TEXTBOOK READING

SHOULDER IMPINGEMENT SYNDROME

By:
Gopinath
A Mutmainna R
Ayustia Risvani Akbar
Nurul Muchliza
Hastuti
Fitra Yahya

Advisors:
dr. Chaniago
dr. Mervin
dr. Rico
dr. Arif

Orthopaedic and Traumatology Department
Faculty of Medicine
Hasanuddin University
2013
DEFENITION
a painful disorder which is thought to
arise from repetitive compression or
rubbing of the tendons (mainly
supraspinatus) under the coracoacromial
arch


Apleys System Of Orthopaedics And Fractures 9
th
Edition

EPIDEMIOLOGY
Prevalence: 5% to 10% of the population
Predominant sex: Males more than females
Predominan Age: >40 yr

,Kennedy, John F. Ferris Clinical Advisor 2013. Philadelphia: Elsevier.

ETIOLOGY
A combination of:
Tendon overload
Microvascular compromise
Compression by surrounding structures
,Kennedy, John F. Ferris Clinical Advisor 2013. Philadelphia: Elsevier.

ANATOMY
Netter
RISK FACTORS
Repetitive overhead activity
Advanced Aged
Trauma
,Kennedy, John F. Ferris Clinical Advisor 2013. Philadelphia: Elsevier.

PATHOPHYSIOLOGY
Repetitive compression/ stress / rubbing of
tendon compressed and irritated slightly
swollen impinging on the
acromioclavicular arch
osteophytes on the anterior edge of the
acromion
Apleys System Of Orthopaedics And Fractures 9
th
Edition

Friction minor tears can develop
scaring, fibrocartilaginous metaplasia or
calcification in the tendon vascular
reaction and local congestion further
impingement
Apleys System Of Orthopaedics And Fractures 9
th
Edition

CLINICAL FINDING
Shoulder pain , with subsequent progress
depends on age, stage of the disorder, and
vigour of healing response.
Three Stages
Stage 1:acute inflammation,edema,hemorrhage
Stage 2:fibrosis and tendinitis
Stage 3:mechanical disruption of the rotator cuff
tendons
Apleys System Of Orthopaedics And Fractures 9
th
Edition

SUB ACUTE TENDINITIS (PAINFUL ARC
SYNDROME)
Due to vascular congestion, microscopic
haemorrhage and oedema
Pain after vigorous or unaccustomed activity
( swimming)
Shoulder looks normal but acutely tender
along the anterior edge of acromion

Apleys System Of Orthopaedics And Fractures 9
th
Edition

CHRONIC TENDINTIS
Pain worse at night, the patient cannot lie
on the affected side, comfortable to sit up
out of bed.
May restrict even simple activities ( hair
grooming or dressing)
Age 40-50
History of recurrent attacks of subacute
tendinitis

Apleys System Of Orthopaedics And Fractures 9
th
Edition

Pain settling down with rest or anti
inflammatory treatment and recur when more
demanding activities resumed
Crepitation over the rotator cuff when
shoulder is passively rotated
Small, unsuspected tears are quite often
found during arthroscopy or operation
Apleys System Of Orthopaedics And Fractures 9
th
Edition

CUFF DISRUPTION
The most advanced stage
Resulting in either partial or full thickness
tear
Aged over 45
History of refractory shoulder pain with
increasing stifness and weakness

Apleys System Of Orthopaedics And Fractures 9
th
Edition

TEST FOR CUFF IMPINGEMENT PAIN:

The painful arc sign :




Apleys System Of Orthopaedics And Fractures 9
th
Edition

On active abduction scapulo- humeral rhythm is disturbed and pain is
aggravated as the arm traverses an arc between 60 and 120 degrees

Neers impingement sign

Apleys System Of Orthopaedics And Fractures 9
th
Edition

the scapula is stabilized
with one hand while with
the other hand the exam-
iner raises the affected arm
to the full extent in pas-
sive flexion, abduction and
internal rotation, thus
bringing the greater
tuberosity directly under
the coracoacromial arch.
The test is positive when
pain, located to the
subacromial space or
anterior edge of acromion
,
is elicited by this
manoeuvre.

Neers test for impingement

If the previous
manoeuvre is positive, it
may be repeated after
injecting 10 mL of 1 per
cent lignocaine into the
subacromial space; if the
pain is abolished (or sig-
nificantly reduced), this
will help to confirm the
diagnosis.

Apleys System Of Orthopaedics And Fractures 9
th
Edition

Hawkins-Kennedy test

The patients arm is
placed in 90 degrees
forward flexion with the
elbow also flexed to 90
degrees. The examiner
then stabilizes the
upper arm with one
hand while using the
other hand to internally
rotate the arm fully.
Pain around the
anterolateral aspect of
the shoulder is noted as
a positive test.

TEST FOR ISOLATED WEAKNESS
The patient is asked to
raise his or her arms to a
position of 90 degrees
abduction, 30 degrees of
forward flexion and internal
rotation. The examiner
stands behind the patient
and applies downward
pressure on both arms,
with the patient resisting
this force. The result is
positive when the affected
side is weaker than the
unaffected side
Apleys System Of Orthopaedics And
Fractures 9
th
Edition

the patient stands holding his

or her arms close to the body
and the elbows flexed to 90
degrees. He or she is
instructed to externally rotate
both arms while the examiner
applies resistance; lack of
power on one side signifies
weakness of infraspinatus.

Apleys System Of Orthopaedics And Fractures 9
th
Edition

Apleys System Of Orthopaedics And Fractures 9
th
Edition


CONT
the patient is asked to
stand and place one arm
behind his or her back with
the dorsum of the hand
resting against the mid-
lumbar spine. The
examiner then lifts the
patients hand off the back
and the patient is told to
hold it there. Inability to do
this signifies subscapularis

IMAGING FOR ROTATOR CUFF DISORDERS
X-ray
Usually normal in early stages
Chronic tendiitis : there may be erosion,
sclerosis or cyst formation
In chronic cases: roughening or overgrowht of
anterior edge at the caudal tilt view
Older patient and late cases: osteoarthritis of the
acromioclavicular joint

Apleys System Of Orthopaedics And Fractures 9
th
Edition


USG
IDENTIFYING AND MEASURING THE SIZE OF
FULL THICKNESS AND PARTIAL THICKNESS
ROTATOR CUFF TEARS
Apleys System Of Orthopaedics And Fractures 9
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Edition

TREATMENT
Non-operative
Operative
Apleys System Of Orthopaedics And Fractures 9
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Edition

NON OPERATIVE
Rest without overhead activity
Physical Therapy
NSAIDs for 7-10 days
Subacromial glucocorticoid injections

OPERATIVE
Open Acromioplasty
Through an anterior incision the deltoid
muscle is split and the part arising from the
anterior edge of the acromion is dissected free,
exposing the coracoacro- mial ligament, the
acromion and the acromioclavicu- lar joint.
The coracoacromial ligament is excised and
the anteroinferior portion of the acromion is
removed by an undercutting osteotomy.

Apleys System Of Orthopaedics And Fractures 9
th
Edition








CONT.
Excres- cences on the undersurface of the a
cromioclavicular joint are pared down.
If the joint is hypertrophic, the outer 1cm of clavicle
is removed; this last step exposes even more of the
cuff and permits recon- struction of larger defects.
An important step is care- ful reattachment of the
deltoid to the acromion, if necessary by suturing
through drill holes in the acromion; failure to obtain
secure attachment may lead to postoperative pain
and weakness. After the operation, shoulder
movements are commenced as soon as pain
subsides.
Apleys System Of Orthopaedics And Fractures 9
th
Edition









Apleys System Of Orthopaedics And Fractures 9
th
Edition


Arthroscopic Surgery
The underside of the acromion must be trimmed and
the coracoacromial ligament divided or removed.
This procedure has now become the gold standard
and allows earlier rehabilitation than open acromio-
plasty because detachment of the deltoid is not per-
formed.
Arthroscopic acromioplasty should achieve the
same basic objectives as open acromioplasty
Arthroscopy allows good visualization inside the
gleno-humeral joint and therefore the detection of
other abnormalities which may cause pain

Apleys System Of Orthopaedics And Fractures 9
th
Edition




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