Shoulder impingement syndrome

1. Subacromial Impingement Syndrome
Subacromial Decompression
Aaron Venouziou
Orthopaedic Surgeon
St. Luke’s Hospital
Thessaloniki

2. Introduction
ü Ill-defined term for a variety shoulder disorders that
manifest as antero-lateral shoulder pain
ü Nonspecific diagnosis
ü Numerous types of shoulder impingement
ü Only a small proportion of these necessitate
decompression

3. Etiology
üExtrinsic
– Primary Impingement
• Oulet stenosis
– Secondary Impingement
• Instability
üIntrinsic
– Degeneration
• Aging
• Avascularity

4. Neer, 1972
Impingement of the rotator cuff by the coraco-acromial
ligament and the anterior third of the acromion and
undersurface of the AC joint
Primary Impingement

5. ü Spurs and bony changes on the undersurface of the
anterior 1/3 of the acromion correlated with rotator
cuff tears
ü 90% of pts treated by acromioplasty had significant
pain reduction, full use of shoulder, <20o of overhead
limitation, and at least 75% normal strength
ü RC injury is a result of primary impingement
Primary Impingement
Neer, 1972

6. ü Popularized the theory of “extrinsic” impingement,
stating that acromial changes were primary as
opposed to secondary changes—causing
impingement
ü 70% of full-thickness RC tears
in type III acromion
ü Never been proven or peer reviewed
Primary Impingement
Bigliani, 1986

7. üGlenohumeral Instability
– Common in the overhead throwing athlete
– Cocking => strain on the static stabilizers occur
• Early phase (45º abd, ER) - MGHL
• Late phase (90º abd, ER) – IGHL
ü Anterior soft tissue deficiency
ü Anterior translation of humeral head
Secondary Impingement
Jobe and Kvitne, 1989

8. üInternal Impingement
– Common in the overhead throwing athlete
– Cocking => tension on the posterosuperior
articular surface of the supraspinatus and
compression between the humeral head and
adjacent glenoid rim
• posterior superior synovitis
• partial under-surface tears
Secondary Impingement
Walch, 1992

9. üGlenohumeral internal rotation deficit (GIRD)
– Common in the overhead throwing athlete
– Posteroinferior capsular contracture
– Posterosuperior humeral head translation
– SLAP
– Internal impingement
Secondary Impingement
Morgan and Rajan, 2004

10. üScapulothoracic Dyskinesis
– Functional scapular instability
– Increased distance from spinous process to
medial border of the scapula
– Loss of acromial elevation
Secondary Impingement

11. ü Tendon degeneration (and fibers failure) is the most
important etiologic factor of symptoms (and cuff
tears) in the subacromial space and not the
impingement syndrome
ü Partial thickness tears are most often on the articular
side
ü Articular side of cuff is hypovascularized
Intrinsic Factors
Ozaky 1988, Ogata & Uhthoff 1990

12. üThe main problem is tendon degeneration and
weakness
Intrinsic Factors
Burkhart, 1995

13. Neer impingement test
Clinical AssessmentLOW SPECIFICITY
Hawkin’s impingement test
Lidocaine injection test

14. Always evaluate the AC joint
Palpation Cross Arm Test Injection

15. Imaging Assessment
X-rays
Axillary Outlet
Zanca

16. MRI
CT arthrogram

17. Treatment
Goal to restore the health of Rotator Cuff
Restoration of neuromuscular balance of the
shoulder girdle and the synchronous motion of the
3 joints about the shoulder to prevent subluxation
Treatment

18. üModification of activity with cessation of
overhead activity
üNSAIDS or subacromial injection
üPhysical therapy: stretching/strengthening
üAcute injury with profound strength loss: MRI
of rotator cuff
Non-operative Treatment

19. üFailed conservative treatment > 6 months
üAcromial prominence/spurs/sclerosis, +
impingement sign, arc of pain, relief from
subacromial injection
üNo evidence of RCT (+/- MRI)
üArthroscopic subacromial decompression
Surgical Treatment

20. Historical background
Ellman, 1987
ü Technically demanding
procedure
ü If a cuff tear is present you
cannot repair it

21. Surgical Technique
Patient Setup
Beach chair position

22. Bony Landmarks
Acromion
ACJ
Coracoid

23. Posterior portal
Same skin
incision for GHJ
arthroscopy
üRedirect cannula
üAim and advance the scope
beneath the anteriolateral
corner

24. Room with a view
ü4 Walls, floor,
ceiling
üCA ligament is
landmark
Clear visualization

25. Lateral portal
ü 3 cm lateral to acromion
ü Spinal needle
ü Triangulation
ü Underneath the anterior
half of the acromion
ü Parallel to it
Skin marking bisects mid AC

26. Introduce a power shaver through the lateral
portal and perform a bursectomy
Expose undersurface
acromion
Release C-A ligament
Define anterior & lateral
edges

27. ü From the undersurface
of the acromion
ü From the distal clavicle
ü Excise the C-A ligament
Use an electrocautery to remove soft tissues

28. Perform a “provisional” anterior
acromioplasty

29. Perform final acromioplasty using the
“Cutting Block” technique
Flatten acromion from posterior to anterior

30. Watch the angle !
ΟΚ ΟΚ

31. Check acromioplasty in both planes
Post. Ant. Med. Lat.

33. üCA ligament released?
üAcromion flat in A-P plane?
üAcromion flat in M-L plane?
üAC joint inspected?
üRotator cuff inspected?
End-point Assessment

34. • Scope posterior /
instruments lateral
– Exposure
Distal Clavicle Resection

35. • Scope lateral /
instruments anterior
– Best access to distal
clavicle
– 70° arthroscope
– 8-10 mm excision of
the distal clavicle
Distal Clavicle Resection

36. What about efficacy of the technique?

37. What about efficacy of the technique?
Odenbring et al Arthroscopy 2008
Long-term Outcomes of Arthroscopic Acromioplasty for
Chronic Shoulder Impingement Syndrome: A Prospective
Cohort Study With a Minimum of 12 Years' Follow-up
31 patients
12-14 years follow-up
29 patients (open acromioplasty) as a control group
No full thickness cuff tears

38. Arth group: Revision acromioplasty in 6 patients
Open group: Revision acromioplasty in 3 patients
Good excellent results in 77%
Better results with arthroscopic acromioplasty
Odenbring et al Arthroscopy 2008

39. Arthroscopic acromioplasty: a 6- to 10-year follow-up
83 patients, mean follow-up 8.3 years
Stephens et al. Arthroscopy 1998
“Overall, 81% of patients in our series had good to
excellent results after 6 to 10 years”.
“To optimize the indications for the procedure, other
causes of impingement, such as occult instability and
degenerative joint disease, should be ruled out”.

40. Long-term Clinical and Ultrasound Evaluation After
Arthroscopic Acromioplasty in Patients With Partial
Rotator Cuff Tears
Minimum 5 year follow-up
26 patients
10 out of 26 patients developed full thickness tear
“Arthroscopic acromioplasty and rotator cuff
debridement in patients with partial tears does not
protect the rotator cuff from undergoing further
degeneration.”
Kartus et al. Arthroscopy 2007

41. The Role of Subacromial Decompression in Patients
Undergoing Arthroscopic Repair of Full-Thickness Tears of
the Rotator Cuff: A Systematic Review and Meta-analysis
Chahal et al. Arthroscopy 2012
“On the basis of the currently available literature,
there is no statistically significant difference in
subjective outcome after arthroscopic rotator cuff
repair with or without acromioplasty at intermediate
follow-up.”

42. Is acromioplasty necessary in the setting of full-thickness
rotator cuff tears? A systematic review.
• 354 patients: SAD and Scope Cuff Repair
• 4 Studies: 2 Level I and 2 Level II
• Conlusions:
– “does not support the routine use of partial
acromioplasty or CA ligament release in the
surgical treatment of rotator cuff disease”
– “in some instances, partial acromioplasty and
release of the CA ligament can result in anterior
escape and worsening symptoms”
Familiari et al. J Orthop Traumatol 2012

43. “Functional outcome of patients with calcific
tendonitis after arthroscopic bursectomy and
debridement of the calcific deposit is not influenced if
performed in combination with or without a
subacromial decompression.”
Clement et al. Arthroscopy 2015 (September)
Short-Term Outcome After Arthroscopic Bursectomy
Debridement of Rotator Cuff Calcific Tendonopathy With
and Without Subacromial Decompression: A Prospective
Randomized Controlled Trial
13 MONTHS FOLLOW-UP

44. “The emphasis of treatment is shifting from that of
decompression to restoring the health of the rotator cuff”
F. Fu, 1991

45. üFailed conservative treatment > 6 months
üAcromial prominence/spurs/sclerosis, +
impingement sign, arc of pain, relief from
subacromial injection
üNo evidence of RCT (+/- MRI)
üArthroscopic subacromial decompression
Surgical Treatment