Selected Instructional Course Lecture   |    
Clinical Evaluation of Impingement: What To Do and What Works
Edward G. McFarland, MD1; Harpal Singh Selhi, MD2; Ekavit Keyurapan, MD3
1 10753 Falls Road, Suite 215, Lutherville, MD 21093. E-mail address: emcfarl@jhmi.edu
2 Department of Orthopaedic Surgery, Dayanand Medical College and Hospital, Civil Lines, Ludhiana-141002, Punjab, India
3 Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknol, Bangkok 10700, Thailand
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2006 in Instructional Course Lectures, Volume 55. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Feb 01;88(2):432-441
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case


Pain over the deltoid that is made worse by abduction against resistance is most often diagnosed as impingement. The evaluation of a painful shoulder in which impingement disease is suspected continues to be a challenge, and what has been called "impingement" in the past probably represents a clinical description of several different entities that have a similar constellation of histories, pain patterns, and findings on physical examination.The etiology of pain in patients with impingement has not been completely established. The commonly accepted theory has been that the rotator cuff tendons impinge on the acromion or the coracoacromial ligament and this produces strain on the tendon, resulting in tears and pain1. The surgery traditionally recommended for this condition has been a partial acromioplasty and a release of the coracoacromial ligament1. However, recent evidence suggests that an acromioplasty and a release of the coracoacromial ligament are not necessary for a satisfactory surgical and clinical result of a rotator cuff repair2. In fact, the coracoacromial ligament should not be released unless absolutely necessary. It has been demonstrated that the coracoacromial ligament is not a vestigial structure that can be sacrificed without possibly creating anterior-superior shoulder instability3,4. These and other findings have raised questions about the role that contact of the rotator cuff with the coracoacromial arch plays in the entity that has been called "impingement" in clinical studies. Another theory to explain rotator cuff wear is that it is primarily a degenerative process that is part of aging5,6. Senescence of the tendon fibroblasts with resulting disruption of the tendon architecture is a common finding in the rotator cuff with aging7,8. It has also been suggested that the disruption of the tendon fibers may be due to differential stress in layers of the tendon9. Others have suggested that the rotator cuff tendons may fail in tension as a result of throwing a baseball or other overhead sports10.
Figures in this Article

    First Page Preview

    View Large
    First page PDF preview
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    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.
    Register for a FREE limited account to get full access to all CME activities
    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.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

    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


    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
    (if multiple authors, separate names by comma)
    Example: John Doe

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    PA - Thomas Jefferson University
    NY - Modern Chiropractic Care, P.C.
    WV - Charleston Area Medical Center
    NY - Columbia University Medical Ctr/Dept of Ortho.Surg