The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 19

Scientific Articles | October 05, 2011

Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder

Anastasios Papadonikolakis, MD¹; Mark McKenna, MD¹; Winston Warme, MD¹; Brook I. Martin, PhD, MPH²; Frederick A. Matsen, III, MD¹

¹ Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 NE Pacific Street, Seattle, WA 98195. E-mail address for F.A. Matsen III: matsen@u.washington.edu
² Department of Orthopaedics, HB7541, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756-0001

View Disclosures and Other Information

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Disclosure statement for author(s): PDF

Investigation performed at the University of Washington, Seattle, Washington

J Bone Joint Surg Am, 2011 Oct 05;93(19):1827-1832. doi: 10.2106/JBJS.J.01748

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (2)

text A A A

Abstract

Background:

Acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. This investigation sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment.

Methods:

We conducted a systematic review of articles relevant to the following hypotheses: (1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions, (2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders, (4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch. Three of the authors independently reviewed each article and determined the type of study, the level of evidence, and whether it supported the concept of the impingement syndrome. Articles with level-III or IV evidence were excluded from the final analysis.

Results:

These hypotheses were not supported by high levels of evidence.

Conclusions:

The concept of impingement syndrome was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. The current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated. Nonoperative and operative treatments are currently being used for the different rotator cuff abnormalities. Future clinical investigations can now focus on the indications for and the outcome of treatments for the specific rotator cuff diagnoses. It may be time to replace the nonspecific diagnosis of so-called impingement syndrome by using modern methods to differentiate tendinosis, partial tears, and complete tears of the rotator cuff.

Level of Evidence:

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

The term impingement syndrome was introduced before modern methods of diagnosis of rotator cuff disorders were widely available. In his 1972 classic article, Neer pointed out that chronic bursitis and partial-thickness tears, calcium deposits, and complete tears of the rotator cuff could not be distinguished one from the others by physical and radiographic findings (nineteen shoulders in the original report had tendinitis or partial tears, while twenty had complete tears of the supraspinatus)¹. As a result, the term impingement syndrome has been used to refer to the full range of rotator cuff abnormalities. There is growing interest in this condition; a PubMed search indicated that the number of articles mentioning "impingement" and "shoulder" in the abstract had doubled in the last decade from seventy-eight per year in 1999 to 159 per year in 2009.

Acromioplasty (Current Procedural Terminology [CPT] code 23130 or 29826) is commonly used as the definitive surgical treatment for the so-called impingement syndrome. Several recent reports have indicated a dramatic increase in the rate at which acromioplasty is being performed. Yu et al.² reported a 575% increase in the rate of acromioplasties performed in Olmsted County, Minnesota, over the two decades from the 1980s to the 2000s. Vitale et al.³ reported a 340% increase in the rate of acromioplasties performed in New York State between 1996 and 2006. The rate at which this procedure is performed in New York State is almost four times the rate in Olmsted County. The rate of increase in New York is seven per 100,000 per year, almost ten times the rate in Olmsted County, which is 0.8 per 100,000 per year. Data from the Healthcare Cost and Utilization Project's (HCUP) State Ambulatory Surgery Database (SASD) for Florida, as well as from the Centers for Medicare and Medicaid Services (CMS), show similar increases (Fig. 1).

Vitale et al. also reported a 240% increase in the number of acromioplasties performed per candidate for the American Board of Orthopaedic Surgery (ABOS) from 1999 to 2008³. Garrett et al.⁴ reported that, from 1999 to 2003, arthroscopic acromioplasty had risen from ninth to second place among the CPT codes reported by ABOS Part-II candidates, with the count increasing by 210% over this interval. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes reported for these cases are nonspecific: 840.4 (rotator cuff [capsule] sprain) and 726.2 (other affections of shoulder region/not elsewhere classified). From the available information, it is not possible to determine how much of the increase in the number of acromioplasties performed per 100,000 individuals is due to an increased prevalence of rotator cuff disease and how much is due to changing indications for surgical treatment.

Against this background, it seems timely to reexamine impingement syndrome as a distinct diagnosis, especially at a time when modern diagnostic tools, such as magnetic resonance imaging (MRI), sonography, and arthroscopy, can accurately differentiate disorders such as tendinosis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. The goal of this investigation was to determine the evidence in the peer-reviewed literature for the five following hypotheses that would support the continued use of the term impingement syndrome and the rationale supporting its treatment by surgical decompression of the rotator cuff with use of acromioplasty:

Clinical signs and tests can reliably differentiate the impingement syndrome from other conditions. If impingement syndrome is a distinct diagnosis, the necessary and sufficient conditions for its differential diagnosis should be specified with satisfactory sensitivity and specificity.
Clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch. The underlying impingement thesis is that "impingement on the tendinous portion of the rotator cuff by the coraco-acromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder."¹
Contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders. If the contact between the coracoacromial arch and rotator cuff is pathogenetic, it should not occur in normal shoulders.
Spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff. As the coracoacromial arch is normally congruent with the rotator cuff, in order to disrupt the rotator cuff, the spur should extend beyond the ligament, rather than lying within it.
Successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch. Since "most supraspinatus and biceps lesions are due to impingement wear, usually caused in part by variations in the shape and slope of the acromion,"⁵ definitive treatment would necessitate decompression by acromioplasty and, furthermore, acromioplasty would be superior to other treatments in randomized controlled trials.

Fig. 1

Rates of acromioplasty per 100,000 individuals. Data are from the Florida Healthcare Utilization Project (HCUP) State Ambulatory Surgery Database (SASD), the recent paper by Vitale et al.³ for the State of New York, the national Centers for Medicare and Medicaid Services (CMS) database, and a recent paper by Yu et al.² regarding Olmsted County, Minnesota. The Medicare data represent the rates of acromioplasty, including inpatient, outpatient, open, and arthroscopic procedures, among Medicare enrollees (individuals sixty-five years and older) from 1994 through 2006 obtained from the CMS. These rates are based on the 5% CMS sample from 1994 to 2001 and the 20% sample from 2002 to 2006. Essentially all of the increase has been in arthroscopic acromioplasty, while the rate of open acromioplasty has remained essentially unchanged. The Florida data show the rate of outpatient acromioplasty among Florida residents over the age of fifteen years from 1997 to 2003. The Florida HCUP SASD database is one of the few available that allows one to calculate population rates of outpatient procedures on the basis of CPT codes rather than ICD codes.

View Large | Download Slide(.ppt)
Add to My JBJS

Materials and Methods

To locate the published evidence in support of the five stated hypotheses, we performed a PubMed search for all articles published prior to September 2010 that mentioned "impingement" and "shoulder"; 1739 such abstracts were thus located. Because of the relevance to hypothesis number 2, we performed a similar search for abstracts including the terms "partial," "cuff," and "tear"; 330 such abstracts were located. Because of the relevance to hypothesis number 4, we performed a similar search for abstracts including the terms "coracoacromial" and "ligament"; 234 such abstracts were located. The authors read each of these abstracts and, if necessary, the papers themselves to exclude from consideration reviews, commentaries, instructional courses, transactions, book chapters, surgical technique papers, articles that did not relate to impingement in the shoulder, articles discussing only internal impingement, articles dealing with acromioclavicular impingement, articles relating to coracoid impingement, articles describing impingement due to fractures and tumors, articles discussing secondary impingement, articles on impingement as a complication of shoulder arthroplasty, articles presenting the outcome of acromioplasty without comparison with other methods of treatment, articles comparing open with arthroscopic acromioplasty, articles dealing primarily with the evaluation and management of rotator cuff tears, articles not in English, and other articles that did not address one of the five hypotheses. We also excluded from consideration articles demonstrating the well-recognized coexistence of various acromial shapes with rotator cuff tears, recalling the dilemma regarding cause and effect: "a characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process was seen frequently, apparently caused by repeated impingement of the rotator cuff and humeral head, with traction on the coracoacromial ligament"¹ as opposed to "most supraspinatus and biceps lesions are due to impingement wear, usually caused in part by variations in the shape and slope of the acromion."⁵

The remaining 124 articles were each read by three of the authors and were evaluated in terms of their support or nonsupport of each of the five hypotheses, the type of study (clinical, cadaveric, animal, normal subject, histological, and observational investigation), the level of evidence for clinical studies, the critical finding, and the gold standard or outcome measure used in the study. The authors applied the Instructions for Authors guidelines from The Journal of Bone and Joint Surgery (American Volume) to determine the levels of evidence⁶. Each evaluator was blinded to the level of evidence assigned by the others. With twenty of the 124 articles, one of the three readers disagreed with the other two as to whether a clinical study was a Level I or II on one hand or a Level III or IV on the other. The three readers again reviewed the twenty articles along with a fourth reader. The final levels of evidence displayed in the five results tables (one for each of the five hypotheses) present the median of the independent evaluations of ninety-two articles, excluding the thirty-two Level-III and IV studies. Our conclusions were based on the data in these tables.

Source of Funding

The DePuy/Douglas T. Harryman II Endowed Chair for Shoulder Research funded this study.

Results

The final analysis included ninety-two articles, of which thirty-five were Level-I clinical studies, seventeen were Level-II clinical studies, twenty-eight were cadaver studies, six were studies of normal subjects, two were animal studies, two were observational studies, and two were histological and/or biochemical. The type of study, level of evidence for clinical studies, critical findings, and gold standard are listed in five tables, one for each of the hypotheses; these tables and the references mentioned in them can be found in the Appendix.

Hypothesis 1: Clinical Signs and Tests Can Reliably Differentiate the So-Called Impingement Syndrome from Other Conditions

Evidence to support this hypothesis was lacking. The preponderance of evidence, including Level-I and II clinical studies, indicates that the physical findings used to diagnose the impingement syndrome, i.e., the Neer sign (pain on forced flexion), the Hawkins sign (pain on internal rotation with the arm elevated to 90°), and the Neer injection test (relief of pain on the Neer sign after subacromial injection of local anesthetic)^1,5,7-9, may be sensitive, but are not specific. The average sensitivity (and standard deviation) of the Neer sign was 76% ± 11%, while the average specificity was 36% ± 22%. The respective values for the Hawkins sign were 80% ± 11% and 41% ± 19%. The intended subacromial injection of the Neer injection test reached the subacromial space between 60% and 100% of the time, but also reached other structures in as many as 63% of the cases. The Hawkins sign is similar to the tests used for posterior capsular tightness and glenohumeral internal rotation deficit, again pointing to the lack of specificity for this clinical finding^10-13. (See Table E-1 and associated references in the Appendix.)

Hypothesis 2: Clinically Common Forms of Rotator Cuff Abnormality Are Caused by Contact with the Coracoacromial Arch

Evidence to support this hypothesis was lacking. Animal studies in which subacromial impingement was created did not produce the type of rotator cuff tears most commonly seen in clinical practice. Furthermore, most partial-thickness tears have been observed to start posterior to the anterior edge of the supraspinatus and on the articular, nonacromial aspect of the rotator cuff as a so-called rim rent¹⁴. (See Table E-2 and associated references in the Appendix.)

Hypothesis 3: Contact Between the Coracoacromial Arch and the Rotator Cuff Does Not Occur in Normal Shoulders

Evidence to support this hypothesis was lacking. In normal shoulders in cadavers and in normal living subjects, the rotator cuff contacts the coracoacromial arch. (See Table E-3 and associated references in the Appendix.)

Hypothesis 4: Spurs on the Anterior Aspect of the Acromion Extend Beyond the Coracoacromial Ligament and Encroach on the Underlying Rotator Cuff

Evidence to support this hypothesis was lacking. The coracoacromial ligament is normally under tension. Displacement and increased tensioning of this ligament occur when the proximal part of the humerus passes beneath it. The acromial spur occurs as a traction enthesophyte within this ligament. (See Table E-4 and associated references in the Appendix.)

Hypothesis 5: Successful Treatment of the Impingement Syndrome Requires Surgical Alteration of the Acromion and/or Coracoacromial Arch

Evidence to support this hypothesis was lacking. Physical therapy, injections, and surgery that do not modify the coracoacromial arch have all been shown to be effective in the treatment of impingement syndrome. Multiple Level-I studies have failed to show the superiority of acromioplasty over alternative treatments that do not modify the coracoacromial arch. (See Table E-5 and associated references in the Appendix.)

Discussion

This investigation did not reveal evidential support for the ongoing use of the term impingement syndrome or for the use of this diagnosis as an indication for acromioplasty. The evidence does not support the view that such a syndrome can be differentiated from conditions that are now readily and precisely definable with modern imaging techniques, such as rotator cuff tendinosis, partial-thickness tears, and full-thickness tears^15,16. The evidence does not support the view that rotator cuff abnormality is, in most cases, caused by rubbing on the coracoacromial arch. Rather, the evidence indicates that the rotator cuff articulates with the coracoacromial arch in the movement of normal shoulders. Furthermore, after an acromioplasty with coracoacromial ligament sectioning was performed in otherwise normal specimens, the superiorly loaded humerus translated anterosuperiorly, indicating that contact between the coracoacromial arch and the rotator cuff normally stabilizes the humerus against upward displacement¹⁷ and suggesting that "the coracoacromial arch has an important duty and should not be thoughtlessly divided at any operation."¹⁸ The spur that is often associated with rotator cuff tears has been demonstrated to form within the coracoacromial ligament, rather than extending below it. Finally, the evidence indicates that therapeutic approaches that do not alter the coracoacromial arch are successful in managing impingement syndrome, and the evidence does not provide support for the view that acromioplasty is superior to these other methods. It is of note that many of the articles relevant to the five hypotheses were published in nonsurgical journals, which may not be routinely accessed by orthopaedic surgeons.

We are not the first to suggest a revision of the historical approach to the rotator cuff disorders previously included under the term impingement syndrome and the use of acromioplasty to treat it. Zarins, in a commentary on Neer's classic article, stated, "It is more likely that rotator cuff dysfunction results in upward displacement of the humeral head and causes impingement of the humeral head against the acromion with shoulder use rather than the reverse. Arthroscopy and magnetic resonance imaging arthrography have elucidated many conditions that cause shoulder pain and that previously have been misdiagnosed as impingement. The liberal use of acromioplasty to treat ‘impingement’ is being replaced by a trend toward making an anatomic diagnosis, such as a partial or a complete tear of the rotator cuff, and performing corrective surgery, such as repair of the torn rotator cuff."¹⁹

Bach and Goldberg¹³ pointed to the potential for confusion between impingement signs and signs of posterior capsular tightness. In a 2006 American Academy of Orthopaedic Surgeons Instructional Course Lecture, McFarland et al. stated, "Future study of the many etiologies of the entity that have been previously called ‘impingement syndrome’ is warranted."²⁰ In their meta-analysis, Hegedus et al.²¹ concluded that neither the Neer nor the Hawkins sign had diagnostic utility for impingement. Hughes et al.²² found, after a systematic review, that most physical examination tests for rotator cuff disorders were inaccurate and cannot be recommended for clinical use. After their review of the diagnostic labeling of shoulder pain, Schellingerhout et al.²³ found that terms such as impingement syndrome lacked uniform definition and that the currently used labels have only fair to moderate reproducibility. They strongly suggested the abolishment of the use of such labels.

A systematic review by Dorrestijn et al.²⁴ led the authors to conclude that "according to the best-evidence synthesis, however, there is no evidence from the available RCTs [randomized controlled trials] for differences in outcome in pain and shoulder function between conservatively and surgically treated patients with subacromial impingement syndrome." After their systematic review of the literature, Beaudreuil et al.²⁵ concluded, "the most extensively studied tests for subacromial impingement—Neer and Hawkins—are sensitive but lack specificity," a conclusion similar to that of Jia et al.²⁶. In their 2009 Cochrane review, Coghlan et al.²⁷ concluded, "There is ‘Silver’ … level evidence from three trials that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non-operative treatment for impingement."

Kuhn²⁸ stated, "Unlike many diagnoses that are based on distorted anatomy, impingement syndrome is a diagnosis based on physical examination. Many different conditions could produce a positive impingement test (e.g., rotator cuff tendinosis, rotator cuff tear, calcific tendinitis, and acute and chronic subacromial bursitis), and perhaps some would respond better to surgery while others to physical therapy. Second, radiographic findings used in determining a diagnosis are no different from those seen in age-matched asymptomatic patients in a control group. When the diagnosis is not clearly defined and may reflect a variety of disorders, it is difficult to discern differences in treatment responses." Harrison and Flatow²⁹ pointed out, "The decision to perform arthroscopic acromioplasty in patients whose conditions are refractory to rest, anti-inflammatory medications, subacromial cortisone injections, and physical therapy has been based more on opinion and retrospective reviews than on high-level evidence." Our broad-based analysis is consistent with the findings of these authors.

Our investigation underscored the observation of Neer¹ that shoulders without rotator cuff tears can have symptoms essentially identical to those with tears. As pointed out by Harryman et al., Sher et al., Yamaguchi et al., and others, the converse is also true: shoulders with rotator cuff tears can be asymptomatic^30-34. These observations reinforce the view that clinical findings alone are not reliable indicators of the status of the rotator cuff. Instead, scientific studies characterizing rotator cuff disorders and the results of treatment of different rotator cuff abnormalities must include advanced imaging, such as sonography or MRI, or arthroscopy.

The results of our study should be viewed in light of certain limitations. First, although the inclusion and exclusion criteria for the articles are clearly stated, it is possible that the selection of articles was subject to bias. Second, standardized guidelines for evaluating the quality of some study types (basic-science, cadaveric, and observational studies and investigations of normal subjects) have yet to be developed. Finally, this investigation did not attempt to clarify the indications for nonoperative or operative management of rotator cuff disorders.

It is appropriate to note that the findings of this study were in large part presaged by Charles Neer in his 1972 article¹. In this preliminary report, he pointed out that the changes in the acromion could be the result of repeated contact with the proximal part of the humerus and the rotator cuff. When he encountered rotator cuff tears in patients with impingement syndrome, they were managed by repair with use of the McLaughlin technique; thus, the results of his surgical treatment were not due to acromioplasty alone. Neer recognized that shoulder stiffness could be associated with impingement syndrome and that often resolution of the stiffness would resolve the patient's clinical problem: "Patients suspected of having incomplete tears were advised not to have surgery until the stiffness of the shoulder had disappeared, and the disability had to persist for at least nine months before surgery was performed. Many patients not included in the series were suspected of having impingement but responded well to conservative treatment. This suggests that while such patients had pathological changes in the cuff that were vulnerable to swelling and inflammation following minor trauma, the acute reaction was reversible."¹ Finally, it is of note that Neer performed operations on only ten patients with impingement syndrome per year (including revision acromioplasties and repairs of full-thickness rotator cuff tears), suggesting his conservative use of the procedure, in contrast to the escalating rate of application being observed today¹.

Clinical Importance

The definition, clinical evaluation, and understanding of rotator cuff disorders have advanced substantially in the last four decades since the introduction of the term impingement syndrome. Physicians now have sonography, contrast MRI, and arthroscopy along with the history and the physical examination to differentiate rotator cuff tendinosis, partial-thickness tears, full-thickness tears, and the condition of tight posterior glenohumeral capsule with diminished internal rotation. Enhanced accuracy in diagnosis should enable physicians to replace nonspecific terminology, such as that represented in the current ICD-9 codes 840.4 (rotator cuff [capsule] sprain) and 726.2 (other affections of shoulder region/not elsewhere classified), with more accurate terms indicating the pathological state of the rotator cuff tendons. This enhanced accuracy will enable better clinical determination of the epidemiology and natural history of rotator cuff disorders, the indications for treatment, and the determination of the effectiveness, efficacy, and appropriateness of different therapeutic approaches.

Appendix

Tables, one for each of the five hypotheses, showing the type of study, level of evidence for clinical studies, critical findings, and gold standard, as well as the references mentioned in the tables, are available with the online version of this article as a data supplement at jbjs.org.

References

Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54:41-50.[PubMed]

Yu E; Cil A; Harmsen WS; Schleck C; Sperling JW; Cofield RH. Arthroscopy and the dramatic increase in frequency of anterior acromioplasty from 1980 to 2005: an epidemiologic study. Arthroscopy. 2010;26( 9 Suppl):S142-7.[PubMed][CrossRef]

Vitale MA; Arons RR; Hurwitz S; Ahmad CS; Levine WN. The rising incidence of acromioplasty. J Bone Joint Surg Am. 2010;92:1842-50.[CrossRef][PubMed]

Garrett WE Jr; Swiontkowski MF; Weinstein JN; Callaghan J; Rosier RN; Berry DJ; Harrast J; Derosa GP. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88:660-7.[CrossRef][PubMed]

Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;173:70-7.[PubMed]

Levels of evidence for primary research question. Instructions for authors. J Bone Joint Surg Am. ww.jbjs.org/public/instructionsauthors.aspx.

Hawkins RJ; Hobeika PE. Impingement syndrome in the athletic shoulder. Clin Sports Med. 1983;2:391-405.[PubMed]

Hawkins RJ; Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8:151-8.[CrossRef][PubMed]

Park HB; Yokota A; Gill HS; El Rassi G; McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005;87:1446-55.[CrossRef][PubMed]

Lintner D; Mayol M; Uzodinma O; Jones R; Labossiere D. Glenohumeral internal rotation deficits in professional pitchers enrolled in an internal rotation stretching program. Am J Sports Med. 2007;35:617-21.[CrossRef][PubMed]

Myers JB; Laudner KG; Pasquale MR; Bradley JP; Lephart SM. Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med. 2006;34:385-91.[CrossRef][PubMed]

Tyler TF; Nicholas SJ; Lee SJ; Mullaney M; McHugh MP. Correction of posterior shoulder tightness is associated with symptom resolution in patients with internal impingement. Am J Sports Med. 2010;38:114-9.[CrossRef][PubMed]

Bach HG; Goldberg BA. Posterior capsular contracture of the shoulder. J Am Acad Orthop Surg. 2006;14:265-77.[PubMed]

Codman EA. The shoulder. Malibar, Florida: R.E. Kreiger; 1934. p91-4.

Codman EA. The shoulder. Malibar, Florida, R.E. Kreiger; 1934. p 124.

Matsen FA 3rd. Clinical practice. Rotator-cuff failure. N Engl J Med. 2008;358:2138-47.[CrossRef][PubMed]

Matsen FA III; Lippitt SB; Bertelsen A; Rockwood CA Jr; Wirth MA. Glenohumeral arthritis and its management. In: Rockwood CA; Matsen FA; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009. p 651.

Codman EA. The shoulder. Malibar, Florida: R.E. Kreiger; 1934. p13-20.

Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. 1972. J Bone Joint Surg Am. 2005;87:1399.[CrossRef]

McFarland EG; Selhi HS; Keyurapan E. Clinical evaluation of impingement: what to do and what works. Instr Course Lect. 2006;55:3-16.[PubMed]

Hegedus EJ; Goode A; Campbell S; Morin A; Tamaddoni M; Moorman CT 3rd; Cook C. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. J Sports Med. 2008;42:80-92.

Hughes PC; Taylor NF; Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Aust J Physiother. 2008;54:159-70.[PubMed]

Schellingerhout JM; Verhagen AP; Thomas S; Koes BW. Lack of uniformity in diagnostic labeling of shoulder pain: time for a different approach. Man Ther. 2008;13:478-83.[CrossRef][PubMed]

Dorrestijn O; Stevens M; Winters JC; van der Meer K; Diercks RL. Conservative or surgical treatment for subacromial impingement syndrome? A systematic review. J Shoulder Elbow Surg. 2009;18:652-60.[CrossRef][PubMed]

Beaudreuil J; Nizard R; Thomas T; Peyre M; Liotard JP; Boileau P; Marc T; Dromard C; Steyer E; Bardin T; Orcel P; Walch G. Contribution of clinical tests to the diagnosis of rotator cuff disease: a systematic literature review. Joint Bone Spine. 2009;76:15-9.[CrossRef][PubMed]

Jia X; Petersen SA; Khosravi AH; Almareddi V; Pannirselvam V; McFarland EG. Examination of the shoulder: the past, the present, and the future. J Bone Joint Surg Am. 2009;91:10-8.[CrossRef][PubMed]

Coghlan JA; Buchbinder R; Green S; Johnston RV; Bell SN. Surgery for rotator cuff disease. Cochrane Database Syst Rev. 2008;1: CD005619.

Kuhn JE. Current evidence fails to show differences in effectiveness between conservative and surgical treatment of subacromial impingement syndrome. J Bone Joint Surg Am. 2010;92:474.[CrossRef][PubMed]

Harrison AK; Flatow EL. Arthroscopic decompression with acromioplasty and structured exercise was no more effective and was more expensive than exercise alone. J Bone Joint Surg Am. 2010;92:1999.[CrossRef][PubMed]

Harryman DT 2nd; Mack LA; Wang KY; Jackins SE; Richardson ML; Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73:982-9.[PubMed]

Keener JD; Wei AS; Kim HM; Steger-May K; Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009;91:1405-13.[CrossRef][PubMed]

Kim HM; Teefey SA; Zelig A; Galatz LM; Keener JD; Yamaguchi K. Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs. J Bone Joint Surg Am. 2009;91:289-96.[CrossRef][PubMed]

Sher JS; Uribe JW; Posada A; Murphy BJ; Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77:10-5.[PubMed]

Yamaguchi K; Ditsios K; Middleton WD; Hildebolt CF; Galatz LM; Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88:1699-704.[CrossRef][PubMed]

Topics

rotator cuff ; shoulder impingement syndrome ; shoulder region ; acromion ; rotator cuff injury ; coracoacromial ligament ; acromioplasty of shoulder

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Rick Matsen

Posted on December 07, 2011

All that glitters is not gold, all that hurts is not 'impingement syndrome'

University of Washington, Orthopaedics and Sports Medicine

How wonderful to get thoughtful comments from authors in Nijmegen, Valencia, and Bethesda! The purpose of our paper was to suggest that in most cases we could replace the diagnosis of 'impingement syndrome' with a more precise and accurate diagnosis by combining what can be gleaned from the literature with a careful physical examination and imaging studies. As the authors of the comment point out, there are many causes of shoulder pain outside the subacromial area, such as those discussed at < http://shoulderarthritis.blogspot.com/2011/03/what-is-difference-between-shoulder.html> and many others. As they also point out, rotator cuff pathology need not be symptomatic, and tears of the rotator cuff may be symptomatic for a variety of reasons, as discussed at < http://shoulderarthritis.blogspot.com/2011/12/rotator-cuff-tears-how-do-symptoms.html >.Finally, their emphasis on trigger points as a source of shoulder pain is well taken, pointing once more that a careful history and physical examination combined with appropriate imaging will enable the best evaluation and management of the patient. Thank you for this meaningful exchange. Rick Matsenhttp://shoulderarthritis.blogspot.com/

Carel Bron, PT, PhD,* J. Bart Staal, PT, PhD,* Jan Dommerholt, PT, DPT, MPS**

Posted on December 06, 2011

Maybe, it is time to think out of the box or, perhaps, out of the subacromial space

Radboud University Nijmegen, Medical Centre, Netherlands; **Bethesda Physiocare, Bethesda, MD, USA; Shenandoah University, Winchester, VA, USA; Universidad CEU Cardenal Herrera, Valencia, Spain

First of all, we would like to compliment the authors with this remarkable and important systematic review. Shoulder impingement syndrome has been considered as the major cause of shoulder pain since Neer published his first article on the topic in 1972. Almost all shoulder pain management strategies, including surgery, injection therapy, and exercise therapy are aimed at the subacromial space. The results of this review show that there is no scientific evidence that would support the five hypotheses related to impingement syndrome. We would like to offer a few brief remarks in addition to the authors’ recommendations. Scientific studies characterizing rotator cuff disorders and the results of treatment of different rotator cuff abnormalities must include advanced imaging, such as sonography or MRI, or arthroscopy. These diagnostic modalities are able to examine for abnormalities in bone, cartilage, tendons and bursae and help to diagnose for bursitis, tendinitis, tendinopathy, partial and full thickness tendon tears. But, as we know from several studies, many of these changes are seen as often in asymptomatic shoulders as in patients with shoulder pain. Kahn found a lack of evidence that pain is related to the inflammation of tendons (Khan, 2002). Signs of inflammation on MRI and sonography, including fluid in the subacromial bursae and the glenohumeral joint are also shown in asymptomatic shoulders (Connor, Banks, Tyson, Coumas, & D'Alessandro, 2003; Girish et al., 2011; Miniaci, Mascia, Salonen, & Becker, 2002). Most rotator cuff tears are part of a natural degenerative process of the shoulder and are not necessarily related to shoulder pain (Milgrom, Schaffler, Gilbert, & van Holsbeeck, 1995; Schibany et al., 2004). In their recommendations, the authors propose to keep focusing on the tissue in the subacromial space, instead of searching for alternative explanations outside this region. A perhaps important cause of deep shoulder pain outside the subacromial space is the presence of myofascial trigger points (TrPs) in shoulder muscles. A TrP is described as a hyperirritable spot in the skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band (Simons, 1999). Firm compression on a TrP may cause referred pain some distance from the painful spot. For example, compression of TrPs in the infraspinatus muscle causes deep ventral or lateral shoulder pain, that is mostly recognized by shoulder patients as their familiar pain (Hidalgo-Lozano et al., 2010). TrPs are highly prevalent in shoulder muscles in patients with unilateral nontraumatic shoulder pain, that can refer pain deep in the shoulder joint and subacromial region (Bron, Dommerholt, Stegenga, Wensing, & Oostendorp, 2011; Hidalgo-Lozano, Fernandez-de-Las-Penas, Calderon-Soto, et al., 2011). We found in a population (n=72) of patients with chronic nontraumatic unilateral shoulder pain in all patients at least two muscles with TrPs that reproduced the shoulder pain when compressed. Treatment of TrPs in patients with chronic shoulder pain shows promising results (Hains, Descarreaux, & Hains, 2010; Bron, de Gast, et al., 2011; Hidalgo-Lozano, Fernandez-de-las-Penas, Diaz-Rodriguez, et al., 2011), although more research is needed to replicate these findings. Therefore, we would like to emphasize that TrPs may provide an alternative explanation of deep shoulder pain. We would like to invite others to focus more on TrPs in future research to gain a better understanding of shoulder pain resulting in better treatment results. Maybe, it is time to think out of the box or, perhaps, out of the subacromial space. BIBLIOGRAFIE: [1] Bron, C., de Gast, A., Dommerholt, J., Stegenga, B., Wensing, M., & Oostendorp, R. A. (2011). Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC Medicine, 9, 8. [2] Bron, C., Dommerholt, J., Stegenga, B., Wensing, M., & Oostendorp, R. (2011). High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. BMC Musculoskelet Disord, 12(139). [3] Connor, P. M., Banks, D. M., Tyson, A. B., Coumas, J. S., & D'Alessandro, D. F. (2003). Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. The American Journal of Sports Medicine, 31(12975193), 724-727. [4] Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. AJR. American journal of roentgenology, 197(4), W713-719. [5] Hains, G., Descarreaux, M., & Hains, F. (2010). Chronic shoulder pain of myofascial origin: a randomized clinical trial using ischemic compression therapy. Journal of Manipulative and Physiological Therapeutics, 33(5), 362-369. [6] Hidalgo-Lozano, A., Fernandez-de-las-Penas, C., Alonso-Blanco, C., Ge, H. Y., Arendt-Nielsen, L., & Arroyo-Morales, M. (2010). Muscle trigger points and pressure pain hyperalgesia in the shoulder muscles in patients with unilateral shoulder impingement: a blinded, controlled study. Experimental Brain Research, 202(4), 915-925. [7] Hidalgo-Lozano, A., Fernandez-de-Las-Penas, C., Calderon-Soto, C., Domingo-Camara, A., Madeleine, P., & Arroyo-Morales, M. (2011). Elite swimmers with and without unilateral shoulder pain: mechanical hyperalgesia and active/latent muscle trigger points in neck-shoulder muscles. Scandinavian Journal of Medicine and Science in Sports. [8] Hidalgo-Lozano, A., Fernandez-de-las-Penas, C., Diaz-Rodriguez, L., Gonzalez-Iglesias, J., Palacios-Cena, D., & Arroyo-Morales, M. (2011). Changes in pain and pressure pain sensitivity after manual treatment of active trigger points in patients with unilateral shoulder impingement: a case series. Journal of Bodywork and Movement Therapies, 15(4), 399-404. [9] Khan, K. (2002). Time to abandon the 'tendinitis' myth. [10.1136/bmj.324.7338.626]. BMJ (Clinical Research Ed.), 324(7338), 626-627. [10] Milgrom, C., Schaffler, M., Gilbert, S., & van Holsbeeck, M. (1995). Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. The Journal of bone and joint surgery British volume, 77-b, 296-298. [11] Miniaci, Mascia, Salonen, & Becker. (2002). Magnetic Resonance Imaging of the Shoulder in Asymptomatic Professional Baseball Pitchers. The American Journal of Sports Medicine(5490281493756507130). [12] Schibany, Zehetgruber, H., Kainberger, F., Wurnig, C., Ba-Ssalamah, A., Herneth, A. M., et al. (2004). Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. [10.1016/S0720-048X(03)00159-1]. European Journal of Radiology, 51(15294335), 263-268. [13] Simons, D. G., Travell, J.G., Simons L.S. (1999). Myofascial Pain and Dysfunction. The trigger point manual. Upper half of body. (second ed. Vol. I). Baltimore, MD: Lippincott, Williams and Wilkins.

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Anastasios Papadonikolakis, Mark McKenna, Winston Warme, Brook I. Martin, Frederick A. Matsen, III; Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder. The Journal of Bone & Joint Surgery. 2011 Oct;93(19):1827-1832.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment
Data Supplements