Subacromial Impingement and Rotator Cuff Tear Adrian Carlos

Subacromial Impingement and Rotator Cuff Tear Adrian Carlos Consultant Orthopaedic Surgeon Newham University Hospital Barts Health NHS Trust

Impingement n Type n n Primary / Secondary n n Subacromial, subcoracoid, internal. . . Os, instability, post-traumatic, calcific. . . Common cause of shoulder pain n 45 -65%

Symptoms n Deltoid (Cuff region) pain n Painful arc n Night pain

Spectrum n n n Impingement Partial thickness Cuff tear Full thickness Cuff tear Massive Cuff tear Cuff Arthropathy

Aetiology n Intrinsic (Hypoxic) n Degenerative (Tensile) n n Articular Extrinsic (Neer: Acromioplasty) n Mechanical (Compressive) n Bursal

Subacromial Impingement n n n Charles Neer 1982 Progressive disease Stage I: oedema and haemorrhage n Stage II: fibrosis and inflammation n Stage III: bone changes and rupture n

Extrinsic n Bigliani 1986 I Flat n II Curved n III Hooked n n Grade III associated n Impingement, cuff tears. . . but also age

Intrinsic n Tendon(itis)? (Lewis 2011) Non-inflammatory (Subacromial pain syndrome) n Fibrosis & degeneration n Tendonopathy, dysfunction with bursitis n n Articular side / intrasubstance tears more common (Codman 1934)

Management n n n History & Exam, Imaging Activity modification NSAIDS Physiotherapy Injection Surgery

Classification

Steroid vs NSAID n n n Karthikeyan et al JBJS (Br) 2010 Anti-inflammatory n n Dermal atrophy, Infection, Collagen necrosis, Tendon damage. . . Steroid better n Diagnostic/Prognostic

Bursectomy vs Acromioplasty n n Henkus et al JBJS (Br) 2009 57 primary impingement Good results with bursectomy alone Better with acromioplasty n Low numbers n

Acromioplasty

Rotator Cuff n 4 muscles/tendons To rotate/function-move n To centre/stabilise n n Anatomy n Boundaries: Triangular / Quad Space

Classification n n n Chronicity Tendon & Site – cable and crescent) Thickness Width Shape Retraction

Cuff Testing n Shoulder examination Jobe’s test n ER and lag sign n Gerber’s lift off, Belly press n Hornblower’s n

Investigations n Radiographs n n Ultrasound n n AH distance As good as MRI FT MRI PT and tendinosis n atrophy n

Goutallier n Fatty degeneration of cuff muscle CT scan n CORR 1994 Prognostic importance n Stages n 0 - normal n 1 - Fatty streaks n 2 - Less than 50% muscle atrophy n 3 - 50% n 4 - More than 50% n