Saturday, October 8, 2011

Time to stop using the term 'impingement'

The October issue of the Journal of Bone and Joint Surgery includes an article entitled Published Evidence Relevant to the Diagnosis of Impingement Syndrome, authored by shoulder fellows Anastasios Papadonikolakis and Mark McKenna. It points to the rapid rise the the rate with which acromioplasty is being performed to treat what has been referred to as 'impingement syndrome' and tests the published support for five hypotheses that relate to the diagnosis of 'impingement syndrome' and its treatment by acromioplasty: (1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions, (2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders, (4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch.

The authors conclude that none of these hypotheses is supported by high level evidence in the published literature. They suggest that "The concept of impingement syndrome was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. The current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated. Nonoperative and operative treatments are currently being used for the different rotator cuff abnormalities. Future clinical investigations can now focus on the indications for and the outcome of treatments for the specific rotator cuff diagnoses. It may be time to replace the nonspecific diagnosis of so-called 'impingement syndrome' by using modern methods to differentiate tendinosis, partial tears, and complete tears of the rotator cuff."

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