Mr Mike Walton presentation from The Arm Clinic's educational event, Friday 30th September 2016.

1. Subacromial Impingement
Surgeon’s Approach
Mr Mike Walton
Consultant Shoulder Surgeon

3. Impingement
• Theory of EXTRINSIC impingement
• Neer (1972) - Anterior acromioplasty for
chronic impingement of the shoulder,“a
preliminary study” JBJS(Am) 54(1):41-50

4. Subacromial Decopression
• “Impingement on the tendinous portion of the rotator cuff by
the coraco-acromial ligament and the anterior third of the
acromion is responsible for a characteristic syndrome of
disability of the shoulder.A characteristic proliferative spur and
ridge has been noted on the anterior lip and undersurface of the
anterior process of the acromion and this area may also show
erosion and eburnation.The treatment of the impingement is to
remove the anterior edge and undersurface of the anterior part
of the acromion with the attached coraco-acromial ligament.”

5. Subacromial Decopression
• “Fifty shoulders in forty-six patients have been subjected to
anterior acromioplasty during the past five years. Nineteen had
proliferative bursitis and tendinitis or partial tears of the
supraspinatus, without roentgenographic evidence of calcium
deposits, and twenty had complete tears of the supraspinatus
and the results in these thirty-nine patients from one to five
years following surgery were good. Eleven patients with
residual impingement following partial lateral acromionectomy
were improved but their results were impaired by pre-existent
deltoid weakness and scar”
• McShane 1987, Hawkins 1988, Bigliani 1989

6. Bigliani Classification

7. Bigliani Classification

8. Acromial Spurs
• Type III acromions associated with cuff
disease (Bigliani 1991, Balke 2013)
• Anterior and Lateral spurs associated with
full thickness cuff tears (Nyffeler 2006,Ames
2012, Fujisawa 2014)

9. Extrinsic Theory
• Acromionplasty
• reduces extrinsic compression
• improves visualisation during cuff repair
• induces healing response through bleeding

10. Arthroscopy
• Developed over the course of the 1980s and
early 1990
• Ellman (1987) - Arthroscopic subacromial
decompression: analysis of 1-3 year results.
Arthroscopy 3(3):173-181

11. • “Forty (80%) of the cases had advanced stage II impingement
without rotator cuff tear. Ten (20%) had full-thickness tears of
the rotator cuff. Patients were evaluated pre and postoperatively
on the UCLA Shoulder Rating Scale, which includes an
assessment of pain, function, range of motion (ROM), strength,
and patient satisfaction. Eighty-eight percent of the cases were
rated "satisfactory" (excellent or good), and 12% were rated
"unsatisfactory" (fair or poor).The procedure is technically
demanding, and to achieve a satisfactory result the criteria of
open anterior acromioplasty must be met.”
Arthroscopy

12. Arthroscopic
SubAcromial

13. Bigliani Classification

14. Extrinsic Problems
• Codman EA (1934) - The
Shoulder: Rupture of the
suprapsinatus tendon and other
lesions in or about the
subacromial bursa.
• Rim Rent tear - “deep surface
of the cuff is torn at its
attachment to the tubersity”

15. End Result Theory
• “So I am called eccentric for saying in public that
hospitals, if they want to be sure of improvement,
• Must find out what there results are
• Must analyse their results, to find their strong and weak
points,
• Must compare their results with other hospitals
• Must welcome publicity not only for their successes but
also for their errors”
EA Codman

16. Intrinsic Theory
• Primary tendon degeneration - tendinopathy
• Cuff & acromial pathology “normal variants”
• Address cuff with strengthening and
“biological” treatment for tendinopathy

17. Exercises vs Surgery
• Arthroscopic surgery compared with supervised exercises
in patients with rotator cuff disease (stage II impingement
syndrome). Brox JI, Staff PH, Ljunggren AE, Brevik JI. BMJ.
1993 Oct 9;307(6909):899-903
• Exercises versus arthroscopic decompression in patients
with subacromial impingement: a randomised, controlled
study in 90 cases with a one year follow up. Haahr JP,
Østergaard S, Dalsgaard J, Norup K, Frost P, Lausen S,
Holm EA,Andersen JH.Ann Rheum Dis. 2005 May;64(5):
760-4.

18. Exercises vs Surgery
• Effect of specific exercise strategy on need for surgery in
patients with subacromial impingement syndrome:
randomised controlled study. Holmgren T, Björnsson
Hallgren H, Öberg B,Adolfsson L, Johansson K. BMJ. 2012
Feb 20;344
• Significant improvement with specific exercise programme
compared to control
• 80% reduction in patients “needing” surgery

19. Exercises vs Surgery
• Specific exercise programme is equally
effective as subacromial decompression
• But subacromial decompression is as
effective as a specific exercise programme
with small but significant set of risks

20. Ketola et al
• No evidence of long-term benefits of arthroscopic acromioplasty in the
treatement of shoulder impingement syndrome. 5 year results of a
randomised controlled trial. BJR 2013;2:132-9
• Which patients do not recover from shoulder impingement syndrome,
either with operative treatment or with non-operative treatment? Acta
Orth 2015, 86;6:641-646
• No difference in long-term development of rotator cuff rupture and
muscle volumes in impingement patients with or without
decompression.Act Orth 2016, 87;4:351-355

21. Ketola et al
• 140 patient RCT:ASAD vs Home Exercise
programme
• No difference at 2 or 5 years between
groups
• No long term “protective effect” of SAD
on radiological muscle volumes or future
rotator cuff tears

22. Ketola et al
• Poor outcomes observed in
• Longer duration of Sx (over 12 months)
• Marital status (single)
• Long Periods of sick leave
• Lack of professional education

23. Intrinsic Problems
• The patient has pain and decreased function
• Has usually “tried” rest and physio
• We don't have a biological treatment
• If they fail is it a failure of rehaber or
rehabee??

24. Failure of conservative?
• Education / Expectations / Compliance
• Patient & Physio
• Pain
• The NHS model makes it very hard to
coordinate injections with therapy
• Wrong diagnosis

25. Role of Surgeon
• Establish a diagnosis
• “Impingement” is a symptom
• Age / Activity
• Cuff tear esp traumatic
• Other - calcific tendinitis /
frozen / capsulolabral

26. What Surgery?
• Bursectomy compared with acromioplasty in the
management of subacromial impingement syndrome: a
prospective randomised study. Henkus HE, de Witte PB,
Nelissen RG, Brand R, van Arkel ER. J Bone Joint Surg Br.
2009 Apr;91(4):504-10
• Small numbers
• Bursectomy and ASAD both effective.ASAD slightly more
so

27. What do we achieve?
• No idea!!!
• Removal of extrinsic compression
• Removal of pain generators - bursa, CAL
• Release of blood factors
• Enforced Exercises Post-op

28. My Conclusions
• Surgery is effective - Evidence and Anecdote
• We operate too frequently but as a result of
system failure
• Rehab is often underfunded, under resourced
and waiting lists far too long
• Need to focus on why some don't get better
rather than ignoring them.