Should surgeons continue to perform acromioplasty for impingement syndrome?

The concept of the "impingement syndrome" and its treatment by acromioplasty (aka subacromial decompression, SAD) were introduced 50 years ago (see this link). 

In  Published evidence relevant to the diagnosis of impingement syndrome of the shoulder the authors pointed out that surgery for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. They sought high levels of evidence (Level I and II studies) in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment: 

(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. 

None of these hypotheses were supported by high levels of evidence. 

They concluded 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. However, the current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated, so that the nonspecific diagnosis of "impingement syndrome" can be discarded in favor of specific diagnoses such as  tendinosis, partial tears, and complete tears of the rotator cuff. The treatment for each these conditions requires careful, well-controlled clinical study.

The authors of On Patient Safety: Shoulder “Impingement”—Telling a SAD Story About Public Trust point out that acromioplasty quickly became one of the most commonly performed orthopaedic procedures; its usage increased five-fold between the 1980s and 2005 in the United States. However, evidence progressively accumulated that acromioplasty might be no more effective than physiotherapy. And the concept of "impingement syndrome" became recognized as a waste-basket term that included such diagnoses as  bursitis,  cuff tendinopathy, rotator cuff tear and  biceps tendinitis.

The author and colleagues launched the Finnish Subacromial Impingement Arthroscopy Controlled

Trial (FIMPACT) in 2005.  In Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial they concluded that arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy alone at 24 months after surgery. In reflection on this study, the British Medical Journal stated that "Subacromial decompression surgery should not be offered to patients with subacromial pain syndrome." 

The author goes on to point out that acromioplasty remains one of the most frequently performed shoulder surgeries in the world. In considering why this might be, he suggests that surgeons trust their own “experiences” with an operation more than randomized clinical trials. While experience do matter, a surgeon's experiences suffers from follow-up that is short, does not include standardized data collection, and does not include the large percentage of patients in a surgical practice do not return for follow-up. This is in contrast to the  FIMPACT trial that followed 81% of enrolled patients for 5 years and evaluated them using validated endpoints that matter to patients. Finally, the author points out that "procedures that carry greater risk (like shoulder surgery) should be superior to interventions with little or no risk (like shoulder exercises), and certainly superior to placebo interventions (such as the diagnostic arthroscopy performed in their controlled trial).

Another recent study, No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial  randomly divided 140 patients into two groups: 1) supervised exercise program (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). While both groups were improved with respect to pain, disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days), no statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. The authors concluded that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome.

An additional observation is that acromioplasty performed in the presence of a rotator cuff tear can give rise to anterosuperior escape and pseudoparalysis as shown here: 

Because it is a major intervention with associated costs and risks, each surgical procedure requires solid evidence that supports clinically significant benefits in comparison to more benign approaches. Such support for acromioplasty does not appear to be present.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Changes acromial shape in patients with rotator cuff tears - cause or effect?

Acromial roof in patients with concentric osteoarthritis and massive rotator cuff tears: multiplanar analysis of 115 computed tomography scans

These authors point out that there are differences in scapular shape between shoulders with rotator cuff tears (RCT) and osteoarthritic shoulders (OA). They analyzed the orientation and shape of the acromion in 70 shoulders with massive degenerative RCT (apparently those having subsequent reverse total shoulders) and 45 shoulders with concentric OA (apparently those having subsequent anatomic total shoulders) using multiplanar computed tomography (CT) analysis.

They found that lateral acromial roof extension was an average of 4.6 mm wider and the acromial area was an average of 156 mm2 larger in RCT than in COA (P < .001). Significant differences of the lateral extension of the acromion margin were limited to the anterior two-thirds. Acromial roof orientation in RCT was average of 10.8° more “externally rotated” (axial plane: P < .001) and an average of 7.8° more tilted downward (coronal plane: P < .001) than in COA. The glenoid in RCT was an average of 5.5° (P < .001) more covered posteriorly compared with COA.

Comment: It is understood that loading of the acromion is different in patients with massive cuff tears than in patients with concentric osteoarthritis and that these changes are reflected by radiographic changes in acromial shape. Compare the acromial shape in the upper AP x-ray of a shoulder with a massive cuff tear with that in the lower AP x-ray of a shoulder with concentric osteoarthritis.

It seems likely that the acromial changes are likely to be adaptive in response to the change in loading of the acromion in patients with massive cuff tears. In 1972 Neer observed "a characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process (of the acromion), apparently caused by repeated impingement of the rotator cuff and the humeral head, with traction of the coracoacromial ligament. . . . Without exception it was the anterior lip and undersurface of the anterior third that was involved."(see this link)

 Evidence remains lacking that surgical alteration of the acromial shape can change the natural history of cuff disease (see this link) or of osteoarthritis.

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Is acromioplasty of value?

Does acromioplasty result in favorable clinical and  radiologic outcomes in the management of chronic  subacromial pain syndrome? A double-blinded randomized clinical trial with 9 to 14 years’ follow-up. 

These authors sought to determine the long-term clinical and radiologic treatment effect of arthroscopic acromioplasty in patients  with chronic "subacromial pain syndrome (SAPS)"  (pain located in the deltoid region for at least 3 months; inability to lie down on the affected shoulder; pain during abduction, backward flexion, or internal rotation; positive Neer or Hawkins impingement test; and positive lidocaine impingement test. In addition, conservative treatment for at least 6 weeks (ie, subacromial infiltration, nonsteroidal anti-inflammatory drugs, and supervised exercises) had to be unsuccessful. The exclusion criteria were calcifying tendinitis, biceps tendinitis, partial- or fullthickness cuff tear, labral tear, signs of glenohumeral instability, passive restriction of glenohumeral motion, osteoarthritis of the acromioclavicular or glenohumeral joint, rheumatic diseases, cervical radiculopathy, history of shoulder trauma, synovitis, and prior surgery on the affected shoulder.)

In this double-blind, randomized clinical trial, 56 patients with chronic SAPS (median age, 47 years; age range, 31-60 years) were randomly allocated to arthroscopic bursectomy alone or to bursectomy combined with acromioplasty and were followed up for a median of 12 years. 

A total of 43 patients (77%) were examined at a median of 12 years’ follow-up. Intention-to treat analysis at 12 years’ follow-up did not show a significant additional treatment effect of acromioplasty
on bursectomy alone in improvement in Constant score, Simple Shoulder Test score, VAS score for pain, or VAS score for shoulder function. 

The chart below shows the SST scores for shoulders with bursectomy alone (hollow bars) and bursectomy along with acromioplasty (solid bars).

The prevalence of rotator cuff tears was not significantly different between the bursectomy group (17%) and acromioplasty group (10%).

The authors concluded that there were no relevant additional effects of arthroscopic acromioplasty on bursectomy alone with respect to clinical outcomes and rotator cuff integrity at 12 years’ follow-up. 

Comment: While it is not clear exactly what entities are included in SAPS, this article again calls in to question the value of acromioplasty using a well-done randomized clinical trial with long term followup. 

This article should be placed in context of three other recent articles on acromioplasty discussed below.


Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder

Acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. This investigation sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment.

The authors conducted a systematic review of articles relevant to the following hypotheses: (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. Three of the authors independently reviewed each article and determined the type of study, the level of evidence, and whether it supported the concept of the impingement syndrome. Articles with level-III or IV evidence were excluded from the final analysis.

These five hypotheses were not supported by high levels of evidence.

The authors concluded 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 socalled impingement syndrome by using modern methods to differentiate tendinosis, partial tears, and complete tears of the rotator cuff.



Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

The typical pathology in these cases is shown in the figure below.

The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.

The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.

The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable. 

They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test

In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. 

For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities

They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

Comment: Currently surgeons are actively pursing a variety of methods for managing patients with symptomatic irreparable rotator cuff tears, including marginal convergence, patch grafts, superior capsular reconstructions, degrading subacromial 'balloons' tendon transfers and reverse shoulder arthroplasty. Each of these procedures is more complex than the smooth and move procedure described in this article and none offers the opportunity for immediate postoperative resumption of active use of the shoulder.

These results from 151 patients having the smooth and move procedure can be contrasted to those from 24 patients having a 'superior capsular reconstruction' using an 8 mm fascia lata graft harvested from the patients thigh have been reported by Mihata et al (see this link). After the superior capsular reconstruction it is recommended that an abduction pillow be used for 4 weeks after the reconstruction with active exercises not started until 8 weeks after surgery.

Of note is that standard dermal grafts that used instead of fascial lata are often <2mm depending on the company selling them.

While future clinical research will hopefully clarify the indications for the superior capsular reconstruction and other more complex procedures, the advantages of the smooth and move procedure lie in its simplicity, its avoidance of tissue autograft or commercially available decellularized dermal allograft, its lack of postoperative 'down time', its high rate of durable improvement, and the fact that it does not preclude other surgical options should it fail to yield the desired result.

The effect of coracoacromial ligament excision and acromioplasty on the amount of rotator cuff force production necessary to restore intact glenohumeral biomechanics.


These authors point out that coracoacromial ligament (CAL) excision and acromioplasty increase superior and anterosuperior glenohumeral translation. They used a cadaver model to estimate how much of an increase in rotator cuff force is required to re-establish intact glenohumeral biomechanics after acromioplasty.

Nine cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state after CAL excision, acromioplasty, and recording of the translations. The rotator cuff force was then increased to normalize glenohumeral biomechanics.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% was required to eliminate the increased translation resulting from CAL excision.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% and 30%, respectively, was required to eliminate the increased translation resulting from acromioplasty and CAL excision.

The authors concluded that after subacromial decompression, the rotator cuff has to increase  its force production to maintain baseline glenohumeral mechanics. Under many circumstances, in vivo force requirements may be even greater after surgical attenuation of the coracoacromial arch.

Comment: As Codman pointed out in 1934 "The coracoacromial ligament has an important duty and should not be thoughtlessly divided at any operation." 

He recognized then, as we should today, that the coracoacromial arch provides an important stabilizing function resisting the superiorly directed force applied by the deltoid or when pushing up from a chair, bed, floor or bar. He pointed to the normal articulation between the superior aspect of the cuff and the undersurface of the coracoacromial arch. 

The center of curvature of the arch is the same as the center of curvature of the humeral head.

The stabilizing effect of the arch remains the same if there is ossification of part of the coracoacromial ligament.

We have previously demonstrated that the acromion is loaded when superiorly directed force is applied through the humeral head (whether or not the cuff is intact).

 When the superior cuff tissue is absent, superiorly directed loads applied to the humeral head produce superior translation of the head until it is stopped by the coracoacromial arch.

Sacrifice of the coracoacromial arch in the cuff deficient shoulder is a common cause of anterosuperior escape and pseudoparalysis.

Where does that leave the concept of 'impingement'? See this link.

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The effect of anxiety and depression

Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression


These authors conducted a review of 86 patients undergoing arthroscopic acromioplasty. Their inclusion criteria were patients with isolated 'subacromial impingement (SI)' aged between 25 and 75 years with shoulder pain on overhead activity or in the mid arc of abduction, a positive Hawkins test result on repeated examination, pain relief of a minimum of 2 weeks after subacromial steroid injection, and radiologic evidence of impingement (sclerosis, cysts, or osteophyte at the grater tuberosity and acromion). They state that "rotator cuff tears were excluded", but cuff imaging findings of the included patients are not provided.  Patients with other concurrent shoulder diseases were excluded, including "SI" accompanied by rotator cuff tear (partial or full thickness) on preoperative ultrasound scan, acromioclavicular arthritis, calcific tendinitis, calcific bursitis, adhesive capsulitis, labral tear, biceps tendinitis, superior labral anteriorposterior  tear, and instability. It is unclear how they excluded diagnosis of frozen shoulder or glenohumeral arthritis.

Patients were analyzed in 2 groups defined by Hospital Anxiety and Depression Scale (HADS) scores, group A being depressed and group B nondepressed. Both groups had less pain and improved Oxford Shoulder Score (OSS) at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction.

Comment: As the authors point out, "subacromial impingement" is frequently used as an indication for acromioplasty. In this paper it is difficult to know exactly what pathology was being treated in these patients with an age span of 50 years. It has been suggested that we can stop using the term "impingement syndrome" now that a clear understanding of cuff pathology is available through a good history, physical exam and MRI as is explained in this post.

With respect to the HADS, anxiety and depression are each rated by assigning a value from 0-3 to each of seven items:

The items on the questionnaire that relate to anxiety are:
I feel tense or wound up
I get a sort of frightened feeling as if something bad is about to happen
Worrying thoughts go through my mind
I can sit at ease and feel relaxed
I get a sort of frightened feeling like butterflies in the stomach
I feel restless and have to be on the move
I get sudden feelings of panic

The items that relate to depression are:
I still enjoy the things I used to enjoy
I can laugh and see the funny side of things
I feel cheerful
I feel as if I am slowed down
I have lost interest in my appearance
I look forward with enjoyment to things
I can enjoy a good book or radio or TV program

So that the anxiety score can range from 0-21 and the depression score can range from 0-21. Apparently these to scales were added so that the maximal value for anxiety+depression was 42.

The relationships between the HADS and three different outcome metrics are shown below

While these effects are significant, it is apparent that a relatively small percentage of the variation on the outcome is associated with the preop HADS score: the respective coefficients of determination (see this link) for the three outcomes were 39%, 7% and 25%.

This study is important because it highlights the fact that many factors, including the patient's emotional heath, can affect the result of a treatment.

There are many different instruments for assessing emotional health. Our practice is to use the SF 36 which includes these three questions about depression:

When we suspect that a patient is depressed or over-anxious we try to explain that these conditions may interfere with the success of treatment and seek whether specialist help may be in order before proceeding with surgery.


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"Impingement Syndrome" - a term of historical interest only

Empty can exercise provokes more pain and has undesirable biomechanics compared with the full can exercise.

These authors studied 28 patients with what they referred to as "subacromial impingement syndrome (SAIS)". They compared pain arm elevation exercises in the scapular plane with the humerus in a position of internal rotation (empty can [EC] exercise) or external rotation (full can [FC] exercise).

They found that participants reported greater pain during the EC exercise vs the FC exercise. Scapular muscle activity was generally higher with the EC.

Comment: As has been pointed out previously (see this link), there are no specific diagnostic criteria   for "impingement syndrome". For example, the patients in this study were selected using the following inclusion criteria: "shoulder pain, and 3 of 5 positive findings: painful arc, pain, or weakness with resisted external rotation, Neer, Hawkins, and Jobe tests." No MRI findings are presented so that we cannot know whether each one had cuff tendinosis, partial tear, full thickness tear or some other condition, such a frozen shoulder or glenohumeral arthritis.

The fact that the shoulders were more comfortable with elevation in external rotation (which relies more on the subscapularis) than elevation in internal rotation (which relies more on the supraspinatus) is consistent with the thought that many these patients had some form of supraspinatus pathology that would have been diagnosable on MRI.

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"Impingement syndrome" (also known as an unspecified disorder of the shoulder tendons and bursae) in the military.

Shoulder impingement in the United States military.

These authors queried the Defense Medical Epidemiology Database was queried for all shoulder impingement injuries using International Classification of Disease, Ninth Addition, Clinical Modification code 726.10 within a 10-year period from 1999 through 2008.

In an at-risk population of 13,768,534 person-years, they identified 106,940 cases of shoulder impingement resulting in an incidence of 7.77/1000 person-years in the U.S. military. 

The incidence of shoulder impingement increased with age, male sex, in service members branches of the service other than the Navy (Air Force, Army, and Marine Corps).

Comment: These authors attributed the diagnosis of "impingement syndrome" to those shoulders in the database with ICD-9-CM code 726.10. which is the code for "unspecified disorders of shoulder tendons and bursae. The code book lists the below as 'disease synonyms'. 

Biceps tendinitis
Bilat rotator cuff syndrome
Bilat shoulder bursa disorder
Bilateral rotator cuff syndrome
Bilateral shoulder bursa disorder
Bilateral supraspinatus tendinitis
Bursitis of bilat shoulders
Bursitis of bilateral shoulders
Bursitis of L shoulder
Bursitis of left shoulder
Bursitis of R shoulder
Bursitis of right shoulder
Bursitis of shoulder
Bursitis of shoulder region
Contracture of tendon of shoulder region
Disorder of bursa of shoulder region
Disorder of rotator cuff
Disorder of shoulder bursa
Disorder of tendon of left shoulder
Disorder of tendon of right shoulder
Disorder of tendon of shoulder region
Enthesopathy of bilat shoulders
Enthesopathy of bilateral shoulders
Enthesopathy of left shoulder
Enthesopathy of right shoulder
Enthesopathy of shoulder
Enthesopathy of shoulder region
Infraspinatus tendinitis
Injury of tendon of the rotator cuff of shoulder
L rotator cuff syndrome
Left rotator cuff syndrome
Left shoulder bursa disorder
Left supraspinatus tendinitis
R rotator cuff syndrome
Right rotator cuff syndrome
Right shoulder bursa disorder
Right supraspinatus tendinitis
Rotator cuff impingement syndrome
Rotator cuff syndrome
Shoulder bursa disorder
Shoulder tendinitis
Supraspinatus syndrome
Supraspinatus syndrome (shoulder condition)
Supraspinatus tendinitis
Supraspinitus tear
Tendinitis AND/OR tenosynovitis of the shoulder region
Tendinitis of bilat shoulders
Tendinitis of bilat supraspinatus tendons
Tendinitis of bilateral shoulders
Tendinitis of bilateral supraspinatus tendons
Tendinitis of left shoulder
Tendinitis of left supraspinatus tendon
Tendinitis of right shoulder
Tendinitis of right supraspinatus tendon
Tendinitis of shoulder
Tendonitis of shoulder
Tendonitis of supraspinatus
Unspecified tendon disorder of L shoulder
Unspecified tendon disorder of left shoulder
Unspecified tendon disorder of R shoulder
Unspecified tendon disorder of right shoulder
Unspecified tendon disorder of shoulder
Applies To

Rotator cuff syndrome NOS
Supraspinatus syndrome NOS

As we've pointed out here and here, it is no longer practical to use the term 'impingement syndrome' as a diagnosis in that it does not tell us what is going on with the shoulder.

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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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Acromioplasty does not improve the clinical results of rotator cuff repair

Rotator Cuff Tears With and Without AcromioplastyRandomized Prospective Trial With2-Year Follow-up

These authors reported the clinical outcomes of 95 patients undergoing arthroscopic repair of full-thickness rotator cuff tears with (52) and without (43) acromioplasty.

There were no significant differences in baseline characteristics, including number of tendons torn, repair configuration, concomitant procedures, and acromion type and angles.

There were no significant differences in Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, University of California–Los Angeles score, or visual analog scale pain score between nonacromioplasty and acromioplasty groups or between

There were 4 revision cuff repairs, 3 in the nonacromioplasty group and 1 in the acromioplasty group. One patient in the nonacromioplasty group had a capsular release and biceps tenotomy. However, this study did not include follow-up imaging to determine if there was an effect of acromioplasty on retear rates,

Comment:

This study found no significant effect of acromioplasty on the clinical outcomes of arthroscopic cuff repair at two years after surgery.

In the normal shoulder the articulation between the coracoacromial arch and the rotator cuff provides an important stabilizing function. While in the past it was thought that rotator cuff tears resulted from ‘impingement’ of the acromion on the cuff, the use ofacromioplasty to treat the ‘impingement sydrome’ is not supported by theevidence currently available.

Previous studies demonstrated that good outcomes from open cuff repair are obtained without acromioplasty – in fact, our approach to cuff repair specifically avoids acromioplasty in order to preserve the function of the coracoacromial arch. 

We reported the results of 96 consecutive primary repairs of full-thickness tears of the rotator cuff that were performed through a deltoid-muscle-splitting incision that preserved the integrity of the acromion and the coracoacromial arch. Thirty-four of the tears involved the supraspinatus tendon alone; sixteen involved the supraspinatus and infraspinatus tendons; and eleven involved the supraspinatus, infraspinatus, and subscapularis tendons. The percentage of shoulders that could be used to perform each of the twelve functions on the Simple Shoulder Test (SST) was significantly increased postoperatively (p < 0.002). Men and women had different degrees of function preoperatively (p < 0.00000001) and postoperatively (p < 0.001), but the improvement in function was essentially identical for the two genders. The mean improvement in the number of SST shoulder functions that could be performed was best for the patients with one-tendon tears (4.9 functions), next best for those with two-tendon tears (3.6 functions), and worst for those with three-tendon tears (3.3 functions . SF-36 scores for physical role (p < 0.003) and comfort (p < 0.0001) were significantly improved postoperatively. We concluded that significant improvement in self-assessed shoulder comfort and in each of the twelve shoulder functions was observed after rotator cuff repairs performed without acromioplasty.

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