Monday, July 27, 2015

Why are we still using the term 'impingement syndrome'?

Medium-term natural history of subacromial impingement syndrome

In their introduction these authors state, "Subacromial impingement syndrome (SIS) is the most frequently reported diagnosis of the shoulder, with a cumulative incidence of 5 per 1,000 patients per year.  SIS is a spectrum of diseases that range from tendinitis to partial or full-thickness rotator cuff tears that affect the daily overhead activities of patients."  For 63 patients two whom they attached the diagnosis of subacromial impingement syndrome, the authors recorded age, gender, profession, body mass index, hand dominance, alcohol and tobacco consumption, comorbidities, causative event of pain, presence of a functional limitation, duration of symptoms, shoulder scores, history of subacromial steroid injections, and magnetic resonance imaging (MRI) classification.

They found that younger age, lower BMI, more functional capacity, a shorter symptomatic period, reversible changes on MRI, and higher Constant and ASES scores at the first evaluation were associated with a better outcomes - that is, healthier, younger patients with less severe disease had better shoulder function 8.5 years later.

Comment: With respect to the term 'impingement syndrome' we have pointed out previously that using the current tools of history, physical examination, and rotator cuff imaging, surgeons should have no difficulty in distinguishing tendinitis from a partial cuff tear and a partial from a full thickness cuff tear. To lump these conditions - each of which affects different groups of patients and has different treatments - together, is like mixing osteoarthritis, rheumatoid arthritis and avascular necrosis under the term 'shoulder arthritis'. The fact that each of the conditions may respond to a subacromial lidocaine injection does not help in defining the pathology.

Natural history studies are studies of the untreated course of a disease. The authors state that this is a 'natural history' study, but it is not clear which of these patients received what treatment except for the statement,  "Seven patients underwent surgical treatment because of a chronic course that did not improve with conservative treatment."

Without clearer definition of the diagnoses and the treatments, we can only conclude that younger, healthier patients with less severe involvement have better function later on.


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