DTSCH Arztebl Int-114-0765
DTSCH Arztebl Int-114-0765
DTSCH Arztebl Int-114-0765
Impingement Syndrome
of the Shoulder
Christina Garving, Sascha Jakob, Isabel Bauer,
Rudolph Nadjar, Ulrich H. Brunner
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FIGURE 1
Subcoracoid
impingement
Overview of causes of primary subacromial impingement syndrome (SIS) and rotator cuff (RC) degeneration.
The RC can be damaged by both intrinsic and extrinsic factors, which can lead to RC rupture and to an abnormally high position of the head
of the humerus. This, among other factors, can cause a non-outlet SIS. Primary SIS, in turn, leads to CAL ossification and acromial osteophyte
formation. Primary SIS is to be distinguished from rarer types of shoulder impingement (gray-shaded boxes). AC, acromioclavicular; CAL,
coraco-acromial ligament
over age 30 suffers from occasional or persistent As the subacromial impingement syndrome is by far
shoulder pain in the course of a single month (2). the most common in practice, the other, rarer forms will
Another study has shown that 16% of the popu- not be discussed any further in this review.
lation has shoulder pain in one month (e1). The subacromial space is delimited caudally by the
Peak incidence is during the sixth decade of life head of the humerus and the rotator cuff and cranially
(2, 3). The most common clinical diagnoses are by the osteofibrous roof of the shoulder, which is
rotator cuff defects (85%) and/or impingement syn- composed of the acromion, the coracoacromial liga-
dromes (74%) (e2). The prevalence of rotator cuff ment, and the coracoid process. The subacromial space
defects rises with age. Up to 30% of persons over contains the subacromial bursa and the rotator cuff. The
age 70 have a total defect, but 75% of such cases subacromial sliding space, biomechanically consid-
are asymptomatic (e3). ered, constitutes an auxiliary joint between the rotator
cuff and the roof of the shoulder (e3). In subacromial
Relevant anatomy and types of impingement impingement syndrome, elevation of the arm leads to
The glenohumeral joint is a load-bearing joint with a an abnormal contact between the rotator cuff and the
wide range of motion (e4). The rotator cuff centers roof of the shoulder (Figure 2).
the head of the humerus in the glenoid cavity. Im-
pingement is classified into four types, depending on Etiology
the site of soft-tissue entrapment (Figure 1): The subacromial impingement syndrome has both
● subacromial impingement syndrome (external primary and secondary forms. Primary impinge-
impingement), ment is due to structural changes that mechanically
● subcoracoid impingement, narrow the subacromial space (1); these include
● posterosuperior inner impingement, and bony narrowing on the cranial side (outlet impinge-
● anterosuperior inner impingement. ment), bony malposition after a fracture of the
Prevalence Etiology
The one-month prevalence of shoulder pain Primary subacromial impingement is due to
is between 16% and 30%. Its most common mechanical narrowing of the subacromial space,
causes are rotator cuff defects and impingement while secondary subacromial impingement is due
syndromes. Peak incidence is during the sixth to a functional disturbance.
decade of life.
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GA
GH
a b
Figure 4: Critical shoulder angle and acromiohumeral index
a) Critical shoulder angle (CSA): the angle (black lines) is measured from the inferior pole of the glenoid between the glenoid plane and the
lateral border of the acromion. A wide CSA is a risk factor for rotator cuff lesions. b) Acromiohumeral index (Al): this is the quotient of the dis-
tance from the glenoid surface to the lateral end of the acromion (GA, dotted arrow) and the distance from the glenoid surface to the lateral end
of the humeral head (GH, black arrow): by definition, AI = GA/GH. A high AI is also a risk factor for rotator cuff lesions
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a b
c d
Figure 5: Subacromial decompression in a patient with an anterolateral bone spur. a) Bone spur on the anterolateral portion of the
acromion (above the red line) in an arthroscopic view from posterior, with an electrosurgical probe and bursa fragments at the lower edge of
the image. c) The spur (red line) can also be seen on an anteroposterior (AP) shoulder x-ray.
b) The same operative field after arthroscopic decompression: the lateral extension of the acromion is now flat (above the red line). A bone
drill can be seen at the lower edge of the image. d) The x-ray shows the surgically widened subacromial space and the flat lower edge of the
acromion (red line)
resected in an open or arthroscopic procedure, along with Rotator cuff damage: Lesions of the rotator cuff can
3–4 mm of the acromion and of the clavicle. Clavicular be partial—affecting the articular part of the joint, the
stability is preserved by the coracoclavicular ligaments bursa, or the tendons—or total (rupture). Complete rup-
and also, if the arthroscopic technique is used, by the tures are assessed in terms of their size, the number and
cranial and posterior ligaments of the AC joint. nature of the affected tendons, and retraction, fatty
Bursectomy Coplaning
As the bursa is usually affected by inflammatory In this controversial technique, inferior acromial
changes, this tissue is removed. A randomized osteophytes and the lateral end of the clavicle are
trial showed no difference in the functional out- removed without total resection of the acromio-
come of bursectomy with and without additional clavicular (AC) joint.
acromioplasty.
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Complications
Surgical complications are rare. Damage arising
from wrong indications or technical errors must
be avoided.
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Corresponding author
Prof. Dr. med. Ulrich H. Brunner
Abteilung für Unfall-, Schulter- und Handchirurgie
Krankenhaus Agatharied GmbH
Norbert-Kerkel-Platz
83734 Hausham, Germany
ulrich.brunner@khagatharied.de
Supplementary material
e-References:
www.aerzteblatt-international.de/ref4517
Please answer the following questions to participate in our certified Continuing Medical Education
program. Only one answer is possible per question. Please select the answer that is most appropriate.
Question 1 Question 3
When is rotator cuff reconstruction absolutely indicated? In what circumstances is surgery for impingement syndrome not
a) at 3 months, regardless of the size of the defect indicated?
b) if the lesion is partial and painless a) if the symptoms have been present for several months
c) in an elderly patient with a partial lesion b) if there is a documented lesion of the supraspinatus tendon
d) if there is a longstanding, severe tendon defect c) if there is marked restriction of glenohumeral movement
d) if the patient is young and has high functional requirements
e) in a young patient with a defect of traumatic origin
e) if there is accompanying pathology
Question 2
Question 4
Which of the following measures plays no role in the conservative What test is useful in the diagnostic assessment of shoulder
treatment of impingement syndrome? impingement syndrome?
a) cortisone injections a) the Finkelstein test
b) physiotherapy b) the Schirmer test
c) analgesia with NSAID c) the Jobe test
d) independently performed exercises d) the Watson–Shift test
e) shock-wave therapy e) the Phalen test
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Question 5 Question 9
The glenohumeral joint is a load-bearing joint. Which of the follow- In a patient with confirmed shoulder impingement syndrome, plain
ing soft-tissue structures plays an active role in the centering of x-rays and an MRI of the affected shoulder are obtained. What
the humeral head in the glenoid cavity? finding is not typical of impingement syndrome?
a) subscapularis muscle a) high humeral head position in the true AP view
b) coracoacromial ligament b) a hooked acromion
c) greater tubercle c) reduced peritendinous fat, tendon indentation, and an abnormality of
d) subacromial bursa the coracoacromial arch on MRI
e) pectoralis major muscle d) a critical shoulder angle (CSA) less than 35 ° and a low acromio-
humeral index
e) complete rupture of the supraspinatus tendon with tendon retraction
Question 6 in the coronal T1-weighted MRI sequence
A 60-year-old man complains of loss of strength in an arm and
difficulty getting dressed. His symptoms persist despite regular
physiotherapy and multiple cortisone injections. Magnetic reso- Question 10
nance imaging reveals a type III acromion and a complete rupture In subacromial impingement syndrome, soft tissue is trapped
of the supraspinatus tendon. The tendon is well preserved, without between the roof of the shoulder and the head of the humerus.
retraction or fatty degeneration. How should this patient be The syndrome has primary and secondary forms. Which of the
treated? following can be a cause of secondary subacromial impingement
a) Intensified physiotherapy should be provided. syndrome?
b) Because of the patient’s age, surgery is no longer an option. a) subacromial bursitis
c) Surgical decompression with rotator cuff reconstruction is indicated. b) type III acromion
d) Another series of intra-articular injections should be performed. c) muscular imbalance of the rotator cuff
e) Because of the patient’s age, the surgical treatment should be d) os acromiale
restricted to tendon debridement. e) type I acromion
Question 7
Subacromial impingement syndrome is often associated with
rotator cuff ruptures. Which of the following is a predisposing
FURTHER INFORMATION ON CME
factor for intrinsic rotator cuff damage?
a) AC joint arthritis This article has been certified by the North Rhine Academy for Post-
b) acromial osteophytes graduate and Continuing Medical Education. Deutsches Ärzteblatt
c) greater tubercle fractures
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A 52-year-old woman complains of longstanding pain during website: cme.aerzteblatt.de.
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c) No further evaluation is needed: the patient clearly has a shoulder “Fitness to Drive in Cardiovascular Disease” (Issue 41/2017) until
impingement syndrome, and surgery is indicated. 7 January 2018,
d) If the ultrasound is normal, no further imaging studies are indicated.
e) As the shoulder impingement syndrome is a self-limiting illness, you “The Treatment of Illnesses Arising in Pregnancy” (issue 39/2017)
examine the patient and then initiate conservative treatment with until 10 December 2017.
analgesics, physiotherapy, and physical treatment measures.
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Deutsches Ärzteblatt International | Dtsch Arztebl Int 2017; 114: 765–76 | Supplementary material I