Download PDF
Semin Musculoskelet Radiol 2008; 12(2): 107-126
DOI: 10.1055/s-2008-1078699
© Thieme Medical Publishers

External Impingement of the Shoulder

Robert S.D Campbell1 , Andrew Dunn1
  • 1Department of Radiology, Royal Liverpool University Hospital, Liverpool, United Kingdom
Further Information

Publication History

Publication Date:
28 May 2008 (online)

Also available at
    Permissions and Reprints

ABSTRACT

The relationship between external shoulder impingement and rotator cuff disease has been the subject of much research, but the theories of cause and effect remain controversial. Patients with symptoms of external impingement are referred for imaging to identify bony abnormalities of the coracoacromial arch and associated bursal and rotator cuff disease. Attempts have been made to identify objective imaging criteria that confirm the diagnosis of impingement, but at present external impingement remains primarily a clinical diagnosis. Therapeutic management varies from rehabilitation with physiotherapy to surgical procedures aimed at decompressing the subacromial space and repairing rotator cuff tears. This article reviews the relevant anatomy, biomechanics, and theories of external impingement, the role of imaging in the diagnosis of external impingement and rotator cuff disease, and implications upon management.

KEYWORDS

Shoulder - impingement - rotator cuff - MRI - ultrasound

REFERENCES

  • 1 Neer II C S. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report.  J Bone Joint Surg Am. 1972;  54(1) 41-50
    PubMedGoogle Scholar
  • 2 Michener L A, McClure P W, Karduna A R. Anatomical and biomechanical mechanisms of subacromial impingement syndrome.  Clin Biomech (Bristol, Avon). 2003;  18(5) 369-379
    CrossrefPubMedGoogle Scholar
  • 3 Kassarjian A, Bencardino J T, Palmer W E. MR imaging of the rotator cuff.  Magn Reson Imaging Clin N Am. 2004;  12(1) 39-60 vi
    PubMedGoogle Scholar
  • 4 Mellado J M, Calmet J, Domenech S, Sauri A. Clinically significant skeletal variations of the shoulder and the wrist: role of MR imaging.  Eur Radiol. 2003;  13(7) 1735-1743
    CrossrefPubMedGoogle Scholar
  • 5 Gallino M, Battiston B, Annaratone G, Terragnoli F. Coracoacromial ligament: a comparative arthroscopic and anatomic study.  Arthroscopy. 1995;  11(5) 564-567
    PubMedGoogle Scholar
  • 6 Petersilge C A, Witte D H, Sewell B O, Bosch E, Resnick D. Normal regional anatomy of the shoulder.  Magn Reson Imaging Clin N Am. 1993;  1(1) 1-18
    PubMedGoogle Scholar
  • 7 Clark J M, Harryman II D T. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy.  J Bone Joint Surg Am. 1992;  74(5) 713-725
    CrossrefPubMedGoogle Scholar
  • 8 Morag Y, Jacobson J A, Lucas D, Miller B, Brigido M K, Jamadar D A. US appearance of the rotator cable with histologic correlation: preliminary results.  Radiology. 2006;  241(2) 485-491
    PubMedGoogle Scholar
  • 9 Burkhart S S, Esch J C, Jolson R S. The rotator crescent and rotator cable: an anatomic description of the shoulder's “suspension bridge”.  Arthroscopy. 1993;  9(6) 611-616
    CrossrefPubMedGoogle Scholar
  • 10 Uri D S, Kneeland J B, Herzog R. Os acromiale: evaluation of markers for identification on sagittal and coronal oblique MR images.  Skeletal Radiol. 1997;  26(1) 31-34
    CrossrefPubMedGoogle Scholar
  • 11 Bigliani L U, Levine W N. Subacromial impingement syndrome.  J Bone Joint Surg Am. 1997;  79(12) 1854-1868
    PubMedGoogle Scholar
  • 12 Ludewig P M, Cook T M. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.  Phys Ther. 2000;  80(3) 276-291
    PubMedGoogle Scholar
  • 13 Howell S M, Imobersteg A M, Seger D H, Marone P J. Clarification of the role of the supraspinatus muscle in shoulder function.  J Bone Joint Surg Am. 1986;  68(3) 398-404
    PubMedGoogle Scholar
  • 14 Poppen N K, Walker P S. Normal and abnormal motion of the shoulder.  J Bone Joint Surg Am. 1976;  58(2) 195-201
    PubMedGoogle Scholar
  • 15 Reddy A S, Mohr K J, Pink M M, Jobe F W. Electromyographic analysis of the deltoid and rotator cuff muscles in persons with subacromial impingement.  J Shoulder Elbow Surg. 2000;  9(6) 519-523
    CrossrefPubMedGoogle Scholar
  • 16 Hallstrom E, Karrholm J. Shoulder kinematics in 25 patients with impingement and 12 controls.  Clin Orthop Relat Res. 2006;  448 22-27
    CrossrefPubMedGoogle Scholar
  • 17 Neer II C S. Impingement lesions.  Clin Orthop Relat Res. 1983;  (173) 70-77
    PubMedGoogle Scholar
  • 18 Vaz S, Soyer J, Pries P, Clarac J P. Subacromial impingement: influence of coracoacromial arch geometry on shoulder function.  Joint Bone Spine. 2000;  67(4) 305-309
    PubMedGoogle Scholar
  • 19 Lohr J F, Uhthoff H K. The microvascular pattern of the supraspinatus tendon.  Clin Orthop Relat Res. 1990;  (254) 35-38
    PubMedGoogle Scholar
  • 20 Chansky H A, Iannotti J P. The vascularity of the rotator cuff.  Clin Sports Med. 1991;  10(4) 807-822
    PubMedGoogle Scholar
  • 21 Ling S C, Chen C F, Wan R X. A study on the vascular supply of the supraspinatus tendon.  Surg Radiol Anat. 1990;  12(3) 161-165
    CrossrefPubMedGoogle Scholar
  • 22 Morrison D S, Frogameni A D, Woodworth P. Non-operative treatment of subacromial impingement syndrome.  J Bone Joint Surg Am. 1997;  79(5) 732-737
    PubMedGoogle Scholar
  • 23 Jacobson S R, Speer K P, Moor J T et al.. Reliability of radiographic assessment of acromial morphology.  J Shoulder Elbow Surg. 1995;  4(6) 449-453
    CrossrefPubMedGoogle Scholar
  • 24 Mayerhoefer M E, Breitenseher M J, Roposch A, Treitl C, Wurnig C. Comparison of MRI and conventional radiography for assessment of acromial shape.  AJR Am J Roentgenol. 2005;  184(2) 671-675
    PubMedGoogle Scholar
  • 25 Nicholson G P, Goodman D A, Flatow E L, Bigliani L U. The acromion: morphologic condition and age-related changes. A study of 420 scapulas.  J Shoulder Elbow Surg. 1996;  5(1) 1-11
    CrossrefPubMedGoogle Scholar
  • 26 Ozaki J, Fujimoto S, Nakagawa Y, Masuhara K, Tamai S. Tears of the rotator cuff of the shoulder associated with pathological changes in the acromion. A study in cadavera.  J Bone Joint Surg Am. 1988;  70(8) 1224-1230
    PubMedGoogle Scholar
  • 27 Chang E Y, Moses D A, Babb J S, Schweitzer M E. Shoulder impingement: objective 3D shape analysis of acromial morphologic features.  Radiology. 2006;  239(2) 497-505
    CrossrefPubMedGoogle Scholar
  • 28 Moses D A, Chang E Y, Schweitzer M E. The scapulacromial angle: a 3D analysis of acromial slope and its relationship with shoulder impingement.  J Magn Reson Imaging. 2006;  24(6) 1371-1377
    CrossrefPubMedGoogle Scholar
  • 29 Codman E A. Rupture of the supraspinatus-1834 to 1934.  J Bone Joint Surg Am. 1937;  19 643-652
    PubMedGoogle Scholar
  • 30 Ogata S, Uhthoff H K. Acromial enthesopathy and rotator cuff tear. A radiologic and histologic postmortem investigation of the coracoacromial arch.  Clin Orthop Relat Res. 1990;  (254) 39-48
    PubMedGoogle Scholar
  • 31 Mehta S, Gimbel J A, Soslowsky L J. Etiologic and pathogenetic factors for rotator cuff tendinopathy.  Clin Sports Med. 2003;  22(4) 791-812
    CrossrefPubMedGoogle Scholar
  • 32 Carr A J, Norris S H. The blood supply of the calcaneal tendon.  J Bone Joint Surg Br. 1989;  71(1) 100-101
    PubMedGoogle Scholar
  • 33 Brooks C H, Revell W J, Heatley F W. A quantitative histological study of the vascularity of the rotator cuff tendon.  J Bone Joint Surg Br. 1992;  74(1) 151-153
    PubMedGoogle Scholar
  • 34 Rees J D, Wilson A M, Wolman R L. Current concepts in the management of tendon disorders.  Rheumatology (Oxford). 2006;  45(5) 508-521
    CrossrefPubMedGoogle Scholar
  • 35 Cohen R B, Williams Jr G R. Impingement syndrome and rotator cuff disease as repetitive motion disorders.  Clin Orthop Relat Res. 1998;  (351) 95-101
    PubMedGoogle Scholar
  • 36 Lewis J S, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance.  J Shoulder Elbow Surg. 2005;  14(4) 385-392
    CrossrefPubMedGoogle Scholar
  • 37 Sjogaard G, Sogaard K. Muscle injury in repetitive motion disorders.  Clin Orthop Relat Res. 1998;  (351) 21-31
    PubMedGoogle Scholar
  • 38 Jobe F W, Kvitne R S, Giangarra C E. Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement.  Orthop Rev. 1989;  18(9) 963-975
    PubMedGoogle Scholar
  • 39 Belling Sorensen A K, Jorgensen U. Secondary impingement in the shoulder. An improved terminology in impingement.  Scand J Med Sci Sports. 2000;  10(5) 266-278
    CrossrefPubMedGoogle Scholar
  • 40 Karduna A R, Kerner P J, Lazarus M D. Contact forces in the subacromial space: effects of scapular orientation.  J Shoulder Elbow Surg. 2005;  14(4) 393-399
    CrossrefPubMedGoogle Scholar
  • 41 Giaroli E L, Major N M, Lemley D E, Lee J. Coracohumeral interval imaging in subcoracoid impingement syndrome on MRI.  AJR Am J Roentgenol. 2006;  186(1) 242-246
    CrossrefPubMedGoogle Scholar
  • 42 MacMahon P J, Taylor D H, Duke D, Brennan D D, O'Brien J, Eustace S J. Contribution of full-thickness supraspinatus tendon tears to acquired subcoracoid impingement.  Clin Radiol. 2007;  62(6) 556-563
    CrossrefPubMedGoogle Scholar
  • 43 Lo I K, Burkhart S S. The etiology and assessment of subscapularis tendon tears: a case for subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis.  Arthroscopy. 2003;  19(10) 1142-1150
    PubMedGoogle Scholar
  • 44 Bennett W F. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of “hidden” rotator interval lesions.  Arthroscopy. 2001;  17(2) 173-180
    CrossrefPubMedGoogle Scholar
  • 45 Friedman R J, Bonutti P M, Genez B. Cine magnetic resonance imaging of the subcoracoid region.  Orthopedics. 1998;  21(5) 545-548
    PubMedGoogle Scholar
  • 46 Lo I K, Parten P M, Burkhart S S. Combined subcoracoid and subacromial impingement in association with anterosuperior rotator cuff tears: An arthroscopic approach.  Arthroscopy. 2003;  19(10) 1068-1078
    PubMedGoogle Scholar
  • 47 McFarland E G, Selhi H S, Keyurapan E. Clinical evaluation of impingement: what to do and what works.  J Bone Joint Surg Am. 2006;  88(2) 432-441
    PubMedGoogle Scholar
  • 48 Eustace J A, Brophy D P, Gibney R P, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms.  Ann Rheum Dis. 1997;  56(1) 59-63
    PubMedGoogle Scholar
  • 49 Naredo E, Cabero F, Beneyto P et al.. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder.  J Rheumatol. 2004;  31(2) 308-314
    PubMedGoogle Scholar
  • 50 Kilcoyne R F, Reddy P K, Lyons F, Rockwood Jr C A. Optimal plain film imaging of the shoulder impingement syndrome.  AJR Am J Roentgenol. 1989;  153(4) 795-797
    PubMedGoogle Scholar
  • 51 Cone III R O, Resnick D, Danzig L. Shoulder impingement syndrome: radiographic evaluation.  Radiology. 1984;  150(1) 29-33
    PubMedGoogle Scholar
  • 52 Hardy D C, Vogler III J B, White R H. The shoulder impingement syndrome: prevalence of radiographic findings and correlation with response to therapy.  AJR Am J Roentgenol. 1986;  147(3) 557-561
    PubMedGoogle Scholar
  • 53 Huang L F, Rubin D A, Britton C A. Greater tuberosity changes as revealed by radiography: lack of clinical usefulness in patients with rotator cuff disease.  AJR Am J Roentgenol. 1999;  172(5) 1381-1388
    PubMedGoogle Scholar
  • 54 Kaplan P A, Bryans K C, Davick J P, Otte M, Stinson W W, Dussault R G. MR imaging of the normal shoulder: variants and pitfalls.  Radiology. 1992;  184(2) 519-524
    CrossrefPubMedGoogle Scholar
  • 55 Park J G, Lee J K, Phelps C T. Os acromiale associated with rotator cuff impingement: MR imaging of the shoulder.  Radiology. 1994;  193(1) 255-257
    PubMedGoogle Scholar
  • 56 Matsuzaki S, Yoneda M, Kobayashi Y, Fukushima S, Wakitani S. Dynamic enhanced MRI of the subacromial bursa: correlation with arthroscopic and histological findings.  Skeletal Radiol. 2003;  32(9) 510-520
    CrossrefPubMedGoogle Scholar
  • 57 Morag Y, Jacobson J A, Miller B, De Maeseneer M, Girish G, Jamadar D. MR imaging of rotator cuff injury: what the clinician needs to know.  Radiographics. 2006;  26(4) 1045-1065
    CrossrefPubMedGoogle Scholar
  • 58 Arslan G, Apaydin A, Kabaalioglu A, Sindel T, Luleci E. Sonographically detected subacromial/subdeltoid bursal effusion and biceps tendon sheath fluid: reliable signs of rotator cuff tear?.  J Clin Ultrasound. 1999;  27(6) 335-339
    CrossrefPubMedGoogle Scholar
  • 59 Hollister M S, Mack L A, Patten R M, Winter III T C, Matsen III F A, Veith R R. Association of sonographically detected subacromial/subdeltoid bursal effusion and intraarticular fluid with rotator cuff tear.  AJR Am J Roentgenol. 1995;  165(3) 605-608
    CrossrefPubMedGoogle Scholar
  • 60 Kjellin I, Ho C P, Cervilla V et al.. Alterations in the supraspinatus tendon at MR imaging: correlation with histopathologic findings in cadavers.  Radiology. 1991;  181(3) 837-841
    CrossrefPubMedGoogle Scholar
  • 61 Kaneko K, De Mouy E H, Brunet M E. Massive rotator cuff tears. Screening by routine radiographs.  Clin Imaging. 1995;  19(1) 8-11
    CrossrefPubMedGoogle Scholar
  • 62 Beggs I. Alternative imaging techniques.  Magn Reson Imaging Clin N Am. 2004;  12(1) 75-96 vi
    CrossrefPubMedGoogle Scholar
  • 63 Hambly N, Fitzpatrick P, MacMahon P, Eustace S. Rotator cuff impingement: correlation between findings on MRI and outcome after fluoroscopically guided subacromial bursography and steroid injection.  AJR Am J Roentgenol. 2007;  189(5) 1179-1184
    CrossrefPubMedGoogle Scholar
  • 64 Middleton W D. Status of rotator cuff sonography.  Radiology. 1989;  173(2) 307-309
    PubMedGoogle Scholar
  • 65 Teefey S A, Hasan S A, Middleton W D, Patel M, Wright R W, Yamaguchi K. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases.  J Bone Joint Surg Am. 2000;  82(4) 498-504
    PubMedGoogle Scholar
  • 66 Zehetgruber H, Lang T, Wurnig C. Distinction between supraspinatus, infraspinatus and subscapularis tendon tears with ultrasound in 332 surgically confirmed cases.  Ultrasound Med Biol. 2002;  28(6) 711-717
    CrossrefPubMedGoogle Scholar
  • 67 Farley T E, Neumann C H, Steinbach L S, Jahnke A J, Petersen S S. Full-thickness tears of the rotator cuff of the shoulder: diagnosis with MR imaging.  AJR Am J Roentgenol. 1992;  158(2) 347-351
    PubMedGoogle Scholar
  • 68 Reinus W R, Shady K L, Mirowitz S A, Totty W G. MR diagnosis of rotator cuff tears of the shoulder: value of using T2-weighted fat-saturated images.  AJR Am J Roentgenol. 1995;  164(6) 1451-1455
    PubMedGoogle Scholar
  • 69 Balich S M, Sheley R C, Brown T R, Sauser D D, Quinn S F. MR imaging of the rotator cuff tendon: interobserver agreement and analysis of interpretive errors.  Radiology. 1997;  204(1) 191-194
    CrossrefPubMedGoogle Scholar
  • 70 van Holsbeeck M T, Kolowich P A, Eyler W R et al.. US depiction of partial-thickness tear of the rotator cuff.  Radiology. 1995;  197(2) 443-446
    PubMedGoogle Scholar
  • 71 Martin-Hervas C, Romero J, Navas-Acien A, Reboiras J J, Munuera L. Ultrasonographic and magnetic resonance images of rotator cuff lesions compared with arthroscopy or open surgery findings.  J Shoulder Elbow Surg. 2001;  10(5) 410-415
    CrossrefPubMedGoogle Scholar
  • 72 Roberts C S, Walker II J A, Seligson D. Diagnostic capabilities of shoulder ultrasonography in the detection of complete and partial rotator cuff tears.  Am J Orthop. 2001;  30(2) 159-162
    PubMedGoogle Scholar
  • 73 Ferrari F S, Governi S, Burresi F, Vigni F, Stefani P. Supraspinatus tendon tears: comparison of US and MR arthrography with surgical correlation.  Eur Radiol. 2002;  12(5) 1211-1217
    CrossrefPubMedGoogle Scholar
  • 74 Meister K, Thesing J, Montgomery W J, Indelicato P A, Walczak S, Fontenot W. MR arthrography of partial thickness tears of the undersurface of the rotator cuff: an arthroscopic correlation.  Skeletal Radiol. 2004;  33(3) 136-141
    CrossrefPubMedGoogle Scholar
  • 75 Tirman P F, Bost F W, Steinbach L S et al.. MR arthrographic depiction of tears of the rotator cuff: benefit of abduction and external rotation of the arm.  Radiology. 1994;  192(3) 851-856
    CrossrefPubMedGoogle Scholar
  • 76 Warner J J, Goitz R J, Irrgang J J, Groff Y J. Arthroscopic-assisted rotator cuff repair: patient selection and treatment outcome.  J Shoulder Elbow Surg. 1997;  6(5) 463-472
    CrossrefPubMedGoogle Scholar
  • 77 Goutallier D, Postel J M, Bernageau J, Lavau L, Voisin M C. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.  Clin Orthop Relat Res. 1994;  (304) 78-83
    PubMedGoogle Scholar
  • 78 Thomazeau H, Rolland Y, Lucas C, Duval J M, Langlais F. Atrophy of the supraspinatus belly. Assessment by MRI in 55 patients with rotator cuff pathology.  Acta Orthop Scand. 1996;  67(3) 264-268
    CrossrefPubMedGoogle Scholar
  • 79 Sofka C M, Haddad Z K, Adler R S. Detection of muscle atrophy on routine sonography of the shoulder.  J Ultrasound Med. 2004;  23(8) 1031-1034
    PubMedGoogle Scholar
  • 80 Strobel K, Hodler J, Meyer D C, Pfirrmann C W, Pirkl C, Zanetti M. Fatty atrophy of supraspinatus and infraspinatus muscles: accuracy of US.  Radiology. 2005;  237(2) 584-589
    CrossrefPubMedGoogle Scholar
  • 81 Brossmann J, Preidler K W, Pedowitz R A, White L M, Trudell D, Resnick D. Shoulder impingement syndrome: influence of shoulder position on rotator cuff impingement-an anatomic study.  AJR Am J Roentgenol. 1996;  167(6) 1511-1515
    CrossrefPubMedGoogle Scholar
  • 82 Pappas G P, Blemker S S, Beaulieu C F, McAdams T R, Whalen S T, Gold G E. In vivo anatomy of the Neer and Hawkins sign positions for shoulder impingement.  J Shoulder Elbow Surg. 2006;  15(1) 40-49
    CrossrefPubMedGoogle Scholar
  • 83 Roberts C S, Davila J N, Hushek S G, Tillett E D, Corrigan T M. Magnetic resonance imaging analysis of the subacromial space in the impingement sign positions.  J Shoulder Elbow Surg. 2002;  11(6) 595-599
    CrossrefPubMedGoogle Scholar
  • 84 Farin P U, Jaroma H, Harju A, Soimakallio S. Shoulder impingement syndrome: sonographic evaluation.  Radiology. 1990;  176(3) 845-849
    PubMedGoogle Scholar
  • 85 Bureau N J, Beauchamp M, Cardinal E, Brassard P. Dynamic sonography evaluation of shoulder impingement syndrome.  AJR Am J Roentgenol. 2006;  187(1) 216-220
    CrossrefPubMedGoogle Scholar
  • 86 Fealy S, April E W, Khazzam M, Armengol-Barallat J, Bigliani L U. The coracoacromial ligament: morphology and study of acromial enthesopathy.  J Shoulder Elbow Surg. 2005;  14(5) 542-548
    CrossrefPubMedGoogle Scholar
  • 87 Woertler K, Waldt S. MR imaging in sports-related glenohumeral instability.  Eur Radiol. 2006;  16(12) 2622-2636
    CrossrefPubMedGoogle Scholar
  • 88 Alvarez C M, Litchfield R, Jackowski D, Griffin S, Kirkley A. A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and Xylocaine to Xylocaine alone in chronic rotator cuff tendinosis.  Am J Sports Med. 2005;  33(2) 255-262
    CrossrefPubMedGoogle Scholar
  • 89 Blair B, Rokito A S, Cuomo F, Jarolem K, Zuckerman J D. Efficacy of injections of corticosteroids for subacromial impingement syndrome.  J Bone Joint Surg Am. 1996;  78(11) 1685-1689
    PubMedGoogle Scholar
  • 90 McInerney J J, Dias J, Durham S, Evans A. Randomised controlled trial of single, subacromial injection of methylprednisolone in patients with persistent, post-traumatic impingement of the shoulder.  Emerg Med J. 2003;  20(3) 218-221
    CrossrefPubMedGoogle Scholar

Robert S.D. CampbellM.D. 

Department of Radiology, Royal Liverpool University Hospital

Prescot St., Liverpool, L7 8XP, UK

Email: Rob.campbell@rlbuht.nhs.uk