Σύνδροµο Υπακρωµιακής Προστριβής
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1 Slide 1 Σύνδροµο Υπακρωµιακής Προστριβής Χρήστος K. Γιαννακόπουλος Ορθοπαιδικός Χειρουργός Διευθυντής Ορθοπαιδικής Κλινικής ΙΑΣΩ General, Αθήνα Γενικός Γραµµατέας Ελληνικής Αρθροσκοπικής Εταιρείας
2 Slide 2 Shoulder Pain Common complaint 35% of patients years Exceed only by back and neck pain in the general population
3 Slide 3 Shoulder Impingement represents a clinical description of several different entities that have a similar constellation of histories, pain patterns, and findings on physical examination.
4 Slide 4 Shoulder Impingement
5 Slide 5 Shoulder Impingement mechanical impingement of the rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forwardflexed and internally rotated position.
6 Slide 6
7 Slide 7 The supraspinatus outlet LHBT CAL Superior capsule SST Upper margins of SSC & ISP tendons Subacromial bursa Inferior surface of ACJ LHB SS IFS
8 Slide 8 Subacromial bursa under anterior 1/3 of acromion major component of the subacromial gliding mechanism contains free nerve endings, Ruffini endings, Pacinian corpuscles, and two kinds of unclassified nerve endings
9 Slide 9 largest concentration of pain fibers Bursa> RC> biceps tendon Soifer TB, Arthroscopy. 1996;12:182
10 Slide 10 Shoulder Impingement
11 Slide 11 Shoulder Impingement
12 Slide 12 Shoulder Impingement Primary Secondary Neer Codman
13 Slide 13 Stages of Shoulder Impingement (Neer) Stage 1 <25 yrs, acute inflammation, edema, and hemorrhage in the RC. Intermittent mild pain with overhead activities Reversible with nonoperative treatment. Stage yrs fibrosis and tendonitis Mild to moderate pain with overhead or strenuous activities Commonly requires operative intervention. Stage 3 >40 yrs RC tear Pain at rest or with activities, night pain, weaknes osteophytosis along the anterior acromion
14 Slide 14 Primary Impingement older age group anterior acromial hook or spur overhead athletes with prominent CAL the most predictable operative success with ASAD
15 Slide 15 Outlet impingement Normal Large acromial spur
16 Slide 16 osseous mass occupying 2/3 of the supraspinatus outlet
17 Slide 17 Secondary Impingement intrinsic tendinous degeneration younger patient population overhead arm motion bony architecture is unremarkable.
18 Slide 18 Extrinsic Causes Secondary impingement Rotator cuff overload/soft tissue imbalance Eccentric muscle overload Glenohumeral laxity/instability Long head of the biceps tendon laxity/weakness Glenoid labral lesions Muscle imbalance Scapular dyskinesia Posterior capsular tightness Trapezius paralysis
19 Slide 19 History Age Hand dominance Occupation Injury? Injury mechanism Length of time symptoms Overhead use -- athletics/repetitive work Night pain Radicular symptoms Neck pain Any injections and location? Specifics rehabilitation? Surgery?
20 Slide 20 Clinical Presentation insidious onset of pain exacerbated by overhead activities anterior and lateral shoulder night pain (RCT)
21 Slide 21 painful arc degrees of elevation
22 Slide 22 Physical Exam: impingement tests Neer impingement test Neer impingement sign Hawkins test Jobe test Internal impingement test
23 Slide 23 Impingement Test I Impingement Test II Impingement Test III Impingement Test IV
24 Slide 24 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 Type III-hooked acromium os acrominale MRI evaluate degree of rotator cuff pathology
25 Slide 25 Tendinopathy Full thickness tear Articular partial tear Articular and bursal partial tears
26 Slide 26 Acromion Types I III II IV
27 Slide 27 Acromion morphology is a secondary occurrence The majority of partial tear are articular
28 Slide 28 Downsloping acromion
29 Slide 29 Os acromiale
30 Slide 30 Subacromial Impingement Associated Injuries / Differential Diagnosis RC tendinopathy RC partial and complete tear Biceps tendonitis Internal impingement Os acromiale Posterior capsule contracture Adhesive capsulitis Shoulder instability AC arthritis SLAP tear Cervical radiculopathy
31 Slide 31 Impingement Syndrome in Athletes
32 Slide 32 Posterior capsule tightness Normal capsular laxity allows the humeral head to remain centered during elevation. Tightness of the posterior capsule may create obligate anterosuperior translation with shoulder flexion.
33 Slide 33 GIRD: glenohumeral internal rotation deficit
34 Slide 34 posterior capsule stretches The two most common stretches for the posterior capsule are: 1. Sleeper stretch 2. Cross body stretch
35 Slide 35 Treatment: Nonoperative physical therapy oral anti-inflammatory medication subacromial injections activity modification modify sports biomechanics
36 Slide 36 Conservative Treatment 2/3 of the pts improve In pts >60 yrs 50% success rate Acromion type I 91% success
37 Slide 37 CS injections Improve the duration of the pain-free period No more than 2 injections
38 Slide 38 Treatment: Operative Subacromial Decompression (Acromioplasty) Os acromiale Best indication: primary extrinsic impingement
39 Slide 39 Be careful! Stiffness OA MDI Workman s compensation Unrealistic expectations
40 Slide 40 Beach Chair Position
41 Slide 41 portals
42 Slide 42 Rockwood acromioplasty Resection of the anterior (5 mm) and inferior part of the acromion (8 mm limit)
43 Slide 43
44 Slide 44
45 Slide 45
46 Slide 46
47 Slide 47
48 Slide 48 Normal Subacromial Space
49 Slide 49
50 Slide 50
51 Slide 51 acromioplasty
52 Slide 52 Improvement after ASD Possive impingement sign (NO) Type III acromion lateral acromion angle < 75 US proven dynamic impingement Bursal side tear
53 Slide 53 Additional Procedures
54 Slide 54 Os Acromiale
55 Slide 55 Distal Clavicle Excision
56 Slide 56 Rotator Cuff Tear
57 Slide 57 Partial Articular Surface RC Tear
58 Slide 58 Full RC tear
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