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Internal Impingement Em Antonogiannakis Orthopaedic surgeon Director Center for shoulder arthroscopy IASO General Hospital Athens.

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Presentation on theme: "Internal Impingement Em Antonogiannakis Orthopaedic surgeon Director Center for shoulder arthroscopy IASO General Hospital Athens."— Presentation transcript:

1 Internal Impingement Em Antonogiannakis Orthopaedic surgeon Director Center for shoulder arthroscopy IASO General Hospital Athens

2 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

3 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

4 Internal Impingement Some contact between these structures is physiologic but repetitive contact with altered shoulder mechanics may be pathologic

5 Internal Impingement For undefined reasons this contact in some athletes become pathologic and produces symptoms

6 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

7 Internal Impingement

8 Mechanism of Internal Impingement Two major theories: Andrew Burkhart & Morgan May co-exist

9 Mechanism of Internal Impingement Andrew Theory: Repeated ABER Dynamic stabilizers fatigue 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 Increased contact of undersurface of RC and posterosuperior glenoid Internal Impingement

10 Mechanism of Internal Impingement Burkhart & Morgan Theory: Repeated ABER Tight posterior capsule Superior translation of Humeral Head Torsional stress to biceps anchor Peel-off Mechanism Peel-off Mechanism SLAP II and Pseudolaxity Increased contact of undersurface of RC and posterosuperior glenoid Internal Impingement

11 Internal impingement 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%

12 Internal Impingement It is essentially an overuse injury associated with overhead athletes

13 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

14 Internal impingement

15 Internal impingement Throwing phases:

16 Internal impingement Throwing phases:

17 Internal Impingement Structures involved: –Humeral head –Anterior capsule –Inferior GHL –Posterior capsule –Rot cuff muscles

18 Chronicity of pain Posterior pain Abduction + external rotation aggravates pain Internal impingement – History

19 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

20 Inspection: –no rot cuff atrophy –no abnormality –Slight hypetrophy of muscles on dominant side Internal Impingement – Clinical Examination

21 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

22 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

23 Provocative tests: –Neers test = negative Internal Impingement – Clinical Examination

24 Provocative tests: Hawkins test = negative Internal Impingement – Clinical Examination

25 Provocative tests: Cross arm adduction test = negative Internal Impingement – Clinical Examination

26 Provocative tests: OBriens test = negative (unless SLAP lesion) Internal Impingement – Clinical Examination

27 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) Internal Impingement – Clinical Examination

28 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 Internal Impingement – Clinical Examination

29 Muscles strength = normal Internal Impingement – Clinical Examination

30 Internal Impingement – MRI findings

31 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 (Bennetts 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

32 Internal Impingement – Bennetts Lesion

33 SLAP lesions Pain more anterior than Internal Impingement. Positive OBrien 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 Internal Impingement – Differential Diagnosis

34 Internal Impingement Why partial rot cuf tears are usually at the articular side? Fewer arteriolars Greater stiffness Less favorable stress- strain curve

35 Internal Impingement – Arthroscopic findings

36 Internal Impingement – Arthroscopic findings

37 Internal Impingement – Arthroscopic findings

38 Internal Impingement – Treatment Conservative Surgical

39 Two main requirements for a good throw: –Large arc of motion –Adequate stability Throwers paradox some laxity to static restrains => some degree of instability => muscles compensate Fine balance is needed Internal Impingement – Conservative Treatment

40 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

41 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 ?

42 Open/Arthroscopic Capsulolabral Reconstruction –Arthrolysis of posterior capsule tightness –Repair of SLAP lesions –Repair of the rot cuff –Address anterior capsule laxity ( % pre-injury level) Internal Impingement – Surgical Treatment

43 Internal Impingement – Surgical Treatment

44 Internal Impingement – Surgical Treatment

45 Internal Impingement – Surgical Treatment

46 Arthroscopic Thermal Capsulorraphy Another method to reduce the anterior capsular laxity At the same time debridement + arthroscopic fixation of labral tears 86% 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

47 Subacromial decompression 22% of throwing athletes returned to the same level of participation after subacromial decompression Tibone,Jobe. CORR 1985 Internal Impingement – Surgical Treatment

48 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

49 Initial treatment: Complete REST + PHYSIOTHERAPY If symptoms persists: Multiple surgical techniques Repair all lesions if possible Take home messages

50 Thank you for your attention

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