Does a Positive Neer Impingement Sign Reflect Rotator Cuff Contact with the Acromion?

Background  

One possible cause of shoulder pain is rotator cuff contact with the superior glenoid (cuff-glenoid contact) with the arm in flexion, as occurs during a Neer impingement sign. It has been assumed that the pain with a Neer impingement sign on physical examination of the shoulder was secondary to the rotator cuff making contact with the anterior and lateral acromion.     

Office evaluation and management of the shoulder impingement syndrome

The shoulder impingement syndrome is the most common cause of shoulder pain. A complete office evaluation can be aided by a printed exam sheet. Careful consideration of the differential diagnosis is important, often employing the Xylocaine injection test. The impingement syndrome responds to conservative treatment the majority of the time. Long follow-up determines the need for an invasive evaluation or surgical treatment.     

Arthroscopic coracoplasty through the rotator interval

Coracoid impingement has been increasingly recognized as a cause of shoulder pain. Although most decompressive techniques involve open anterior surgery, the arthroscopic treatment of such impingement has only rarely been reported. In this report, the authors describe an intra-articular method of coracoplasty through the rotator interval. This method is easier to perform than a subacromial approach and allows appropriate orientation of the coracoplasty in the plane of the subscapularis tendon.     

Shoulder impingement presenting as neck pain

BACKGROUND: Chronic neck pain can be a difficult problem to evaluate and treat, as it can have several different causes. We studied a series of patients with neck pain near the superomedial aspect of the scapula that was referred pain from inflammation of the shoulder secondary to chronic impingement. We postulate that some patients with specific clinical findings and neck pain can benefit from treatment of shoulder impingement. METHODS: We conducted a retrospective review of the charts of thirty-four patients with neck pain who met three criteria for the diagnosis of shoulder impingement syndrome: (1) a positive impingement sign with pain referred to the neck, (2) radiographic abnormalities, and (3) relief of neck pain after injection of lidocaine and cortisone into the subacromial space. Subjective pain scores were determined before and after the injection. RESULTS: Thirty of the thirty-four patients obtained immediate relief of the neck pain following injection into the subacromial space, and the remaining four had substantial pain relief when they were evaluated three weeks following the injection. Avoidance of the shoulder impingement position (forward elevation of the arm above 90 degrees ) subsequently minimized recurrences. CONCLUSIONS: In selected patients, chronic neck pain may be caused by shoulder impingement, which can be easily diagnosed with standard techniques. The difficulty in making this diagnosis is that the patient presents with neck pain rather than with the typical shoulder pain. The differential diagnosis of chronic lower neck pain should include shoulder impingement syndrome, which can be identified by classic physical and radiographic signs and can be treated with injection into the subacromial space and avoidance of the shoulder impingement position.     

Subacromial impingement syndrome: pathogenesis, clinical features, and examination methods

Although subacromial impingement syndrome is the most common cause of shoulder pain with a specific diagnosis, it is not the only cause of pain in the anterosuperior aspect of the shoulder. Appreciation of the pathophysiology plays a key role in the diagnosis and management of this syndrome. The purpose of this paper is to review some essential aspects of pathogenesis, physical examination, and diagnosis in the light of the current literature.     

Posterior capsular contracture of the shoulder

Posterior capsular contracture is a common cause of shoulder pain in which the patient presents with restricted internal rotation and reproduction of pain. Increased anterosuperior translation of the humeral head occurs with forward flexion and can mimic the pain reported with impingement syndrome; however, the patient with impingement syndrome presents with normal range of motion. Initial management of posterior capsular contracture should be nonsurgical, emphasizing range-of-motion stretching with the goal of restoring normal motion. For patients who fail nonsurgical management, arthroscopic posterior capsule release can result in improved motion and pain relief. In the throwing athlete, repetitive forces on the posteroinferior capsule may cause posteroinferior capsular hypertrophy and limited internal rotation. This may be the initial pathologic event in the so-called dead arm syndrome, leading to a superior labrum anteroposterior lesion and, possibly, rotator cuff tear. Management involves regaining internal rotation such that the loss of internal rotation is not greater than the increase in external rotation. In the athlete who fails nonsurgical management, a selective posteroinferior capsulotomy can improve motion, reduce pain, and prevent further shoulder injury.     

The impact of subacromial impingement syndrome on muscle activity patterns of the shoulder complex: a systematic review of electromyographic studies

Background  

Subacromial impingement syndrome (SIS) is a commonly reported cause of shoulder pain. The purpose of this study was to systematically review the literature to examine whether a difference in electromyographic (EMG) activity of the shoulder complex exists between people with SIS and healthy controls.     

Evaluation and treatment of internal impingement of the shoulder in overhead athletes

One of the most common pathologic processes seen in overhead throwing athletes is posterior shoulderpain resulting from internal impingement. "Internal impingement" is a term used to describe a constellation of symptoms which result from the greater tuberosity of the humerus and the articular surface of the rotator cuff abutting the posterosuperior glenoid when the shoulder is in an abducted and externally rotated position. The pathophysiology in symptomatic internal impingement is multifactorial,involving physiologic shoulder remodeling,posterior capsular contracture,and scapular dyskinesis. Throwers with internal impingement may complain of shoulder stiffness or the need for a prolonged warm-up,decline in performance,or posterior shoulder pain. On physical examination,patients will demonstrate limited internal rotation and posterior shoulder pain with a posterior impingement test. Common imaging findings include the classic "Bennett lesion" on radiographs,as well as articular-sided partial rotator cuff tears and concomitant SLAP lesions. Mainstays of treatment include intense non-operative management focusing on rest and stretching protocols focusing on the posterior capsule. Operative management is variable depending on the exact pathology,but largely consists of rotator cuff debridement. Outcomes of operative treatment have been mixed,therefore intense non-operative treatment should remain the focus of treatment.     

Postoperative subcoracoid impingement syndrome in patients with rotator cuff tear

Impingement of the tendinous rotator cuff on the coracoid process (subcoracoid impingement syndrome) has rarely been reported as a cause of pain after surgery for rotator cuff tear. We evaluated clinical features, surgical results, and histopathology findings of resected coracoid processes in patients with subcoracoid impingement syndrome after anterior acromioplasty and management of rotator cuff tear. Pain at the anterior aspect of the shoulder, localized tenderness of the coracoid process, anterior shoulder pain on horizontal adduction testing, and positive subcoracoid block suggest subcoracoid impingement syndrome. Postoperative subcoracoid impingement syndrome was investigated in 11 of 216 cases with rotator cuff surgery. The average patient age at the time of surgery was 61.2 y (range, 28-78 y). Coracoplasty (partial resection of the posterolateral side of the coracoid process) was performed in 9 shoulders that had not responded to a 6-month regimen of conservative treatment. Complete pain relief was achieved in all cases. Histopathologic findings revealed hypertrophic changes of the fibrocartilage layer at the posterior aspect of the resected coracoid process. We concluded that subcoracoid impingement syndrome was an important factor in unsuccessful rotator cuff surgery and recommend that coracoplasty be performed on patients with symptoms of subcoracoid impingement syndrome after management of the rotator cuff tear.     

Bilateral Os Acromiale in a Division I Basketball Player

An unfused acromial epiphysis, called os acromiale, can become unstable and mobile when the deltoid contracts. This may cause pain and lead to impingement syndrome and rotator cuff tearing. After sustaining a direct blow to the right shoulder, a male division I basketball player was diagnosed with impingement syndrome and an os acromiale. Following failed conservative treatment, the athlete underwent arthroscopic subacromial decompression & debridement of the loose os acromiale in the right shoulder. One year later, following a fall on the left shoulder, the athlete was diagnosed with os acromiale, impingement syndrome and a superior labrum anterior-posterior (SLAP) lesion. Arthroscopic repair of the unstable type II SLAP lesion, together, with arthroscopic subacromial decompression, and resection of the os acromiale was performed on the left shoulder. Both surgeries were successful and the athlete was able to return to competition subsequent to completing a progressive shoulder rehabilitation program. Symptomatic os acromiale is rarely seen in young athletes. However, proper diagnosis and management is necessary for a successful recovery. Os acromiale should be considered as a part of the differential diagnosis in any athlete with rotator cuff impingement symptoms.Key Words: Injury, shoulder, athlete, rehabilitation, diagnosis     

Subcoracoid impingement syndrome: a painful shoulder condition related to different pathologic factors

Subcoracoid impingement syndrome represents a rare cause of shoulder pain. To date, there are a few papers in literature that have addressed specifically the subcoracoid impingement. We reviewed 13 consecutive patients suffering from this syndrome who underwent an arthroscopic treatment. There were 4 men and 9 women with a mean age of 45 years (range, 23-58 years). The diagnosis of subcoracoid impingement was carried out on the basis of clinical examination and magnetic resonance imaging finding. Arthroscopic surgery consisted of a coracoplasty alone in 2 patients, coracoplasty and acromioplasty in 2 patients, coracoplasty and subscapularis tendon repair in 4 patients, and in the last 5 patients no coracoplasty was done and surgery consisted in treating a minor shoulder instability. Patients were reviewed at a mean follow-up of 2.4 ± 0.7 years. We evaluated the difference between preoperative and final postoperative range of motion, VAS, UCLA, SST and Constant score using a Student's t test. At follow-up, we observed a significant improvement in range of motion and shoulder scores; moreover, clinical findings of subcoracoid impingement were negative in all patients. Different pathological shoulder conditions can be responsible for a subcoracoid impingement that can be primary or secondary to factors different from mechanic attrition against the coracoid because of its morphology. In case of primary impingement, coracoplasty is a good treatment to relieve clinical symptoms. In patients suffering from an associated minor shoulder instability with MGHL capsulolabral lesion, surgical treatment of this lesion without coracoplasty led to the improvement in symptoms.     

Impingement syndrome following total shoulder arthroplasty and humeral hemiarthroplasty: treatment with arthroscopic acromioplasty

Pain following total shoulder arthroplasty or humeral hemiarthroplasty is uncommon. Impingement syndrome can be an infrequent source of pain following shoulder arthroplasty. We retrospectively reviewed six patients with refractory impingement syndrome treated with arthroscopic acromioplasty following either total shoulder arthroplasty (four patients) or humeral hemiarthroplasty (two patients). Chronic impingement syndrome requiring acromioplasty affected 3% of all patients who underwent total shoulder arthroplasty or humeral hemiarthroplasty during the study period. A thorough history, physical examination, and radiographic findings made the clinical diagnosis of impingement syndrome. All six patients had positive impingement signs and a positive impingement test with subacromial lidocaine injection. Preoperative radiographs revealed a type II or III acromion and subacromial outlet narrowing in five of six patients. Other sources of shoulder pain including prosthesis loosening, infection, and rotator cuff tear were ruled out preoperatively by physical examination and radiographic findings, and were confirmed by arthroscopic examination. The results of arthroscopic acromioplasty were a reduction in pain from 7.5 preoperatively to 1.6 postoperatively, on a scale from 0 to 10. Five of six patients were completely satisfied with the results of their arthroscopic surgery. Overall, according to the University of California at Los Angeles end-result score, the results were rated as excellent or good in five patients, and unsatisfactory in one patient. Arthroscopic acromioplasty can be a successful technique for the treatment of chronic impingement syndrome following total shoulder arthroplasty or hemiarthroplasty in appropriate patients.Arthroscopy 1998 Oct;14(7):665-70     

Failed anterior reconstruction for shoulder instability

We report a retrospective study of 46 patients with continuing difficulties after anterior reconstruction of a shoulder for instability. In 31 patients instability was still present; in 12 of these, posterior or multidirectional instability had not been recognised and a further 11 had an uncorrected anatomical defect. In 20 patients with significant pain there was often more than one cause: impingement syndrome was seen in nine, osteoarthritis in seven, implant irritation in four and instability alone in two. A disabling medial rotation contracture was seen in 10 patients, four of whom had painful osteoarthritis. We conclude that recurrence of symptoms may imply that the direction of the instability was not recognised, that an anterior repair should not be too tight, and that pain after successful stabilisation is often due to impingement.     

Evidence that central sensitisation is present in patients with shoulder impingement syndrome and influences the outcome after surgery

Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative central sensitisation and the outcomes following arthroscopic subacromial decompression. We recruited 17 patients with unilateral impingement of the shoulder and 17 age- and gender-matched controls, all of whom underwent quantitative sensory testing to detect thresholds for mechanical stimuli, distinctions between sharp and blunt punctate stimuli, and heat pain. Additionally Oxford shoulder scores to assess pain and function, and PainDETECT questionnaires to identify 'neuropathic' and referred symptoms were completed. Patients completed these questionnaires pre-operatively and three months post-operatively. A significant proportion of patients awaiting subacromial decompression had referred pain radiating down the arm and had significant hyperalgesia to punctate stimulus of the skin compared with controls (unpaired t-test, p < 0.0001). These are felt to represent peripheral manifestations of augmented central pain processing (central sensitisation). The presence of either hyperalgesia or referred pain pre-operatively resulted in a significantly worse outcome from decompression three months after surgery (unpaired t-test, p = 0.04 and p = 0.005, respectively). These observations confirm the presence of central sensitisation in a proportion of patients with shoulder pain associated with impingement. Also, if patients had relatively high levels of central sensitisation pre-operatively, as indicated by higher levels of punctate hyperalgesia and/or referred pain, the outcome three months after subacromial decompression was significantly worse.     

The treatment of symptomatic os acromiale

Os acromiale is an uncommon condition of the shoulder. When symptomatic, os acromiale may cause impingement pain, rotator cuff tears, or pain through abnormal motion at the unfused apophysis. Treatment of symptomatic os acromiale is controversial. This article reports on four patients with symptomatic meso-acromions who were treated with open reduction and internal fixation. All four patients recovered full function postoperatively with UCLA shoulder rating scores improving from 19 preoperatively to 35 postoperatively. Open reduction and internal fixation of a symptomatic meso-acromion is a reliable and reproducible technique in which the deltoid attachment and lever arm are minimally affected.     

Arthroscopic repair of partial-thickness rotator cuff tears and SLAP lesions in professional baseball players

Internal impingement is a primary cause of shoulder pain in throwers; however, instability, internal rotation deficit, scapula muscle dysfunction, and core muscle dysfunction are also important elements of the internal impingement process. Articular surface rotator cuff tears, posterior superior labrum tears, SLAP lesions, anterior capsular ligament attenuation, and posterior capsular ligament contracture are commonly seen in throwers. Each of these conditions must be recognized and appropriately treated to ensure the best possible outcome. There is little potential for spontaneous healing of rotator cuff tears and SLAP lesions after debridement.     

Post-traumatic pain syndromes of the shoulder joint--differentiation and treatment

The main symptom of posttraumatic trouble in the shoulder-joint is the painful immobility. We had to differentiate between genuine shoulder pain originating in shoulder alternation and shoulder pain in consequence of other diseases. Significant causes of posttraumatic shoulder pain are the impingement syndrome with tendon alteration or lesion or, due to fractures, the instable shoulder joint as well as shoulder rigidity. An exact diagnosis and, in consequence an exact treatment can only be accomplished basing on accurate history and specific clinical examination.     

Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement

STUDY DESIGN: Random allocation of subjects into a placebo-controlled, crossover study. OBJECTIVES: To investigate the effect of changing thoracic and scapular posture on shoulder flexion and scapular plane abduction range of motion in asymptomatic subjects, and in subjects with subacromial impingement syndrome. BACKGROUND: Changes in upper body posture and concomitant imbalance of the muscle system have been proposed as one of the etiological mechanisms leading to subacromial impingement syndrome. Although clinicians commonly assess posture and devise rehabilitation programs to correct posture, there is little evidence to support this practice. METHODS AND MATERIALS: Selected postural, range of movement, and pain measurements were investigated in 60 asymptomatic subjects and 60 subjects with subacromial impingement syndrome, prior to and following thoracic and scapular taping intended to change their posture. RESULTS: Changing posture had an effect on all components of posture measured (P<.001) and these changes were associated with a significant increase (P<.001) in the range of motion in shoulder flexion and abduction in the plane of the scapula. Changing posture was not found to have a significant effect on the intensity of pain experienced by the symptomatic subjects, although the point in the range of shoulder elevation at which they experienced their pain was significantly higher (P<.001). CONCLUSIONS: The findings of this investigation suggest that changing 1 or more of the components of posture may have a positive effect on shoulder range of movement and the point at which pain is experienced.     

Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study

Seventeen athletes presenting with unexplained shoulder pain on throwing underwent arthroscopic examination. All but one practiced a throwing sport. The dominant arm was involved in all patients except one bodybuilder. Their mean age was 25 years (range 15 to 30 years), and they had symptoms present for a mean of 27 months. None had clinical, radiologic, or arthroscopic evidence of anterior instability. Preoperative clinical examination typically revealed localized pain on full external rotation and 90° abduction, signs of rupture of the rotator cuff, and positive impingement sign. In 10 cases computed tomographic arthrogram showed evidence of abnormality at the posterior edge of the glenoid. The mean humeral retrotorsion was 10° (range 5° to 30°). Under arthroscopy, with the arm placed in full external rotation and 90° abduction (the throwing position), impingement was found between the posterosuperior border of the glenoid and the undersurface of the tendinous insertions of supraspinatus and infraspinatus. A partial rupture of the cuff, which was demonstrated by arthrogram, was confirmed in eight patients, whereas a partial capsulotendinous rupture, which was not demonstrated by arthrogram, was seen in nine patients. Twelve patients had further lesions of the posterosuperior labrum. This study suggests that in addition to Neer's "impingement syndrome" and Jobe's "instability with secondary impingement," impingement of the undersurface of the cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease of the shoulder in the thrower.     

Anterior internal impingement

Purpose: The source of pain in patients with a stable shoulder and clinical signs of impingement is traditionally thought to be subacromial or outlet impingement, as popularized by Neer. This report introduces the concept of anterior internal impingement in patients with signs and symptoms of classic impingement syndrome and arthroscopic evidence of articular-side partial rotator cuff tear. Contact that occurs between the fragmented undersurface of the rotator cuff and the anterosuperior labrum is the apparent source of pain in these patients. Type of Study: Case series. Methods: Ten patients with a primary symptom of pain and an arthroscopic finding of a partial rotator cuff tear were reviewed. Arthroscopic visualization of the subacromial space revealed no evidence of subacromial impingement or bursitis in any patient. All patients had clinical signs and symptoms of classic impingement. The initial part of the surgical procedure consisted of a complete diagnostic arthroscopy in a low-volume gas medium using a single posterior portal. While performing the Hawkins test, the locations of any areas of abnormal soft-tissue contact and impingement were observed directly. Results: There was anterior internal impingement in all 10 patients with partial-thickness rotator cuff tears. The abnormal and fragmented rotator cuff tissue made contact with the anterior superior labrum when the shoulder was visualized from the posterior portal while performing the Hawkins test. Preoperative magnetic resonance imaging correctly showed a partial-thickness rotator cuff tear in 20% of the cases. Conclusions: Recognition of anterior internal impingement as a clinical entity is important because magnetic resonance imaging results are often misleading. This is of particular importance in young patients with isolated lesions in whom arthroscopic acromioplasty and capsular reefing procedures would be unnecessary. When anterior internal impingement is recognized as the source of unresolved shoulder pain, patient selection for surgery and procedure selection can be improved.