Hari Goonatillake

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Impingement Syndrome and Rotator Cuff Tears
By Hari Goonatillake

By Hari Goonatillake…

The rotator cuff is formed by the tendons infraspinatus, supraspinatus and subscapularis muscles. The supraspinatus tendon passes below the coracoacromial arch consisting of the coracoid process, the coracoacromial ligament and acromial process. Abnormal contact between the coracoacromial arch and the rotator cuff can lead to shoulder pain and impingement syndrome.

Intrinsic factors such as muscle weakness, tendinitis or tendon degeneration lead to a muscle imbalance and proximal migration of the humeral head leading to impingement.

Extrinsic factors such as acromial shape or morphology, subacromial spurs and AC join osteophytes can lead to encroachment of the subacromial space and impingement.

Rotator cuff tears occur as a result of tendon degeneration, impingement or trauma. A traumatic event can be repetitive or a single event such as a fall. In particular glenohumeral joint dislocation in a person over 40 years of age can lead to a rotator cuff tear.

Three clinical stages have been described by Neer.(1)

  1. Stage One occurs in individuals less than 25 years old with reversible changes of oedema and haemorrhage affecting the rotator cuff. These patients usually respond to conservative treatment.
  2. Stage Two involves fibrosis and tendinitis of the rotator cuff with patients presenting with recurrent pain after activity.
  3. Stage Three occurs in patients over 40 years of age with bony spurts and rotator cuff tears, which lead to progressive disability.

Patients present with pain, particularly with overhead activities as well as pain at night. There may be associated weakness especially with rotator cuff tears. Examination may reveal supraspinatus and infraspinatus wasting, a painful arc in the mid range of shoulder elevation with impingement tests being positive. Investigations should include X-rays and an ultrasound or MRI scanning.

Non-operative treatment consists of rotator cuff strengthening exercises to address the muscle imbalance and anti-inflammatory agents. A subacromial injection of a corticosteroid with local anaesthetic may be required to help with this stage of treatment.

Failure to respond to conservative treatment is an indication for surgery, which consists of subacromial decompression and rotator cuff repair if a tear is present. Symptomatic rotator cuff tears should be repaired as these do not heal with conservative treatment and usually remain symptomatic. They may also enlarge with time. A small percentage may progress to rotator cuff arthropathy. Age is not a contraindication to surgery.

A recent prospective study concluded that "surgery for chronic rotator cuff disease reliably and significantly improves general health status".(2)

References

  1. Neer, C.S. Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder.
    J. Bone and Joint Surg.
    54-A: 41-50, Jan., 1972.
  2. McKee, M.D., Yoo, D.J. The Effect of Surgery for Rotator Cuff Disease on General Health Status. Results of a Prospective Trial.
    J. Bone and Joint Surg.
    82-A(7):970-978, 2000.