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Old 12-23-2012, 04:15 PM   #26
FastFreddy
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Originally Posted by Pacific lefty View Post
Hi EC, the mri showed an inflamed supraspinatus, no tear. I tried the cortisone and pt for 18 months and nothing seemed to work. I think the surgery certainly made more space for the tendon because after rehab and now that I am playing again I definitely am not getting that catching "impingement" feeling. Somebody on this forum pointed out to me that some people just don't have enough space for the tendons to move around freely.

Certainly it is a lot of committment to complete the rehab and be patient while everything heals. That is why I definitely wouldn't recommend it unless all other options were tried first.
I would stay away from cortisone since it's really bad fr your tendon. I have a type 3 ac joint so it's shaped like a hook so their is very little room for the tendon.

Possible Causes of Shoulder Impingement


Outlet impingement

Subacromial spurs

Type 2 and type 3 acromions


Osteoarthritic spurs of acromioclavicular joint (includes subacromial spurs)


Thickened or calcified coracoacromial ligament

Nonoutlet impingement

Loss of rotator cuff causing superior migration of humerus (tear, loss of strength)

Secondary impingement from unstable shoulder

Acromial defects (os acromiale)


Anterior or posterior capsular contractures (adhesive capsulitis)


Thick subacromial bursa

Normal anatomic variants can cause compression. Three distinct types of acromion (Figure 2) can readily be seen on radiographs, especially on the angled outlet Y view. The type I acromion, which is flat, is the “normal” acromion. The type II acromion is more curved and downward dipping, and the type III acromion is hooked and downward dipping, obstructing the outlet for the supraspinatus tendon.3 Cadaveric studies have shown an increased incidence of rotator cuff tears in persons with type II and type III acromions.2,3
The coracoacromial ligament can also calcify, usually secondary to trauma, and cause impingement. In most cases, acromioclavicular joint arthritis is the culprit, resulting from previous trauma (separations) or, most often, nontraumatic osteoarthritis. The os acromiale (an unfused acromial apophysis) has also been associated with impingement.4

Impingement may occur as a result of loss of competency of the rotator cuff. Pain from any cause, such as overuse or injury, may lead to disuse or weakness of the cuff. The weakness results in cephalad migration of the humeral head due to loss of depressors. This superior migration of the humeral head increases the impingement, thus reinforcing the cycle.

Classification of the Impingement Syndrome

Several classification systems are used with the impingement syndrome. Neer5 divided impingement syndrome into three stages. Stage I involves edema and/or hemorrhage. This stage generally occurs in patients less than 25 years of age and is frequently associated with an overuse injury. Generally, at this stage the syndrome is reversible. Stage II is more advanced and tends to occur in patients 25 to 40 years of age. The pathologic changes that are now evident show fibrosis as well as irreversible tendon changes. Stage III generally occurs in patients over 50 years of age and frequently involves a tendon rupture or tear. Stage III is largely a process of attrition and the culmination of fibrosis and tendinosis that have been present for many years.

History and Physical Examination

Pain, weakness and loss of motion are the most common symptoms reported. Pain is exacerbated by overhead or above-the-shoulder activities. A frequent complaint is night pain, often disturbing sleep, particularly when the patient lies on the affected shoulder. The onset of symptoms may be acute, following an injury, or insidious, particularly in older patients, where no specific injury occurs.

The key feature of the physical examination is an assessment for signs of impingement. All the impingement tests involve moving the shoulder passively (through forward flexion, internal and external rotation with the arm abducted 90 degrees, and adducted) with approximately 5 to 10 lb of force directed inferiorally on the acromion, thus narrowing the subacromial space. The examiner tests to see if pain appears with these maneuvers and disappears when the examiner removes the downward acromial push.6

The shoulder assessment in Figure 3 is a modification of a form developed by the Research Committee of the American Shoulder and Elbow Surgeons.7,8 Since the development of this form, studies on rotator cuff muscles show that the supraspinatus is more effectively tested with the thumb-up position (i.e., “full can”) rather than the thumb-down position as shown in the form and that Gerber's lift-off test recruits the sub-scapularis better than forceful internal rotation does.9 (In Gerber's lift-off test [not depicted], the patient places the hand over the spine posteriorally at the belt line with the palm facing posteriorly. The patient is then instructed to “lift off” the hand in a posterior direction against resistance and this movement is compared with the contralateral arm.)
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