Schulterimpingement

The impingement syndrome is a clinical entity characterized by shoulder pain due to primary or secondary mechanical irritation of the rotator cuff. The primary factors for the development of impingement are a curved or hook-shaped anterior acromion as well as subacromial osteophytes, which may lead to tearing of the supraspinatus tendon. Secondary impingement is mainly caused by calcific tendinopathy, glenohumeral instability, os acromiale and degenerative changes of the acromioclavicular joint. Conventional radiographs are initially obtained, mainly for evaluation of the bony structures of the shoulder. If available, sonography can be used for detection of lesions and tears of the rotator cuff. Finally, MR-imaging provides detailed information about the relationship of the acromion and the acromioclavicular joint to the rotator cuff itself. In many cases however, no morphologic cause for impingement syndrome can be found. While patients are initially treated conservatively, chronic disease usually requires surgical intervention.     

Shoulder arthroscopy: its role in evaluating shoulder disorders in the athlete

We retrospectively reviewed 100 initial shoulder arthroscopies from a general sports medicine orthopaedic practice to determine if arthroscopy is helpful diagnostically and to see if specific lesions correlate well with specific diagnoses. Seventy-two percent of the patients in the review had glenoid labral tears. Ninety-two percent of patients who had a diagnosis of either recurrent anterior dislocation or recurrent anterior subluxation demonstrated a tear of the anterior inferior margin of the glenoid labrum. Sixty-eight percent of patients with a diagnosis of impingement demonstrated tears at the superior margin of the labrum. There was a significant difference between throwing and nonthrowing athletes. Partial rotator cuff tears were noted in 18 patients, the majority occurring in throwing athletes. Other abnormalities, such as degenerative joint changes and biceps tendon lesions, were also noted at the time of arthroscopy. A large number of glenoid labral tears found at the time of arthroscopy appeared to be associated with conditions other than instability, which may or may not affect the throwing athlete. There also appeared to be a high correlation between tears in the anterior inferior glenoid labrum and anterior instability. Arthroscopy enabled us to identify other significant information about the status of the biceps tendon or the undersurface of the rotator cuff. These are areas in which problems might otherwise have been missed. Degenerative changes of the articular surface, not apparent on plain radiographs, may also be better evaluated arthroscopically.     

Shoulder impingement syndrome: impingement view and arthrography study based on 100 cases

A prospective evaluation combining the shoulder impingement view and arthrography was made in patients presenting with chronic shoulder pain. Five hundred and twenty-three patients with chronic shoulder pain were X-rayed using conventional views and impingement views. One hundred of these patients (mean age 62 years) had subacromial bony spurs on the impingement view; these underwent arthrography. They were divided into two groups according to the degree of spur formation — whether or not the size of the spur exceeded one half of the acromial width as measured from the outer margin to the acromioclavicular joint. Of the 100 subacromial spurs demonstrated on the impingement view, only 18 were visible on the conventional view as assessed by an independent radiologist. Arthrography showed 35 cases of rotator cuff tear. The size of the bony spur was strongly associated with the incidence of rotator cuff tear (P < 0.02).     

Sports ability after Bankart procedure in professional athletes

Recurrent anterior shoulder instability and the restoration of sports ability after surgery are common problems, especially among professional athletes. The purpose of this study was to evaluate the rate, level and time of returning to sports activity after Bankart procedure in anterior shoulder instability in high level atheletes. From 1992–1994 61 patients suffering from recurrent anterior shoulder instability were operated on open Bankart procedure. 44 out of 61 were professional athletes. There were 7 handball, 7 basketball, 6 football, 2 waterpolo and 1 base-ball player and 4 wrestlers, 2 weightlifters, 2 boxers, 3 bicyclists, 2 motorists, 2 swimmers, 2 sailors, 2 kayakers and 2 skiers. The mean duration of instability was 19.1 months (3–72) before operation. 29 patients had posttraumatic recurrent anterior dislocation and 15 patients had posttraumatic anterior subluxations. The average number of redislocations was 4.4, ranging from 2 to 11. At the follow-up examination the patients were tested clinically for instability using the special score created by Walch and Duplay and the Constant functional score. We measured the strength of the rotator cuff by Kintrex isokinetic device from the 10th postoperative week. 35 out of 44 professional athletes could be fellowed-up. The average follow-up period was 14.2 months, from 6 to 31. 88% of the patients were able to return to sports participation, 66% on the previous levels and 22% on a lower level. 12% of the patients finished their professional sports career. The mean rehabilitation period was 5.8 months, the average period of full restoration of sports ability was 9.3 months. Similar results were documented with the Constant score and the Walch-Duplay test (88% excellent or good, 12% fair). The main reason for the inability to continue sports activity was some pain during extreme abduction and extrnal rotation of the arm and recurrent sensations of subluxation (3 cases). Based on the results of the follow-up examinations an early diagnosis is paramount followed by timely surgical intervention to restore anatomical integrity in proven cases of shoulder instability in professional athletes. The open Bankart procedure is preferred giving excellent functional results and providing good chances for the atheletes to return to their previous sports level.     

Diagnostic evaluation of athletes with posttraumatic chronic shoulder pain

We examined 20 consecutively admitted athletes suffering from chronic shoulder pain for more than 6 months following a single shoulder trauma without dislocation. All had pain during loading, especially during over-the-head activities with a clicking sensation, and symptoms of dead arm were also present. On examination, 8 patients had decreased range of motion and 14 patients had a positive apprehension test. Three had signs of impingement. Diagnostic evaluation with special X-ray, ultrasonography, magnetic resonance imaging (MRI) and arthroscopy identified IS lateral tears, 3 partial and 1 total rotator cuff lesions and 2 patients with synovitis of the rotator cuff with subacromial impingement. Three patients had tendinitis of the biceps tendon and 1 had a lesion of the greater tubercle. In conclusion, chronic shoulder pain after a single nondislocated shoulder trauma in athletes should be evaluated due to a possible intraarticular cause of the pain. MRI seems to be the most valuable noninvasive method of evaluating patients with chronic shoulder pain and should be performed before arthroscopy and operative procedures.     

Special shoulder problems in the throwing athlete: pathology, diagnosis, and nonoperative management

Shoulder problems in the overhead and throwing athlete can result in rotator cuff tendinitis. Biomechanically, there is a delicate balance between mobility and stability of the shoulder complex. Repetitive overhead stressful motion can lead to overuse tendinitis, subtle instability, labral changes, and eventual fiber failure of the rotator cuff. Secondary impingement symptoms are commonly present. An accurate diagnosis along with an early and aggressive rehabilitation program is essential in the treatment of these athletes.     

Secondary impingement in the shoulder. An improved terminology in impingement

Non-traumatic shoulder pain in the overhead athlete is a diagnostic challenge. In the last decade shoulder arthroscopy and magnetic resonance imaging (MRI) techniques have extended our knowledge. Previously unknown pathologic changes in the glenohumeral joint have been demonstrated and it is recognized that impingement symptoms and instability are often related. Shoulder dysfunction in overhead athletes may be caused by shoulder instability. However, a possible instability in the shoulder is often "silent" and difficult to demonstrate by ordinary tests and has therefore by some been termed "functional instability". It is now thought that functional instability in the shoulder may lead to a vicious cycle involving microtraumata and attenuation of the capsular complex, and may eventually lead to shoulder pain. Changes in shoulder proprioception, measured by testing kinaesthetic sense and position sense, can be related to different pathologic changes in the shoulder, and sensory motor control may be an important factor for functional stability in the shoulder. MRI and arthroscopical findings in athletes with shoulder pain are changes in the glenoid labrum, the humeral head, the rotator cuff, biceps tendon and the capsular complex. However, these findings often present other clinical entities than impingement and are not always associated with instability. Clinically, there are tests that can objectively distinguish some of the pathological findings. However, we need more exact methods to further improve our clinical diagnoses of the painful shoulder. One of the keys could be an extended knowledge about the pathophysiology behind functional instability. This review focuses on an improved terminology in impingement based on the current knowledge of impingement and instability in the shoulder.     

Rehabilitation of overuse injuries of the shoulder

The most common overuse injuries in sports medicine are rotator cuff tendinitis and shoulder impingement. Anatomic and biomechanical analysis of the shoulder complex demonstrates the likelihood of overuse injury to this region. Total rehabilitation includes relief of inflammation, restoration of normal joint arthrokinematics, and rotator cuff strengthening. The reduction of force overload to the shoulder in sport-specific activities and total arm strengthening are also emphasized in a comprehensive rehabilitation program.     

Schultergelenkverletzungen bei Überkopfsportarten

Overhead sport places great demands on the shoulder joint. Shoulder pain in overhead athletes and throwers can in the majority of cases be attributed to lesions resulting from chronic overuse of tendons and capsuloligamentous structures or to sequels of microinstability and secondary impingement. Due to its great impact on therapeutic decisions, imaging in athletes with unclear shoulder pain is a challenge. In this connection, magnetic resonance (MR) arthrography represents the cross-sectional imaging modality of first choice, as it allows depiction and exclusion of pathologic alterations of all relevant joint structures with sufficient confidence. This article reviews the biomechanical and clinical aspects and MR arthrographic features of the most common shoulder pathologies in overhead athletes, including biceps tendinopathy, superior labral anterior-posterior (SLAP) lesions, rotator cuff lesions, as well as extrinsic and intrinsic impingement syndromes.     

Shoulder imaging in athletes

Shoulder pain and injuries are common in athletes. Overhead athletes, in particular, place great demands on the shoulder and supporting structures. Magnetic resonance (MR) imaging is well suited to evaluation of the osseous structures and soft tissues of the shoulder and plays an important role in evaluation of shoulder pain in athletes. Primary extrinsic impingement is well evaluated on MR imaging as are the less common posterior superior glenoid impingement and subcoracoid impingement. Rotator cuff tendinosis as well as partial- and full-thickness tears are frequently encountered in the athletic shoulder. The biceps tendon and rotator interval capsular structures are important sources of shoulder pain. Glenohumeral instability that results from a traumatic event or atraumatic multidirectional recurrent instability is assessed. The biceps labral complex is a source of considerable anatomic variability and pathology.     

Respiratory Adaptation to Altitude

Rotator cuff injuries in sports brief are usually a result of microtrauma from repetitive movements. Classic, or primary, impingement results directly from overhead motions, and secondary impingement is related to underlying shoulder instability. A variety of physical maneuvers are used to assess pain, muscle weakness, and shoulder stability. The workup also includes plain x-rays, supplemented by other imaging tests if a cuff tear is suspected. Nonoperative treatment, which may include steroid injections, is often effective for an inflamed rotator cuff tendon. Surgery is indicated if the patient has no improvement after at least 6 weeks of physical therapy.     

Rotator cuff contusions of the shoulder in professional football players: epidemiology and magnetic resonance imaging findings

BACKGROUND: No published reports have studied the epidemiology and magnetic resonance imaging findings associated with rotator cuff contusions of the shoulder in professional football players. PURPOSE: To determine a single professional football team's incidence, treatment, and magnetic resonance imaging appearance of players sustaining rotator cuff contusions of the shoulder. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2005, a North American professional football team's injury records were retrospectively reviewed for athletes who had sustained a rotator cuff contusion of the shoulder during in-season participation. Those patients who had magnetic resonance imaging of the shoulder with a 1.5-Tesla magnet were reviewed by a musculoskeletal radiologist and graded according to the appearance and severity of clinical injury. RESULTS: Twenty-six players had a rotator cuff contusion. There was an average of 5.5 rotator cuff contusions per season (47% of all shoulder injuries). The predominant mechanism of injury was a direct blow in 70.3%. Magnetic resonance imaging findings included peritendon edema at the myotendinous junction, critical zone tendon edema, and subentheseal bone bruises. Treatment consisted of a protocol involving modalities and cuff rehabilitation in all patients. Six patients had persistent pain and weakness for a minimum of 3 days and were given a subacromial corticosteroid injection. Overall, 3 patients (11.4%) required later surgical treatment on the shoulder. CONCLUSION: Rotator cuff contusions accounted for nearly half of all shoulder injuries in the football players in this study. Magnetic resonance imaging is an extremely useful tool in determining severity of injury and integrity of the rotator cuff. The majority of athletes are able to return to sports with conservative treatment; a minority of shoulders might progress to more severe injuries such as rotator cuff tears.     

Ultrasonographic and MR diagnosis of rotator cuff disorders & shoulder joint instability

Objective

To evaluate the role and efficacy of U/S and MR in diagnosis of rotator cuff disorders and shoulder joint instability.

Patients and methods

This study included 30 patients with shoulder pain and/or movement limitation. They underwent shoulder U/S examination followed by MR examination. The U/S & MR diagnostic criteria of each patient were analyzed, compared and correlated with arthroscopic and/or orthopedic surgical findings.

Results

15 patients had with rotator cuff disorders 15/30 (50%) and 11 patients had shoulder instability 11/30 (36.7%). Out of 15 patients with rotator cuff disorders, 12 patients had rotator cuff tears 12/15 (80%) and 3 patients had tendenosis 3/15(20%). The supraspinatus muscle was involved in all cases (100%), without a significant comparable difference between U/S and MR. Out of 11 patients with shoulder instability 8 patients had anterior labral tear 8/11 (72.7%); 2 patients had superior labral tear 2/11 (18.2%) and only one patient with posterior labral tear.

Conclusion

U/S and MRI are valid diagnostic modalities in detecting, characterizing and discriminating the rotator cuff disorders, with no significant comparable difference. U/S has many challenges in patients with shoulder instability, while MR provides accurate diagnosis even without contrast.     

The latarjet procedure for recurrent anterior shoulder instability: Rationale and technique

Posterosuperior glenoid impingement (PSGI) is defined as mechanical impingement of the greater tuberosity onthe posterosuperior aspect of the glenoid rim during shoulder abduction, external rotation, and extension. Although this contact is present in most of the population, throwing athletes are particularly vulnerable to developing symptoms related to this impingement, predominantly from partial thickness tears of the rotator cuff. It has been suggested that subtle or “micro”-instability is the underlying source of this “internal” impingement. After examining these claims with regard to our experience and experience of others, this does not seem to be the case. Additionally, we report our preferred treatment regimen for PSGI including our technique for humeral derotational osteotomy.     

Imaging of shoulder pain in overhead throwing athletes

Overhead sports are widely practiced around the world and overhead athletes can present with pain and dysfunction in the throwing shoulder, generally due to degenerative changes secondary to overuse. Numerous etiologies can be taken into account, including rotator cuff and glenoid labrum tears, biceps pathologies, internal impingement, and gleno-humeral instability. In this setting, imaging plays a central role in early diagnosis, thus allowing for a prompt management, correct rehabilitation, and quick return to competition. This review is aimed to discuss the role of imaging to diagnose the most common types of overhead-related shoulder injuries.     

Arthroscopic acromioclavicular resection

Injury to the acromioclavicular joint is common and represents the source of many shoulder-related symptoms.Frequently, nonoperative treatment regimens such as physical therapy, oral antiinflamatory medication, and corticosteroid injections resolve symptoms. However, certain patients with cases refractory to conservative therapy require an operative intervention. The traditional open resection of the distal clavicle, as described independently by Mumford and Gurd has been a reproducible and reliable surgical method of treatment in patients with posttraumatic, degenerative disease of the acromioclavicluar joint associated with osteoarthritis, distal clavicle osteolisis, fractures and separations, and shoulder impingement syndrome. Advances in arthroscopic shoulder surgery and subacromial decompression have made debridement of the acromioclavicular joint and resection of the distal clavicle a viable alternative to the open approach, avoiding complication such as AC joint instability and residual postoperative shoulder weakness, and with distinct advantages like 1) evaluation of glenohumeral joint, 2) evaluation and treatment of coexistent impingement and rotator cuff pathology, 3) generally, performed on an outpatient basis, which decreases hospital cost and increases patient convenience.     

Shoulder impingement syndrome: MR findings in 53 shoulders

The shoulder impingement syndrome refers to a condition in which the supraspinatus tendon and subacromial bursa are chronically entrapped between the humeral head inferiorly and either the anterior acromion itself, spurs of the anterior acromion or acromioclavicular joint, or the coracoacromial ligament superiorly. As a result, the space for the bursa and tendon is reduced, and repeated trauma to these structures leads to bursitis and rotator cuff injury. Although pain and limitation of motion are common early findings, the diagnosis is often delayed until a complete tear of the rotator cuff has occurred. In an attempt to determine if MR can be used to depict the abnormalities associated with impingement syndrome (subacromial bursitis, supraspinatus tendinitis, and rotator cuff tear), we reviewed 107 MR scans of painful shoulders. Changes consistent with impingement syndrome were found in 53 patients (50%), 32 of whom underwent subsequent arthrography or surgery. MR was found capable of depicting several soft-tissue and bony abnormalities that have been clinically described in impingement syndrome. In regions of inflammation, we found that the supraspinatus tendon and/or the subacromial bursa were compressed by spurs (25 shoulders), capsular hypertrophy of the acromioclavicular joint (six shoulders), and/or low-lying acromion (14 shoulders). While T1-weighted MR imaging was highly sensitive to abnormalities of the supraspinatus tendon, tendinitis could be differentiated from a small tear of the supraspinatus tendon only with T2-weighted imaging. Large, full-thickness tears, especially if chronic, produced characteristic MR findings on both T1- and T2-weighted images. We conclude that MR can be used to detect several abnormalities associated with the shoulder impingement syndrome.     

MRI of internal impingement of the shoulder

OBJECTIVE: Internal impingement is a condition that occurs in athletes in which the shoulder is put in extreme abduction and external rotation during overhead movements. During this motion, the posterior fibers of the supraspinatus tendon, anterior fibers of the infraspinatus tendon, or both can get impinged between the humeral head and the posterior glenoid. The purpose of this study was to evaluate the ability of MRI to show the findings of internal impingement of the shoulder. CONCLUSION: As opposed to our six patients with clinically and surgically diagnosed internal impingement, the control patients had isolated pathology in the rotator cuff, labrum, or humeral head. We found that the constellation of findings of undersurface tears of the supraspinatus or infraspinatus tendon and cystic changes in the posterior aspect of the humeral head associated with posterosuperior labral pathology is a consistent finding diagnostic of internal impingement.     

肩关节损伤MRI与关节镜的对比分析

目的探讨常规MRI对肩关节损伤的诊断价值。方法回顾性分析因肩关节损伤行常规MRI和关节镜检查的55例病人资料,MRI观察指标包括肩袖、盂唇形态及信号,有否肩峰下撞击及骨性损伤。以肩关节镜为诊断金标准,统计MRI对不同类型肩关节损伤的诊断结果,并分别计算MRI的诊断敏感度、特异度和准确度。采用Kappa检验分析MRI与肩关节镜诊断结果的一致性。结果肩关节损伤的MRI征象中分别有25%部分肩袖撕裂、13.3%Bankart’s损伤、20%盂唇上部前后方向(SLAP)损伤和11.6%肩峰下撞击漏诊。MRI诊断损伤性病变的特异度及肩袖全层撕裂(100%)、骨性损伤(100%)、肩峰下撞击(88%)和Bankart’s损伤(87%)的敏感度较高,诊断SLAP损伤(75%)和肩袖部分撕裂(75%)的敏感度较低;诊断肩袖全层撕裂(100%)和骨性损伤(100%)的准确度最高,其次是Bankart’s损伤(96%),诊断SLAP损伤(89%)的准确度较低。MRI和关节镜诊断肩袖全层撕裂、骨性损伤的κ值为1,结果完全一致,诊断Bankart’s损伤的κ值为0.904,一致性较好,诊断肩袖部分撕裂、SLAP损伤和肩峰下撞击的κ值虽稍低,但均0.75,一致性也较好,P均0.05。结论 MRI是有效诊断肩关节损伤的影像方法,但对SLAP损伤和肩袖部分撕裂的诊断准确度有待提高。     

Rotator cuff coactivation ratios in participants with subacromial impingement syndrome

Coactivation of the rotator cuff is vital to glenohumeral joint stability by centralising the humeral head within the glenoid fossa. Yet in individuals with subacromial impingement, it is hypothesised that rotator cuff coactivation abnormalities are present that could contribute to their shoulder pain. The purpose of this study was to determine if abnormal rotator cuff coactivation and deltoid activation patterns exist in participants with subacromial impingement. Rotator cuff (supraspinatus, infraspinatus, and subscapularis) coactivation and middle deltoid activation was assessed during an elevation task. ANOVA models were used to compare muscle activation patterns in 10 participants with subacromial impingement and 10 control participants. Participants with impingement exhibited decreased rotator cuff coactivation (subscapularis–infraspinatus and supraspinatus–infraspinatus) and increased middle deltoid activation at the initiation of elevation (0–30° of humeral elevation). The participants with impingement also had higher subscapularis–infraspinatus and supraspinatus–infraspinatus coactivation above the level of the shoulder where pain is typically present (90–120° of humeral elevation). The results indicate that individuals with subacromial impingement exhibit rotator cuff muscle coactivation and deltoid activation abnormalities during humeral elevation that might contribute to the encroachment of the subacromial structures associated with subacromial impingement.