Shoulder Impingement
Transcription
Shoulder Impingement
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 z=7&hl=en&start=1&tbnid=6wAYvvsLPD81iM:&tbnh=112&tbnw=99&prev=/images%3Fq%3Dhumeral%2Bhead%2Bmigration%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa% 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. http://www.google.co.nz/imgres?imgurl=http://2.bp.blogspot.com/__92tNSF6TCc/TRC9zWkr2iI/AAAAAAAAACA/3yOCDIM40V E/s1600/rotator%2Bcuff%2Bmuscle.jpg&imgrefurl=http://clarybeephysiolife.blogspot.com/&usg=___fDSbfxkduCADaLhY3TvK9cOdL A=&h=330&w=330&sz=15&hl=en&start=10&zoom=1&tbnid=9EivJvUKw9BstM:&tbnh=119&tbnw=119&ei=E4YpUMCEOYyXiAfx8ID QBQ&prev=/images%3Fq%3Drotator%2Bcuff%2Btendon%2Battachments%26hl%3Den%26sa%3DX%26gbv%3D2%26tbm%3Disc h&itbs=1