Click here to view next page of this article
Rotator cuff impingment. Outlet impingement. Again, we’ve talked a little bit about impingement but the outlet is between the acromion – your coracoacromial ligament – and your rotator cuff in this area. So this is what we call the supraspinatus outlet in this area. Your rotator cuff can be injured by an acromial spur, by a thickened coracoacromial ligament or even some thickened bursa that eventually causes inflammatory changes in the rotator cuff.
Impingement. In your older patient and again ages 35-40 and above, you may have some primary impingement process. But in athletes, if you’ve got an 18, 20 year old athlete, generally we don’t see primary impingement. It is usually secondary to some type of instability. Neer has written about the impingement stages. The irreversible swelling is seen in your young athlete, 20-25 years old. When they get to the age of 25-35 with shoulder pain, they get the irreversible thickening of the bursa on the rotator cuff. This will eventually progress to Stage III of impingement in which is, say, your 35-40 year old patient with a partial or small tear and this can progress on to a large tear. So it’s a progressive thing that can happen with this rotator cuff disease.
We talked about the physical examination. The positive Neer and Hawkins impingement signs and injection tests. One way to do the injection test is 8 cc of 1% plain lidocaine in the subacromial space and see if that relieves some of the pain. If they have good strength and that has taken away their pain, that is a good way of documenting impingement and ruling out rotator cuff impingement.
One of the x-rays that is helpful is called the outlet view. But the acromion morphology on an outlet view or a transcapular lateral view we can grade as a Type I which is a flat acromion, a Type II which is a gentle curved acromion or a Type III which has a large hook anteriorly. So these are important to help you to determine if there are any significant spurs that may be causing some impingement. So this is a helpful x-ray.
Nonoperative treatment of impingement. Physical therapy is a very important part of treating all of these shoulder problems. I will make a patient pretty much show me that they have failed rehab before we start talking about surgery unless there is some obvious tearing or obvious things that we have documented on examination that we know aren’t going to get better with time. But a good stretching and good rotator cuff strengthening program. These are published in a lot of different places. I usually work with a good stretch band, internal/external rotation, some upright rowing to work the supraspinatus.