SHOULDER
Impingement series – what and
y
why?
ANATOMY
Bony elements of the
shoulder include
• Humerus
• Scapula
• Clavicle
http://www.frozenshoulder.ca/anatomyimages/bones3.jpg
ROTATOR CUFF
•
•
•
•
•
Supraspinatus
Infraspinatus
T
Teres
minor
i
Subscapularis
The tendons of these muscles also
provide stability
p
y for the jjoint
http://drserrick.files.wordpress.com/2010/02/rotator-cuff-muscles.jpg
6.
PATHOLOGY
• Frozen shoulder
• Impingement
• Rotator
R t t cuff
ff tear
t
Frozen shoulder
• A frozen shoulder is a shoulder joint with
significant
g
loss of its range
g of motion ((ROM)) in
all directions.
patient attempts
p
• The ROM is limited when the p
motion, but also when the doctor attempts to
move the joint fully while the patient relaxes.
• A frozen shoulder is also referred to as adhesive
capsulitis
IMPINGEMENT
• Impingement interval between acromion
and humeral head
• Supraspinatus and subacromial bursa are
entrapped between humeral head and
acromion.
acromion
Neers 3 stages
Stage 1
• Oedema and/or hemorrhage.
• Syndrome
S d
iis reversible
ibl
• Patients less than 25 years of age
• Frequently associated with an overuse
j y
injury.
Neers 3 stages
Stage II
• Fibrosis and thickening
• Partial
P ti l ttear
• Recurrent pain
• 25-40 years old
Neers 3 stages
Stage III
• Complete tear of rotator cuff
• Progressive
P
i di
disability
bilit
• 40 years +
Causes of impingement
• Subacromial spurs
• Type 2 and type 3 acromions
• Osteoarthritic
O t
th iti spurs off acromioclavicular
i l i l
joint (includes subacromial spurs)
• Thickened or calcified coracoacromial
ligament
Causes of impingement
• Loss of rotator cuff causing superior
migration of humerus (tear, loss of
g )
strength)
• Secondary impingement from unstable
shoulder
• Acromial defects (os acromiale)
• Anterior or posterior capsular contractures
(adhesive capsulitis)
• Thick subacromial bursa(1)
ACROMION VARIANTS
• The type I acromion
acromion, which is flat
flat, is the
"normal" acromion
• The type II acromion is more curved and
downward dipping
• Type
T
III acromion
i is
i hooked
h k d and
d
downward dipping, obstructing the outlet
f the
for
th supraspinatus
i t tendon.
t d
(1)
http://www.aafp.org/afp/980215ap/fongemie.html
SUPERIOR MIGRATION
• Impingement may occur as a result of loss
of competency of the rotator cuff.
• Pain may lead to disuse or weakness of
the cuff.
• The
Th weakness
k
results
lt in
i cephalad
h l d
migration of the humeral head, which
i
increases
iimpingement.
i
t
http://images.google.co.nz/imgres?imgurl=http://www.orthoassociates.com/images/ShoulderXray.jpg&imgrefurl=http://www.orthoassociates.com/shoulderRCD.htm&h=258&w=228&s
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3DG
Os Acromiale
• Os acromiale is an
unfused epiphysis of
the anterior part of the
acromion
Rotator cuff syndrome
•
•
•
•
Tear to a rotator cuff tendon
Usually supraspinatus
T
Trauma
Repetitive events
SOUTHLAND HOSPITAL
PROTOCOL
•
•
•
•
↓30 AP
↓30°
↓10° AP
↓12°
12° outlet
tl t view
i
Axial
↓ 30° AP
• AP view of shoulder with 30°
30 caudal
angulation
• Palm facing leg
• Demonstrates the anterior portion of
acromion
i nott seen on conventional
ti
l AP
views
• Neutral rotation profiles supraspinatus
insertion on greater tuberosity
↓ 30° AP
Tendon
calcification
↓10 ° AP
•
•
•
•
•
Angle patient 45°
45 toward affected side
Angle CR 10° caudal
Rotate arm for internal rotation
Demonstrates the gleno-humeral joint in profile
Use of internal rotation profiles the attachments
of infraspinatus and teres minor
• External rotation would profile the subscapularis
attachment on the lesser tuberosity.
• Caudal angle allows for excellent visualisation of
subacromial space
Tendon calcifications
Outlet View
• Position as for lateral scapula
• Angle CR 10-15° caudal
• Superimpose
S
i
flfloor off th
the supraspinatus
i t
fossa on the glenoid
• Clear the humeral head from the acromion
• Used to assess acromion shape
p and slope
p
• Demonstrates acromial thickness,
corocoacromial spurring
4
Axial
• Visualizes the acromion and the coracoid
process, as well as coracoacromial
g
calcifications (1)
ligament
• An os acromiale is best depicted on the
y view.
axillary
• Used to image anterior and posterior
p
of g
glenoid fossa and g
gleno
aspects
humeral relations.
Axial
• Must demonstrate the gleno
gleno-humeral
humeral
relationship
• Must penetrated enough so the acromion
is visualised through the head of the
humerus
AXIAL
Axial radiograph showing failure
of fusion (arrow) of the metameta
acromion
and mesoacromion. The latter is
the most common type of os
acromiale.
i l
References
1.
2.
3.
4.
5.
http://www.aafp.org/afp/980215ap/fongemie.html
Imaging
g g shoulder impingement
p g
Richard H. Gold,, M.D.,, Leannc L. Seeger,
g , M.D.,, Lawrence Yao,, M.D. Skeletal Radiol (1993)
(
) 22:555561
Anderson, J., Read, J.W., Steinweg, J. (1998) Atlas of imaging in sports medicine, McGraw Hill Roseville
Troubleshooting the supraspinatus outlet view Xavier A. Duralde, MD, and Susan J. Gauntt, BSRT, Atlanta, Ga Journal of Shoulder
Elbow Surg (I999);8 pg:3 I4-9 (
Management of Shoulder Impingement Syndrome and Rotator Cuff Tears
ALLEN E.
E FONGEMIE,
FONGEMIE M.D.,
M D DANIEL D.
D BUSS,
BUSS M.D.,
M D and SHARON J.
J ROLNICK,
ROLNICK PH
PH.D.,
D Minneapolis
Minneapolis, Minnesota
Am Fam Physician. 1998 Feb 15;57(4):667-674.
6.
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