December, 30th 2021

SUBACROMIAL
IMPINGEMENT
Supervisor:
Dr. dr. Muhammad Sakti, Sp.OT (K)

Team:
ADULT RECONSTRUCTION DIVISION (FM/RW)

Orthopaedic & Traumatology Department

Hasanuddin University, Makassar, Sulawesi Selatan
 INTRODUCTION
• SAIS is an encroachment of the
subacromial tissues as a result of
narrowing of the subacromial space
• the most common disorder of shoulder
• ± 44-65% of all complaints of shoulder
pain

Orthopedic Reviews 2012; volume 4:e18

https://www.youtube.com/watch?v=o3bIGZijKzY&t=42s
 INTRODUCTION
• Subacromial space is defined by:
• the humeral head inferiorly,
• the anterior edge and under surface of
the anterior third of the acromion,
coracoacromial ligament and the
acromioclavicular joint superiorly.
• The height of space between acromion
and humeral head ranges from 1.0 to
1.5 centimeters as seen on radiographs.

Orthopedic Reviews 2012; volume 4:e18

https://www.duncansportspt.com/2015/03/rotator-cuff/
 PATOPHYSIOLOGY
• subacromial impingement is thought to be a combination of
• Extrinsic compression
• of the rotator cuff between the humeral head and
• anterior acromion
• coracoacromial ligaments
• acromioclavicular joint

• Intrinsic degeneration
• supraspinatus
• attrition of the supraspinatus leads to inability to balance the humeral head on
the glenoid causing superior migration and narrowing of the subacromial
space

• inflammatory process
• inflammation of the subacromial bursa due to abutement between
the humerus and rotator cuff, and acromion and associated
ligaments
https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 Extrinsic Compression
• Lateral acromion vs cuff in midarc of abduction
(Watson – Jones)
• Rotator cuff and humeral head vs undersurface
of anterior acromion and CAL (Neer)

https://www.orthobullets.com/shoulder-and-elbow/3054/internal-impingement
Harrison AK, Flatow EL. Subacromial Impingement Syndrome. J Am Acad Orthop Surg 2011; 19: 701 – 708
 Intrinsic Degeneration
• Diminished vascular supply, aging, tensile forces 
rotator cuff failure
• Lohr & Uhthoff  zone of hypovascularity in
supraspinatus  degenerative tendinopathy + tear
• Weakening of supraspinatus  humeral head
migrates superior  abutting tuberosity & cuff vs
acromion  Osteophytes + tuberosity erosion

Harrison AK, Flatow EL. Subacromial Impingement Syndrome. J Am Acad Orthop Surg 2011; 19: 701 – 708
 NEER (three stages of impingement lesions)

https://link.springer.com/chapter/10.1007/978-1-4471-6572-9_33
https://journals.lww.com/clinorthop/citation/1983/03000/impingement_lesions.10.aspx
 ASSOCIATED CONDITION
• hook-shaped acromion
• os acromiale
• posterior capsular contracture
• scapular dyskinesia BIGLIANI Classification
• tuberosity fracture malunion
• instability

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 DIAGNOSIS
• SYMPTOMS : PAIN
• PHYSICAL EXAMINATION

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 DIAGNOSIS: Physical Examination
• Neer impingement sign
• Neer impingement test
• Hawkins test
• Jobe test
• Painful Arc Test
• Yocum Test
• Internal Impingement test

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
Neer Sign
Hawkin’s Test
Jobe Test
Painful Arc
Yocum Test
 IMAGING
• Conventional X-Ray
• true AP of the shoulder
• 30° caudal tilt view
• supraspinatus outlet view
• axillary lateral

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 IMAGING
• Conventional X-Ray
• true AP of the shoulder
• 30° caudal tilt view
• supraspinatus outlet view

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 IMAGING
• MRI
• degree of rotator cuff pathology
• subacromial and subdeltoid bursisits
• CT arthography
• can also accurately image the rotator
cuff tendons and muscle bellies
• Ultrasound
• can also accurately image the rotator
cuff tendons and muscle bellies

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 Presentation
Pain in the right shoulder with difficulties in raising the arm

https://radiopaedia.org/cases/subacromial-impingement-1
 MANAGEMENT
• Non-operative
• physical therapy,
• oral anti-inflammatory
medication,
• subacromial injections (CS, PRP)
• Operative
• subacromial decompression /
acromioplasty

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
Arthroscopic Surgery
 Open anterior acromioplasty

Campbell’s, 2021
 COMPLICATIONS
• Deltoid dysfunction
• resulting from a failed deltoid repair following an open
acromioplasty or an excessive acromionectomy during an
arthroscopic procedure
• secondary to direct excision of an os acromiale
• Anterosuperior escape
• avoid acromioplasty and CA ligament release to preserve the
coracoacromial arch in patients with massive, irreparable
rotator cuff tears

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
QUIZ
 #1

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 Preferred response: 4
(Will likely have no effect on pain, function or range of motion at one year, compared to therapy alone)

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 #2

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 Preferred response: 2 (Metalloproteases)

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 #3

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
 Preferred response: 3 (Meso os acromiale)

https://www.orthobullets.com/shoulder-and-elbow/3041/subacromial-impingement
THANK YOU
https://youtu.be/-DT4VMkDETI
https://www.orthobullets.com/shoulder-and-elbow/3054/internal-impingement
 A brief review in anatomy…

Netter’s Concise Orthopaedic Anatomy, 2nd Ed.

Rockwood Matsen
• 816
Rockwood Matsen
•?
Rockwood Matsen
1159
https://www.physio-pedia.com/index.php?title=Classification_of_Shoulder_Pain&veaction=edit&section=11
https://www.physio-pedia.com/index.php?title=Classification_of_Shoulder_Pain&veaction=edit&section=11
https://somepomed.org/articulos/contents/mobipreview.htm?24/19/24882