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Muslim = TerroristImmigrant = Terrorist
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Impingement = SpursImpingement = ASD
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Subacromial Impingement
My Approach (in 2016)Lennard Funk
Wrightington Upper Limb Unit
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HistoryJarjavay 1867- described subacromial bursitis Duplay
1872- periarthritis humeroscapularisCodman 1934 - described
supraspinatus tearsArmstrong 1949 - Acromionectomy for
Supraspinatus Syndrome 1950s - 1970s - Radical AcromionectomiesNeer
1972 - Limited Anterior AcromionectomyNeer 1982 - Impingement
Syndrome & Extrinsic Theory
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Neer (1982)
Non-operative treatment
Surgery is considered only after 18m of rehab &
injection.Limited bursectomy & divide CAL
Indications for surgery: 1. No cuff tear after 1yr rehab +
positive injection test 2. Cuff tear full thicknessAcromioplasty+/-
Cuff repair
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Over 40yrs Impingement Sign Impingement Test Normal Arthrogram
Non-op for 18 monthsNeer Stage 2
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AcromioplastyMinnesota, USA: six-fold incr. from 1980 to
1985
New York State: 254% incr. from 1999 to 2008Yu et al.
Arthroscopy. 2010Vitale et al. JBJS-Am. 2010
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A review of the Rochester Epidemiology Project servicing
Olmstead County, Minnesota, USA demonstrated an almost six-fold
increase in the incidence of acromioplasty, from 3.3 per 100,000
between 1980 and 1985 to 19.0 per 100,000 between 2000 and 2005
[5]. Similarly, a review of the New York Statewide Planning and
Research Cooperative System ambulatory surgery database showed a
254% increase in the volume of acromioplasties from 1999 to 2008,
representing an increase from 30.0 to 101.9 per 100,000. A review
of the American Board of Orthopaedic Surgery database for Part 2
candidates demonstrated a 142% increase in acromioplasty (Current
Procedural Terminology codes 23130 and 29826) from 1998 to 2008.
This represented an increase from a mean of 2.6 to a mean of 6.3
per candidate [6]
Arthroscopic Acromioplasty (ASD)UK: 746% incr. from 2000 to
2010Judge et al. BJJ. 2014
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The number of procedures rose by 746.4%, from 2523 patients in
2000/2001 (5.2 per 100 000 (95% CI 5.0 to 5.4)) to 21 355 in
2009/2010
ASD vs. other treatments
From: Movarek et al. S&E. 2012NO DIFFERENCENONE FOLLOWED
NEERS CRITERIA!!ALL DIFFERENT STUDY DESIGNS
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Current OpinionsImpingement:Does not existNever needs surgeryASD
is successful, so does need surgeryNever give steroid
injections
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Case Example42 year old office worker3 months painpouring
kettleoverhead reachingsleeping on affected shoulderNSAIDs
ineffective
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ClinicalFull Passive GHJ ROM (incl. Int Rot in Abd.)No
WeaknessSymptom Modification Tests NegativeACJ Tests negative
Neers Sign positive - mid-arc!Copelands modification
positive
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Scapula Assistance + Scapula Correction
Scapula ModificationsJeremy Lewis. BJSM. 2009Ben Kibler
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Thoracic ModificationJeremy Lewis. BJSM. 2009
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Techniques to reduce the thoracic kyphosisScapular positioning
techniquesHumeral head positioning proceduresPain and symptom
neuromodulation procedures
SSMPShoulder Symptom Modification Procedures Jeremy Lewis. BJSM.
2009
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Neer & Copeland SignsNeers Sign = mid-arc pain on passive
elevation in IRCopeland = pain eliminated repeated in ER
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ImagingPlain X-Rays - OA, Calcific tendonitisUltrasound Scan -
rotator cuff tear, calcific tendonitis, bicepsMRI - all of the
above, plus ACJ oedema and osteophytes, GHJ capsulitis,
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ManagementAll secondary causes excluded.i.e. Neers Stage 2
Patient-specific rehab:SimpleLifestylePainlessAssess and address as
necessary:Cuff; Scapula, Posture, SpinePainless!!
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Patient Guide
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Subacromial Injections
Reduce bursal inflammation
Corticosteroids:Temporary Anti-inflammatory onlyShort-acting
(weeks)No good evidence for dose, frequency, typeProteolytic
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Subacromial Injections
WHY?To aid rehab.
WHEN?When pain restricting rehab.
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Accuracy (Blind)76% Posterior approach69% Anteromedial
approach66% correlation between injectors confidence and accuracy
(MRI)Accurate injection = pain reductionVAS & CS returned to
pre-injection at 6 weeks in all !51% rotator cuff injectedHenkus et
al. Arthroscopy. 22(3):277-82. March 2006
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Accuracy StudiesEustace JA, Brophy DP, Gibney RP, Bresnihan B,
Fitzgerald O. Comparison of the accuracy of steroid placement with
clinical outcome in patients with shoulder symptoms. Ann Rheum Dis
1997;56:59-63.Sethi PM, Kingston S, El Attrache N. Accuracy of
anterior intra-articular injection of the glenohumeral joint.
Arthroscopy 2005;21:77-80.Yamakado K, The targeting accuracy of
subacromial injection to the shoulder: An arthrographic evaluation.
Arthroscopy 2002;18:887-891.Naredo E, Cabero F, Beneyto P, Cruz A,
Mondejar B, Uson J, Palop MJ, Crespo M. A randomized comparative
study of short term response to blind injection versus
sonographic-guided injection of local corticosteroids in patients
with painful shoulder. J Rheumatol. 2004 Feb;31(2):308-14.
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Ultrasound Guided Injections41 Randomised Blind vs USS
guidedNaredo et al.. J Rheumatol. 2004 Feb;31(2):308-14.
Number of patients with 50% decrease in VAS for pain (VAS 50)
and SFA score (SFA 50) at 5 weeks.
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40 PatientsBlind RCTAbduction range improved more in US Guided
groupNo significant difference in PainChen et al. Am J Phys Med
Rehabil. 2006. JanUltrasound Guided Injections
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My ApproachBlind:InitialQuickSimpleWorks >70%Guided:Failed
initialDiagnosticPrevious ASDDone by Radiologist
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SurgeryWHY?To treat the cause!
WHEN?When there is a surgically treatable causeBut, how do you
know???
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How do you know?Clinical:Positive Passive Neers SignNegative
Copelands signNegative Corrective / Modification
TestsRadiological:ACJ / Cuff tear / calcific / labral tear,
etc.Treatment Response:Positive Response to good SAINegative
response to correct rehab.
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Indications for SurgerySpace occupying lesionCalcific
TendonitisACJ osteophytesSecondary Cuff Dysfunction Frozen
ShoulderRotator Cuff TearBiceps PathologyInstability}Treat the
Cause(Not ASD)
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Impingement Audit, 201265 patients with SIS over 1 yearSecondary
causes excluded on imaging.23% +ve modification tests -> rehab -
all recovered77% - SAI:69% positive response to SAI at 6wks90%
recovered with rehab by 3months11 patients (17%) = ASD+ve SAI =
100% full recovery-ve SAI = 60% full recoverySelina Sandher,
Medical Student
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Failed ASD Review, 201454 patients with mean age 51yrsTime from
ASD to revision = 27m (8-168)Procedures:AC joint Excision 41%Biceps
Tenotomy 20% Cuff Repair 19%Capsular Release 7% Microfracture
3%Excision of calcific deposits 2% Anterior Stabilisation 2%Ravi
Badge & Emma TorrancePresented at SECEC, 2015
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SummarySubacromial Impingement does existIt is a collection of
symptom & signs Not a pathological diagnosis
Exclude secondary causesPassive / DynamicSymptom Modification
tests positive = No Surgery!Surgery = Treat causeThere is a role
for ASD alone, but it is not common
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NHS Commissioning Gude, 2013
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THANK [email protected]
IMPINGEMENT
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Neer (1972) Anatomical Rationale for Anterior
AcromioplastyTheory: caused by repeated impingement of the rotator
cuff and the humeral head with traction of the CA ligamentDissected
100 shoulders and found evidence of mechanical impingement in 11,
with acromial spursReported 50 Open Acromioplasty procedures with
good results.
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