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Internal ImpingementInternal Impingement
www.shoulder.gr
Em AntonogiannakisOrthopaedic surgeon
DirectorCenter for shoulder arthroscopy
IASO General HospitalAthens
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• Overhead athletes subject their shoulder to tremendous forces during competition
• During the late cocking phase of throwing the arm may achive 170 to 180 degrees of ext. rotation to generate the torque required
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Internal Impingement - Definition
Injury and dysfunction due to repeated contact
between the undersurface of the rot cuff tendons and the posterosuperior glenoid
Walch JSES 1992
www.shoulder.gr
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Internal Impingement
Some contact between these structures is physiologic but
repetitive contact with altered shoulder mechanics
may be pathologic
www.shoulder.gr
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Internal Impingement
For undefined reasons this contact in some athletes become pathologic and
produces symptoms
www.shoulder.gr
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Internal Impingement
Normally
in abduction and external rotation (ABER) there is
obligate posterior & inferior translation
of the humerus that allows for
more motion and less contact
between the greater tuberosity and
the posterosuperior glenoid rim
www.shoulder.gr
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Internal Impingement
www.shoulder.gr
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Mechanism of Internal Impingement
Two major theories:
• Andrew
• Burkhart & Morgan
May co-exist
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Mechanism of Internal ImpingementAndrew Theory:
www.shoulder.gr
Repeated ABER
Repeated ABER
Dynamic stabilizers
fatigue
Dynamic stabilizers
fatigue
Increase stress to anterior & IGHL
Increase stress to anterior & IGHL
Anterior capsule laxity
to allow max ABER
Anterior capsule laxity
to allow max ABER
Reduction of posterior & inferior translation of HH
Reduction of posterior & inferior translation of HH
Increased contact of undersurface of RC and posterosuperior glenoid
Increased contact of undersurface of RC and posterosuperior glenoid
Internal Impingement
Internal Impingement
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Mechanism of Internal ImpingementBurkhart & Morgan Theory:
www.shoulder.gr
Repeated ABER
Repeated ABER
Tight posterior capsule
Tight posterior capsule
Superior translation of Humeral Head
Superior translation of Humeral Head
Torsional stress to biceps anchor
Torsional stress to biceps anchor
Peel-off
Mechanism
Peel-off
MechanismSLAP II and Pseudolaxity
SLAP II and Pseudolaxity
Increased contact of undersurface of RC and posterosuperior glenoid
Increased contact of undersurface of RC and posterosuperior glenoid
Internal Impingement
Internal Impingement
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Internal impingement
www.shoulder.gr
• SLAP lesions are not caused by internal impingement, they are rather the result of excessive torsional stress to the biceps anchor
• Once produced SLAP lesions may increase the anterior translation of the humeral head up to 6 mm and the strain to the inferior glenohumeral ligament up to 100%
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Internal Impingement
It is essentially an overuse injury associated with
overhead athletes
www.shoulder.gr
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Internal Impingement
• Typically symptoms are present only while playing
• No symptoms with activities of daily living
• Represents about 80% of the problems seen in the overhead athletes
www.shoulder.gr
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Internal impingement
www.shoulder.gr
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Internal impingement
www.shoulder.gr
Throwing phases:
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Internal impingement
www.shoulder.gr
Throwing phases:
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Internal Impingement
Structures involved:
– Humeral head– Anterior capsule– Inferior GHL– Posterior capsule
– Rot cuff muscles
www.shoulder.gr
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• Chronicity of pain
• Posterior pain
• Abduction + external rotation aggravates pain
Internal impingement – History
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• Insidious onset
• Increases as the season progresses
• Dull posterior pain
• Worse at late cocking phase
• Rarely can remember any traumatic episode
• Loss of control and velocity
Internal impingement – History
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Inspection:
– no rot cuff atrophy
– no abnormality
– Slight hypetrophy of
muscles on dominant side
Internal Impingement – Clinical Examination
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Palpation:
– pain can be elicited over the infraspinatous
– pain worse posteriorly than on GT, (vice versa on rot cuff tendonitis)
– Anterior part of the shoulder, biceps groove and tendon are not painful.
– No bony abnormalities.
Internal Impingement – Clinical Examination
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ROM: – usually full range of motion – dominant arm tends to have
– 10-15 deg more ext rotation and – 10-15 deg less internal rotation at 90 deg abduction
– The most common for an overhead athlete is: – 2+ anterior laxity, – up to 1+ posterior laxity, – some inferior laxity,– but a firm endpoint
Internal Impingement – Clinical Examination
www.shoulder.gr
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Provocative tests:
– Neer’s test = negative
Internal Impingement – Clinical Examination
www.shoulder.gr
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Provocative tests:
www.shoulder.gr
Hawkins test = negative
Internal Impingement – Clinical Examination
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Provocative tests:
Cross arm adduction test = negative
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Internal Impingement – Clinical Examination
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Provocative tests:
O’Brien’s test = negative (unless SLAP lesion)
www.shoulder.gr
Internal Impingement – Clinical Examination
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Provocative tests: – Internal Impingement test = positive
(patient supine, 90 deg abduction and max external rotation. If pain experienced at the posterior part of the joint = positive, 90% sensitive)
– Relocation test = positive, (different from relocation test for anterior translation)
www.shoulder.gr
Internal Impingement – Clinical Examination
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Relocation test of Jobe:Pain in the posterior joint line when the arm is brought in abduction external rotation with the patient supine that is relieved when a posterior directed force is applied to the shoulder
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Internal Impingement – Clinical Examination
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Muscles strength = normal
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Internal Impingement – Clinical Examination
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Internal Impingement – MRI findings
www.shoulder.gr
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• Rot cuff tendonitis or bursitis Pain usually worse the day AFTER activity than DURING the actual
event. Typically deep soreness. Unlikely internal impingement pain is more diffuse and not localized to
the posterior aspect of the shoulder. Difficulty in lifting the arm, pain at the GT, that improves with rest and
NSAID after a short period.
• Throwers’ exostosis (Bennett’s lesion). Pain at the posterior part of the shoulder (more toward the inferior
than the superior aspect of the shoulder). Ceases with rest. Radiographs can help (stryker notch view= calcification at the
posteroinferior glenoid rim consistent with an exostosis).
Internal Impingement – Differential Diagnosis
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www.shoulder.gr
Internal Impingement – Bennett’s Lesion
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• SLAP lesions Pain more anterior than Internal Impingement. Positive O’Brien test and SLAPrehension test. These tests are
negative for internal impingement. Coronal oblique MRI can help
• Isolated posterior labrum tear The most difficult to differentiate from internal imp. Both posterior pain in the abducted and ext rotated position. Arthroscopy can help
www.shoulder.gr
Internal Impingement – Differential Diagnosis
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Internal Impingement
Why partial rot cuf tears are usually at the articular side?
• Fewer arteriolars• Greater stiffness• Less favorable stress-
strain curve
www.shoulder.gr
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Internal Impingement – Arthroscopic findings
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www.shoulder.gr
Internal Impingement – Arthroscopic findings
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www.shoulder.gr
Internal Impingement – Arthroscopic findings
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Internal Impingement –Treatment
• Conservative
• Surgical
www.shoulder.gr
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• Two main requirements for a good throw:– Large arc of motion– Adequate stability
• Thrower’s paradox
some laxity to static restrains => some degree of instability
=> muscles compensate
• Fine balance is needed
Internal Impingement – Conservative Treatment
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• Rest (complete stop of throwing is critical)
• Rehabilitation (physical therapy as soon as possible) to
– improve posterior flexibility– improve dynamic stabilization – increase strength of rot cuff muscles
• Then gradual return to throwing
• Improvement of throwing technique
• +/- NSAID
• Most athletes return to sport
Internal Impingement – Conservative Treatment
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Internal Impingement – Surgical Treatment
• Diagnostic arthroscopy (other pathology
found…SLAP, biceps tendonitis, rot cuff tears etc)
• Arthroscopic
Debridement 25-85% return to pre-injury
activity => effective ?
www.shoulder.gr
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• Open/Arthroscopic Capsulolabral Reconstruction
– Arthrolysis of posterior capsule tightness – Repair of SLAP lesions
– Repair of the rot cuff
– Address anterior capsule laxity
(50 - 81% pre-injury level)
Internal Impingement – Surgical Treatment
www.shoulder.gr
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Internal Impingement – Surgical Treatment
www.shoulder.gr
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Internal Impingement – Surgical Treatment
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Internal Impingement – Surgical Treatment
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• Arthroscopic Thermal CapsulorraphyAnother method to reduce the anterior capsular laxity At the same time debridement + arthroscopic fixation of labral
tears86% return to pre-injury level
• Rotational Osteotomy
Derotation osteotomy of humerous => increase of retroversion + shortening of subscapularis => less impingement
55% return to pre-injury level
Internal impingement – Surgical Treatments infrequently Used Today
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Subacromial decompression
• 22% of throwing athletes returned to the same level of participation after subacromial decompression
Tibone ,Jobe. CORR 1985
Internal Impingement – Surgical Treatment
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Take home messages
• Internal Impingement is a relatively common problem in overhead athletes
• Difficult to treat
• Caused by repetitive contact between the undersurface of the rot cuff and posterosuperior glenoid
www.shoulder.gr
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• Initial treatment:• Complete REST +
PHYSIOTHERAPY
• If symptoms persists:
• Multiple surgical techniques
• Repair all lesions if possible
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Take home messages
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Thank you for your attention
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