Internal Impingement

Author: David Abbasi

Topic updated on 04/24/13 7:42pm

Introduction

Internal impingement refers to pathology on undersurface of rotator cuff
- in contrast to subacromial or "external" impingement which occurs on bursal side of rotator cuff)
- internal impingement covers a spectrum of injuries including
  - fraying of posterior rotator cuff
  - posterior and superior labral lesions
  - hypertrophy and scarring of posterior capsule glenoid (Bennet lesion)
  - cartilage damage at posterior glenoid
Epidemiology
- major cause of shoulder pain in throwing athletes
Pathoanatomy
- caused by impingement of posterior under-surface of supraspinatus tendon on the posterosuperior glenoid rim
  - impingment occurs during maximum arm abduction and external rotation during late cocking and early acceleration phases of throwing
  - causes"peel-back" phenomenon of posteriorsuperior labrum
- thought to be due to combination of
  - tightness of posterior band of IGHL
  - anterior micro instability
Associated conditions
- associated with GIRD

Anatomy

Glenohumeral joint anatomy

Presentation

Symptoms
- diffuse pain in posterior shoulder along the posterior deltoid
  - shoulder pain worse with throwing
    - especially during late cocking and early acceleration
Physical exam
- increased external rotation
- decreased internal rotation
  - loss of > 20° of IR at 90°
    - must stabilize the scapula to get true measure of glenohumeral rotation
- often can demonstrate rotator cuff weakness

Imaging

Radiographs
- recommended views
  - complete shoulder series
- findings
  - usually unremarkable
  - AP may show a Bennett lesion (glenoid exostosis)
MRI
- can show associated rotator cuff and/or labral pathology
  - such as partial articular sided supraspinatus tendon avulsion (PASTA) or tear
  - signal at greater tuberosity and/or posterosuperior labrum

Treatment

Nonoperative
- posterior capsule stretching PT for 6 months
  - indications
    - most internal impingement can be treated non-operatively
  - technique
    - posterior capsule stretching with sleeper stretches
    - rotator cuff stretching and strengthening
Operative
- arthroscopic debridement and/or repair of rotator cuff tear and labrum
  - indications
    - failed nonoperative treatment
    - partial thickness rotator cuff tear (PASTA) compromises the integrity of the rotator cuff
      - partial rotator cuff tears >50%
    - Bennet lesions
- posterior capsule release vs anterior stabilization
  - indications
    - failed nonoperative treatment
    - shoulder instability
  - technique
    - surgical techniques are controversial
      - some perform a posterior capsule release
      - some perform anterior stabilization
  - complications
    - inferior suprascapular nerve (infraspinatus) is at greatest risk during posterior capsule release

Please Rate Educational Value!

4.0

Average 4.0 of 10 Ratings

Qbank (5 Questions)

TAG

(OBQ11.140) Internal impingement commonly occurs in overhead athletes and is very common amongst elite baseball pitchers. In which phase of throwing does this pathologic process occur? Topic

Review Topic

1. Wind-up
2. Early cocking
3. Late cocking
4. Deceleration
5. Follow-through

PREFERRED RESPONSE ▶

DISCUSSION: Internal impingement refers to the impingement within the glenohumeral joint which occurs as the posterosuperior glenoid labrum makes contact with the greater tuberosity, causing impingement on the posterior rotator cuff. This occurs commonly among baseball pitchers during late cocking and early acceleration as the shoulder joint reaches it's maximum external rotation.

Drakos et al studied internal impingement in overhead athletes. In their review, they describe how adaptations to throwing including increased external rotation, increased humeral and glenoid retroversion, and anterior laxity, all predispose these individuals to internal impingement. They recommend initial nonoperative treatment, with a focus on increasing the range of motion and improving scapular function. If this fails, surgical treatment should address microinstability to ensure good outcomes.

Illustration A shows example of internal impingement as the shoulder reaches its maximal external rotation. The posterior rotator cuff is "pinched" between the greater tuberosity and the posterosuperior labrum.

Illustrations: A

REFERENCES:

1. Drakos MC, Rudzki JR, Allen AA, Potter HG, Altchek DW. Internal impingement of the shoulder in the overhead athlete. J Bone Joint Surg Am. 2009 Nov;91(11):2719-28. PMID:19884449 (Link to Abstract)

Question Authors:

David Abbasi MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 5 Ratings

TAG

(OBQ10.174) A 19-year-old left-hand dominant collegiate baseball pitcher has left shoulder pain with late cocking and early acceleration of the ball. His velocity has decreased over the past 2 months. Rotator cuff strength is normal, he denies symptoms of instability, and Hawkins impingement testing is unremarkable. MRI with contrast reveals no intra-articular lesions. What is the most likely physical exam finding in this patient? Topic

Review Topic

1. Positive sulcus sign
2. Decreased external rotation of the affected shoulder
3. Positive Speed's test
4. Decreased abduction of the affected shoulder
5. Decreased internal rotation of the affected shoulder

PREFERRED RESPONSE ▶

DISCUSSION: Internal rotation contracture (GIRD - glenohumeral internal rotation deficit) occurs most commonly in throwing athletes and is thought to be due to a tight posteroinferior capsule. It typically presents with pain while throwing and decreased velocity. Physical exam will often reveal increased external rotation, and an isolated internal rotation deficit without further positive provocative tests. Sulcus sign testing is performed by pulling downward on elbow or wrist with the shoulder in an adducted position and is usually indicative of inferior glenohumeral instability, due to superior glenohumeral laxity. The Speed's test, which is commonly used to evaluate for biceps tendinitis, involves positioning the arm in 90 deg of forward flexion (FF) and the forearm in supination. The patient then resists attempts at pushing the arm downward, with pain/weakness being a positive test.

Burkhart et al, in Part 1 of 3, present a thorough summary of the disabled throwing shoulder that encompasses biomechanics, pathoanatomy, kinetic chain considerations, surgical treatment, and rehabilitation.

REFERENCES:

1. Burkhart SS. Internal impingement of the shoulder. Instr Course Lect. 2006;55:29-34. Review. PMID:16958436 (Link to Abstract)

2. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20. PMID:12671624 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 4 Ratings

TAG

(OBQ09.142) Mineralization of the posterior-inferior glenoid has been implicated as a possible source of pain in which athletic population? Topic

Review Topic

1. football players
2. swimmers
3. basketball players
4. rowers
5. baseball pitchers

PREFERRED RESPONSE ▶

DISCUSSION: The Bennett's lesion is mineralization of the posterior-inferior glenoid observed in overhead athletes. it is felt to be a traction spur of the posterior inferior gelnohumeral capsule which is repetitively stressed during the deceleration and follow-through phases of the throwing cycle.

Wright and Paletta documented 22% of major league pitchers in their series had radiographic evidence of a Bennett's lesion, although none required surgical treatment.

REFERENCES:

1. Galatz LM (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 125-133

2. Wright RW, Paletta GA Jr: Prevalence of the Bennett lesion of the shoulder in major league pitchers. Am J Sports Med 2004;32:121-124 PMID:14754734 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Eric Shirley MD,

Please Rate Educational Value!

3.0

Average 3.0 of 13 Ratings

TAG

(OBQ08.4) The term internal impingement is used in throwers to describe a condition where the posterior-superior glenoid labrum impinges on which structure? Topic

Review Topic

1. The anterior rotator cuff
2. The posterior rotator cuff
3. The anterior glenohumeral ligaments
4. The posterior glenohumeral ligaments
5. The biceps tendon

PREFERRED RESPONSE ▶

DISCUSSION: Internal impingement is seen in throwers with the arm in a cocked position of abduction and external rotation. Often due to posterior soft tissue tightness, the posterior cuff impinges on the posterior superior labrum and is felt to contribute to SLAP tears and articular sided cuff tears.

REFERENCES:

1. Heyworth BE, Williams RJ 3rd. Internal impingement of the shoulder. Am JSports Med. 2009 May;37(5):1024-37. Epub 2008 Dec 4. PMID:19059895 (Link to Abstract)

2. Paley KJ, Jobe FW, Pink MM, Kvitne RS, ElAttrache NS. Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff. Arthroscopy. 2000 Jan-Feb;16(1):35-40. PMID:10627343 (Link to Abstract)

3. 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 Mar;34(3):385-91. PMID:16303877 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

Please Rate Educational Value!

4.0

Average 4.0 of 10 Ratings

TAG

(OBQ07.38) A baseball pitcher has aching pain in the posterior shoulder after throwing. On exam, he has a 30 degree internal rotation deficit and is diagnosed with internal impingement. Stretching should focus on which aspect of the joint capsule? Topic

Review Topic

1. Superior
2. Anterior
3. Antero-inferior
4. Inferior
5. Postero-inferior

PREFERRED RESPONSE ▶

DISCUSSION: Internal impingement is when the posterior rotator cuff pinches against the poster-superior labrum. It is implicated in the development of articular sided rotator cuffs and SLAP tears. This patient has a glenohumeral internal rotation deficit (GIRD) which is felt to contribute to this pathology. Treatment is directed at posterior capsule and rotator cuff stretching. This if often performed with the sleeper stretch, which is shown in the illustration below. The paper by Burkhart et al reviews the pathoanatomy of the throwing shoulder and notes that the use of a prophylactic posterior-inferior stretching program has been shown to decrease both GIRD and subsequent throwing injuries. The reference by Tehranzadeh reported the MRI finding of thickening of the posterior band of the inferior glenohumeral ligament on a small series of throwers with GIRD.

Illustrations: A

REFERENCES:

1. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420. PMID:12671624 (Link to Abstract)

2. Tehranzadeh AD, Fronek J, Resnick D. Posterior capsular fibrosis in professional baseball pitchers: case series of MR arthrographic findings in six patients with glenohumeral internal rotational deficit. Clin Imaging. 2007 Sep-Oct;31(5):343-8. PMID:17825744 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

Please Rate Educational Value!

4.0

Average 4.0 of 7 Ratings

Videos

Arthroscopic debridement for Internal Impingement of the shoulder

Sports - Surgical Techniques - Internal Impingement

Video shows arthroscopic shoulder debridement for Internal Impingement in a pitc...

1/26/2013

209 views

See More Videos

Posts

Arthroscopic Findings in the Overhand Throwing Athlete: Evidence for Posterior Internal Impingement of the Rotator Cuff. Includes Poll

Paley KJ, Jobe FW, Pink MM, Kvitne RS, ElAttrache NS
Arthroscopy. 16(1):35-40. PMID: 10627343 (Link to Pubmed)

Sports - Journal Club - Internal Impingement

4/14/2013

13 responses

See More Posts

Groups

ABOS II: Internal Impingement

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Drakos MC, Rudzki JR, Allen AA, Potter HG, Altchek DW. Internal impingement of the shoulder in the overhead athlete. J Bone Joint Surg Am. 2009 Nov;91(11):2719-28. PMID:19884449 (Link to Abstract)

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

Burkhart SS. Internal impingement of the shoulder. Instr Course Lect. 2006;55:29-34. Review. PMID:16958436 (Link to Abstract)
Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20. PMID:12671624 (Link to Abstract)
Galatz LM (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 125-133
Wright RW, Paletta GA Jr: Prevalence of the Bennett lesion of the shoulder in major league pitchers. Am J Sports Med 2004;32:121-124 PMID:14754734 (Link to Abstract)
Heyworth BE, Williams RJ 3rd. Internal impingement of the shoulder. Am JSports Med. 2009 May;37(5):1024-37. Epub 2008 Dec 4. PMID:19059895 (Link to Abstract)
Paley KJ, Jobe FW, Pink MM, Kvitne RS, ElAttrache NS. Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff. Arthroscopy. 2000 Jan-Feb;16(1):35-40. PMID:10627343 (Link to Abstract)
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 Mar;34(3):385-91. PMID:16303877 (Link to Abstract)
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420. PMID:12671624 (Link to Abstract)
Tehranzadeh AD, Fronek J, Resnick D. Posterior capsular fibrosis in professional baseball pitchers: case series of MR arthrographic findings in six patients with glenohumeral internal rotational deficit. Clin Imaging. 2007 Sep-Oct;31(5):343-8. PMID:17825744 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Internal Impingement

Qbank (5 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Videos

Posts

Groups

Evidence & References Show References

Topic Comments