Friday, October 25, 2013

"Impingement syndrome" - why are we still using this term?

Is radiofrequency treatment effective for shoulder impingement syndrome? A prospective randomized controlled study.

It is now recognized that the diagnosis of 'impingement syndrome' is but a catchall term for a host of non-arthritic shoulder pathologies that can be distinguished using clinical and imaging tests. Cases of what used to be called 'impingement syndrome' are now recognized to be cuff tendinosis, partial cuff tear, full thickness cuff tear or tightness of the posterior capsule (GIRD).

Yet some articles persist in using the old terminology. 

This paper reports on 384 consecutive patients with "shoulder impingement syndrome".

The authors report that of these patients, 202 were diagnosed with full-thickness tears, and 93 patients were diagnosed with partial-thickness rotator cuff tears. Are they saying that cuff tear = impingement syndrome?

They further report that the remaining 89 patients were diagnosed with "impingement syndrome".  Didn't they say that all 384 had "impingement syndrome"?

They report that all 89 patients without evident cuff tears presented with supraspinatus tendinosis on the preoperative MRI with physical signs of pain on stretching the posterior capsule (pain when the arm was brought into full elevation in the scapular plane with the arm internally rotated by the examiner or  pain when the arm was forcibly internally rotated with the shoulder placed in 90 of forward flexion and the elbow was bent 90 by the examiner) or clinical evidence of tendon involvement (pain or weakness presented when the patient resists a downward force applied by the examiner to the wrist with the arm at 90 of elevation in the scapular plane with an internal rotation with the thumb pointing down).

One should ask, why not in this series of patients and for others, scrap the term 'impingement syndrome' and simply report that of the 384 cases with non-arthritic shoulder symptoms, 202 had full thickness cuff tears, 93 had partial thickness cuff tears and 89 had cuff tendinosis and tight posterior capsule? With that degree of clarity, we can better understand the pathology that is being treated.

In the old days we used the term "internal derangement of the knee" to refer to non-arthritic problems of the knee: "Internal derangement of the knee (IDK) is a chronic disorder of the knee due to a torn, ruptured or deranged meniscus of the knee, or a partial or complete cruciate rupture, with or without injury to the capsular ligament of the knee, resulting in ongoing or intermittent signs and symptoms such as pain, instability, or abnormal mobility of that knee." We now joke that IDK means "I don't know"; current diagnostic methods enable us to differentiate a meniscus tear from a cruciate tear.

It seems that "impingement syndrome" is the IDK of the shoulder.

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