the acromion.
removing
the anterior
surface.
B: The
osteotomy

ligament
and
the deep
facet
for the clavicle.
C: Having
removed
this wedge-shaped
acromioclavicular
joint
are palpated.
and if prominent.
is required,
this joint
is excised.

supraspinatus

in the

would
be expected.
of the shoulder,
the

subscapularis

of the anterior
posterolaterally

could

was

Because
humerus

readily

well

exposed.
THE

center

of the

of the slope
was brought

be visualized.
At this
JOURNAL

field

and

of the
forward

BONE

AND

JOINT

or

provided

acromion.
and with

With flexion
and
stage,
with patience
OF

is

exterand

SURGERY

ANTERIOR
persistence,

in most

brought

into

out

tension

part

of

when
the

the stability

had

dinous

was

at the side.

to the

oforigin

that

in the deltoid

day

and,

depending

tient

Abduction

supine.

there

secondary

stressed.

repairs

I have

with

the

full

status

was

or on

was

end

flap

was

sutured

dorsuni

ofthe

the
were

to aid

the

first

distal

prohibited

of the

not

used

then

early

for

rotation
They

cuff,

overhead

were

primarily

purposeful

on

its groove

the

on the

enhance

it is thought

flap

lateral

external
exercises.

assisted

and

worked

elevation

Assisted
pendulum

splints

and

groove

medial

upward

to

traction

greater

sutured
of the

to
clavi-

to its tenacromion.

last.

on

was

biceps

6) or when

The

reflected

forward

a chance
to reattach.
important,
and so were
until

later

closed

active

ly increased

muscle.

been

biceps

with-

the distal

Bateman,

because

in the

(Fig.

trapezius

by

repair

repairs,

excessive

of the

removed.
The

be adequately

to allow
cuff

advised

to avoid

head

could

cut

difficult

transplanted

tissues
were
was important.

had

was

Postoperatively,

pecially

long

acromioclavicularjoint

excised,

been

care

rarely

was

more

Osteophytes

bursal
deltoid

been

or fourth

has

with

the
was

tendon

a groove

In the

as

incision,

stump

the deltoid

where

but

shoulderjoint.

of the

of a supraspinatus

excised

tendon

and thickened
repair
of the

split

cated

be

of the
This

of the

tuberosity
The
cle

arm
to

end

supraspinatus,

inspected.

capsule

humerus

to closure

routinely

the

torn

the

had

of the
nerve.

Prior

the

with
the

clavicle

mobilization
suprascapular

The

cases

contact

47

ACROMIOPLASTY

the

motions

extension,

assisted

days

were

done

postoperatively

for recovery

ten

to

give

was thought
to be eswere begun
on the third
progressive-

first

except

with

the

in a few

pa-

compli-

external

rotation

exercises

were

range

ofmotion.

Strength

comes

ofthe

use.

Findings

and

Results

The results
were graded
as satisfactory
or unsatisfactory.
In a satisfactory
resuIt, the patient
was satisfied
with the operation
and had no significant
pain.
He had
full use of the shoulder,
less than 20 degrees
of limitation
of overhead
extension,
and
at least
not

75

per

cent

of normal

strength.

In an

unsatisfactory

result,

these

criteria

were

met.

C/zro,iic

Bursitis

The

wit/i

period

Fraying

or

Partial

of hospitalization

days.
have

At surgery,
proliferative

anterior

third

all nineteen
bursitis
and

of the

Tear

following
patients
with
a prominence

acromion.

There

were

of the

Supraspinatus

surgery

in this

group

averaged

this type
of lesion
were
of the coraco-acromial
distinct

excrescences

also

seven
found

to

ligament

in eight.

and

Irregulari-

ties in the greater

tuberosity
were
common.
Minute
calcium
deposits
inapparent
roentgenographically
were found
in six. The long head of the biceps
was abnormal
in five and ruptured
in one. It was transplanted
in three.
The acromioclavicular
joint
was found to be involved
by hypertrophic
arthritis
in three
and it was excised
in two
of the

patients.
There

tively

were

and

they

was

discharged

too

vigorous

cant

two

patients

required
from

the

activity

complications.
The results

in this

of the

VOL.

was
54-A,

NO.

in a patient
I, JANUARY

of

hospital

and

on

a large

1972

the

had

were
in

arthritis

to

day,

evaluated
not

shoulder
partially

who

range,

of the

patient,

detached

strength.

cervical

spine

not

be

no

other

and

of

insufficient

an

by

signifi-

satisfactory

because

could
and

who

his deltoid

were

fifteen

two

preopera-

One

There

were:

evaluated,
full

stiffness

be rehabilitated.

developed.

a patient

deltoids,

significant

second

shoulders

sixteen

who

with
months

hematoma

unsatisfactory.
Three
shoulders
interval
since
surgery
and
one
satisfactory
ratings
had normal
rating

group

a number

one

located.
Those
with
The unsatisfactory
and

of

the

acromio-

48

C. S. NEER,

TABLE
CLINICAL

SERIES

AND

II

I
1965

RESULTS,

With
bursitis
with tendinitis
tears of the supraspinatus

or partial
Complete

tears

Impingement

of supraspinatus
after

Satisfactory
Results

19

15 of

20

19 of 20

11

50

clavicular

joint,

should

Coniplete

have
Tears

16

lateral

acromionectomy
Total

joint

1970

Acromioclavicular
Joint Excision

Acromioplasty
Proliferative

TO

which
been

was not
excised.

excised.

It was

thought

4 of 11
38of47

that

his

acromioclavicular

of the Supraspinatus

No previous
surgery
had been performed
in the twenty
shoulders
in this group.
were found
to have degenerative
changes
in the tendon
as well as coniplete,
but
not acute,
tears. The lesion
was always
centered
in the supraspinatus
tendon
and in
the overlapping
insertion
of the infraspinatus.
It extended
posteriorly
for a varying

All

distance.
Calcium
two centimeters

deposits
were noted
in two, three centimeters

in three
patients.
The width
in nine, and four centimeters

lengths
ranged
from
three
centimeters
to seven
centimeters.
the larger
lesions
required
high dissection
and preliminary
the exposure
offered
by this approach
was no handicap
and
the McLaughlin
technique.
The outer
portion
of the clavicle

of the tears were

in nine. Their

While
mobilization
of
traction
on the tendons,
all could
be repaired
by
was excised
in two pa-

tients.

The results
in all twenty
shoulders
operation)
were:
nineteen
satisfactory,
unsatisfactory.
The unsatisfactory
result
and who damaged
his shoulder.
Lateral
acromionectoniies
previously

in eleven

tendon
and
ing degrees

patients,

had

one

healed
found

full-thickness

sinuses
to have

between
anterior

tients
had niassive
muscles.
The outer
central

factory

was

six

of the cuff
renioved

months

tendinitis

without

to four

years

a tear

in the

All eleven
patients
had
previously
had an incomplete

for biceps
tendinitis
and also
anterior
acromial
excrescences

tear.
Of the ten patients
the shoulder
joint
and
inlpingelllent.
The cuffwas

attenuation
clavicle

from

tears (no previous

normal,
and one
seizures
occurred

a lateral
acromionecand to have a three-

who had prior cuff repairs,

the old skin incision
and
found
to be intact
in six.

and retraction
to facilitate

varyIc-

two had
all were
Two pa-

of the tendons
of the
repair
in four patients.

cuff
The

part
The

tomies,

performed

a supraspinatus

of the supraspinatus.
The patient
who

sion and had had one operation

tomy was found
to have marked
centimeter

been

for

ten for complete

tears
of deltoid
weakness.

operated
on for complete
all of which
approached
was in a patient
in whom

of the deltoid
was found
reattached
to the humerus
in six patients.
results
in the eleven
patients
who previously
had had lateral
acromionecall of whom
had less pain but residual
weakness,
were rated,
four as satisand seven
as unsatisfactory.
Of the unsatisfactory
results,
three were border-

line. Two
more,
fortable
but the

who had niassive,

shoulders
were quite

cle, as described
by Debeyre
provement.
The remaining
tendons
were found
intact,
pain related
to fatigue
and,

retracted,
weak.

and associates,
two unsatisfactory
but

they

in one

had

patient,

cuff tears,
Advancement

became
of the

much
more
supraspinatus

commus-

was later attempted

in one without
imresults
were in patients
whose
rotator
marked

deltoid

deficiencies

an osteoarthritic
THE

JOURNAL

and

acromioclavicular
OF

BONE

AND

JOINT

bouts

joint.
SURGERY

of

ANTERIOR

This

patient

joint

at the

was

one

same

Over-All

of the

time

that

cases-in

anterior

49

retrospect

acromioplasty

we

should

was

done.

five

patients

have

excised

the

Results

There
tomas

were

no

developed

new-bone

postoperative

that

the deltoid

was

detached

responded

to

rehabilitation

a deficient

deltoid

in those

has

been

did

not

and

The

described

occur

and,

in acute

had

who

had

cases,

Excessive

following

only
intact,

partial

the

anterior

half

this

muscle

quickly

normal

high

henna-

healed.

problem

recovered

in the

lateral

well

Since

remained

role

subcutaneous

were

series.

portion

a major

scars

as a serious

in this

the central

played

patients

In

spontaneously.

which

acromionectomy

results

infections.

resolved

formation,

lateral

trast,

early

ACROMIOPLASTY

strength.

incidence

of

In con-

of unsatisfactory

acromionectomies.

Discussion
The

majority

spinatus

did

had

not

prove

been

bicipital

group

were

patients

in

of the

group.

tuberosity

of

the

extended

into

were

abnormal

to operate

on

of the

biceps

tissues

were

patients

ty of a concomitant

The
flammation

from

involved

that

groove

and

rupture
ofthe
cent literature

bicipital

The
when

close relationship
one considers
the

cuff

tendon

was

alone

allows

supraspinatus
suggests
that

patients

in this

tendon.

In

developed
area

of

impingement.

excrescences

on

the

impingement.

At

times

associated

with

completely

We

now

considered

patients
greater
these

scarring

tendsynovitis
tendon
and

torn.
having

those

because

of the

of bicipital
how often this

without

the

frequently

in two-thirds

were

of

to imadjoining
consider

the

it

possibili-

impingement.

is thought
that

appropriate

wear

of

critical

in or

the

of subacromial

the

the

by the

impingement;

and
it retards

to

suprawhich

most

biceps

to have

normal

of the

arthrograms
had

the

thought

cysts

acromioplasty

chronic

structures
and

had

had

third
of

caused

biceps

of anterior

one

presumably

element

value

were

tears

had
diagnosis

stated,

head

when

the

incomplete
Many

abnormalities

tendon

head of the biceps.

becomes
obvious

structures

been

in the

the

humerus,

having
years.

provisional

have

adjoining
of

for

has
to

long

Some

excrescences

them;

As

and

group

previous

at operation

tendon

this

unwise

The

abnormalities

biceps

the long
pingement

in the
problems

tenosynovitis.
found

proximity

The

patients

diagnostic

diagnostic.

the

of the

of

been

caused

to be that

technically
measures

to

by persistent

tendon
or ofthe
long
the repair
of complete

it relieves

it improves
be

taken

in-

reference

and

biceps,
requires

and

of other

with

impingement

head ofthe
cuff tears

pain

exposure
may

or both.
more

to

prevent

The recompli-

cated techniques
4,8,
but judging
from a review
of the operative
findings
in our clinic
over the past ten years,
it is a rare cuff tear that cannot
be repaired
through
this simple approach.
This is in agreement
with Bateman
who has evolved
a similar
anterior
approach
important
be

with
that

treated

the objective
the occasional

promptly,

that an effective
irreparable
tear
gain

surprising

before

of resection
of the acromioclavicular
joint.
However,
it is
patient
with a massive
tear of the supraspinatus
tendon
fixed

shortening

of the

cuff

muscles

repair
can be accomplished
by any method.
The
can be made
more comfortable
if impingement
function

if the deltoid

is permitted

to remain

makes
rare

it unlikely

patient

is relieved

with
and

an
can

strong.

Summary
Impingement
al ligament
syndrome
has been
acromion
VOL.

54-A,

on the tendinous

portion

of the rotator

cuff

by the coraco-acromi-

and the anterior

third of the acromion
is responsible
for a characteristic
of disability
of the shoulder.
A characteristic
proliferative
spur and ridge
noted
on the
and this area
NO.

1, JANUARY

anterior
lip and undersurface
may also show erosion
and
1972

of the
eburnation.

anterior
The

process
treatment

of the
of the

50

S. NEER,

C.

impingement
the acromion
also

is to remove
the anterior
edge and
with
the attached
coraco-acromial

involve

the

tendon

compress
the tendon
avoid
transplanting
mio-clavicular
abduction

and,

pri nci pIes

of anterior

during

partial

tears

tients

with

the

may

of

of

the

residual

area

the

and

which

if it does,
niay

be

part

it is best

lipping

to debut

at the

tendon
when
be resected.

of

may

in its groove,

Hypertrophic

supraspinatus
this joint
should

patients

have

Nineteen

had

without

impingement

been

subjected

to

proliferative

bursitis

roentgenographic

following

were
may

loss

anterior
inipingenient

The

to

acro-

the arm is in
These
are the

impaired

offer

better

of deltoid

partial

relief

of chronic
it provides
further

and

acromio-

tendinitis
of

or

calcium

and the results

in these
were good.
Eleven
pa-

lateral

by pre-existent
while
prevent

anterior

evidence

complete
tears of the supraspinatus
one to five years
following
surgery

results

without

biceps

if possible.

with mechanical
impingement,
of the supraspinatus,
and may

critical

ligaI1ent.

osteophytes

supraspinatus,

had
from

the

of the

undersurface

ioplasty.

five years.

acromioplasty

patients
ing tears

head

impinge

acrom

past

but their

Anterior

long

in forty-six

and twenty
patients

improved

the

if the lip is prominent,

shoulders

plasty

of

and remove
any
the biceps
tendon

joint

Fifty

deposits,
thirty-nine

II

acromionectomy

deltoid

weakness

pain

in carefully

better
exposure
impingement
and

were

and

scar.

selected
for repairwear at the

power.

References
J. R.: Excision
of the Acromion
in Treatment
of the Supraspinatus
Syndrome.
of Ninety-five
Excisions.
J. Bone and Joint Sung., 31-B: 436-442,
Aug. 1949.
2. BATEMAN,
J. E.: Personal
communication.
3. CODMAN, E. A.: The Shoulder.
Rupture
of the Supraspinatus
Tendon
and Other
Lesions
in
or About
the Subacromial
Bursa.
Ed. 2, p. 98. Boston,
Privately
Printed,
1934.
4. DEBEYRE,
J.; PATTE,
D.; and
ELMELIK,
E.: Repair
of Ruptures
of the Rotator
Cuff of the
Shoulder.
With a Note on Advancement
of the Supraspinatus
Muscle.
J. Bone and Joint
Sung., 47-B: 36-42, Feb. 1965.
5. HAMMOND,
GEORGE:
Complete
Acromionectomy
in the Treatment
of Chronic
Tendinitis
of
1.

ARMSTRONG,

Report

the Shoulder.
MCLAUGHLIN,

J. Bone

and

Joint

Sung.,

44-A:

494-504,

Apr.

1962.

H. L.: Lesions
of the Musculotendinous
Cuff of the Shoulder.
I. The Exposure
of Tears with Retraction.
J. Bone and Joint Sung., 26: 3 1-51, Jan. 1944.
7. MOSELEY,
H. F.: Shoulder
Lesions.
Ed. 3, pp. 68-74.
Edinburgh,
E. and S. Livingstone,
1969.
8. RATHBUN,
J. B., and MACNAB,
IAN: The Microvascular
Pattern
of the Rotator
Cuff.
J. Bone
and Joint Sung., 52-B: 540-553,
Aug. 1970.
9. SMITH-PETERSEN,
M. N.; AUFRANC,
0. E.; and LARSON, C. B.: Useful Surgical
Procedures
for
Rheumatoid
Arthritis
Involving
Joints
of the Upper
Extremity.
Arch.
Sung., 46: 764-770,
1943.
10. WATSON-JONES,
REGINALD:
Fractures
and Joint
Injuries.
Ed. 4, Vol.
II, pp. 449-451.
Baltimore, The Williams
and Wilkins
Co., 1960.
6.

and

Treatment

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY