Outlet (subacromial) Impingement

Introduction

Impingement and rotator cuff disease are a continuum of disease including impingement, calcific tendonitis, rotator cuff tears, and rotator cuff arthropathy
There is an increased risk of outlet impingement with
- hooked shaped acromium
- os acrominale
- posterior capsule contracture
- scapular dyskinesia

Presentation

Symptoms
- insidious onset of pain exacerbated by overhead activities
- night pain, which is a poor indicator for nonoperative management
Physical Exam
- impingement tests (see complete physical exam of shoulder )
  - Neer impingement test
  - Neer impingement sign
  - Hawkins test
  - Jobe test
  - Internal impingement test

Imaging

Radiographs
- AP may show
  - traction osteophytes
  - calcification in the coracoacromial ligament
  - cystic changes within the greater tuberosity
  - proximal migration of humerus seen with chronic RCT
- outlet view may show a
  - Type III-hooked acromium
  - os acrominale
MRI
- evaulate degree of rotator cuff pathology

Treatment

Nonoperative
- physical therapy with aggressive rotator cuff and scapular-stabilizer strenthening
  - in the presence of scapular dyskinesia an integrated rehabilitation program is indicated
    - the first stage involves attaining full motion and coordinating the scapula with trunk and hip motions
- oral anti-inflammatory medication
- subacromial injections
Operative
- acromioplasty
  - in the presence of os acrominale, direct excision can lead to deltoid dysfunction. Therefore, a two stage procedure may be required. First fuse the os acrominale with a bone graft. Then, in a second procedure perform an acromioplasty.

TAG

(OBQ05.208) Arthroscopic subacromial decompression with acromioplasty has been shown to yield lower subjective satisfaction scores in patients with which of the following preoperative factors? Topic

Review Topic

1. Dominant arm involvement
2. Males
3. Workers' compensation
4. Smokers
5. Age <60

PREFERRED RESPONSE ▶

DISCUSSION: The first two referenced articles found that patients with active worker’s compensation claims reported significantly decreased satisfaction postoperatively compared to the rest of the cohort. The most recent article reported similar scores, but longer time to return to work.

REFERENCES:

1. Hawkins RJ, Plancher KD, Saddemi SR et al. Arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2001 May-Jun;10(3):225-30. PMID:11408902 (Link to Abstract)

2. Connor PM, Yamaguchi K, Pollock RG et al. Comparison of arthroscopic and open revision decompression for failed anterior acromioplasty. Orthopedics. 2000 Jun;23(6):549-54. PMID:10875414 (Link to Abstract)

3. Nicholson GP. Arthroscopic acromioplasty: a comparison between workers' compensation and non-workers' compensation populations. J Bone Joint Surg Am. 2003 Apr;85-A(4):682-9. PMID:12672845 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Connor PM, Yamaguchi K, Pollock RG et al. Comparison of arthroscopic and open revision decompression for failed anterior acromioplasty. Orthopedics. 2000 Jun;23(6):549-54. PMID:10875414 (Link to Abstract)
Hawkins RJ, Plancher KD, Saddemi SR et al. Arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2001 May-Jun;10(3):225-30. PMID:11408902 (Link to Abstract)
Nicholson GP. Arthroscopic acromioplasty: a comparison between workers' compensation and non-workers' compensation populations. J Bone Joint Surg Am. 2003 Apr;85-A(4):682-9. PMID:12672845 (Link to Abstract)

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