Shoulder:Shoulder Impingements - Revision history

Alexandre.laedermann at 13:41, 2 June 2021

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Alexandre.laedermann at 09:34, 2 June 2021

2021-06-02T09:34:00Z

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 ====Surgical Technique====
 Typically, with internal rotation of the humerus the middle glenohumeral ligament is seen “cutting” into the upper boarder of the subscapularis (Figure 35) or creating a superior abrasion on the upper part of the tendon (Figure 36). The middle glenohumeral ligament must be divided with electrocautery. Eventually anterior glenoplasty or coracoplasty, in order to allow proper gliding of the superior border of the tendon, is performed.<ref name=":14" />
 <references />

@@ Line 208: / Line 208: @@
 =====Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA)=====
 Magnetic resonance imaging (MRI), enhanced or not with gadolinium contrast to
-increase the diagnostic value, is the most utilized imaging modality to confirm posterosuperior impingement. This modality will confirm articular-sided rotator cuff tears found in up to 40% of professional baseball pitchers<ref name=":68" /> and in up to 60% of professional tennis players,<ref name=":18" /><ref name=":19" /><ref name=":20" /><ref name=":21" /><ref name=":68">P.M. Connor, D.M. Banks, A.B. Tyson, J.S. Coumas, D.F. D'Alessandro "Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5-year follow-up study." ''Am J Sports Med'', '''2003''', 31, 724-727.</ref><ref>J.L. Brasseur, O. Lucidarme, M. Tardieu, M. Tordeur, B. Montalvan, J. Parier, P. Le Goux, A. Gires, P. Grenier "Ultrasonographic rotator-cuff changes in veteran tennis players: The effect of hand dominance and comparison with clinical findings." ''Eur Radiol'', '''2004''', 14, 857-864.</ref> cystic changes in the  posterior aspect of the humeral head (Figure 26), posterosuperior labral pathology (Figure 27), possible presence of a spinoglenoid cyst (Figure 28) and mature periosteal glenoid formation. Jung et al. report a sensitivity of 85% and a specificity of 86% for superior labral tears.<ref>J.Y. Jung, Y.C. Yoon, S.H. Choi, J.W. Kwon, J. Yoo, B.K. Choe "Three-dimensional isotropic shoulder MR arthrography: Comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 t." ''Radiology'', '''2009''', 250, 498-505.</ref> Sequences with the shoulder in both the abducted and abducted and externally rotated position (ABER) appear to improve the diagnostic accuracy of soft tissue anterior and posterior labral tears, SLAP tears, and bony glenoid lesions.<ref>J.Y. Choi, S.H. Kim, H.J. Yoo, S.H. Shin, J.H. Oh, G.H. Baek, S.H. Hong "Superior labral anterior-to-posterior lesions: Comparison of external rotation and active supination CT arthrography with neutral CT arthrography." ''Radiology'', '''2012''', 263, 199-205.</ref><ref>C.S. Modi, S. Karthikeyan, A. Marks, A. Saithna, C.D. Smith, S.B. Rai, S.J. Drew "Accuracy of abduction-external rotation MRA versus standard MRA in the diagnosis of intra-articular shoulder pathology." ''Orthopedics'', '''2013''', 36, e337-342.</ref>
+increase the diagnostic value, is the most utilized imaging modality to confirm posterosuperior impingement. This modality will confirm articular-sided rotator cuff tears found in up to 40% of professional baseball pitchers<ref name=":68" /> and in up to 60% of professional tennis players,<ref name=":18" /><ref name=":19" /><ref name=":20" /><ref name=":21" /><ref name=":68">P.M. Connor, D.M. Banks, A.B. Tyson, J.S. Coumas, D.F. D'Alessandro "Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5-year follow-up study." ''Am J Sports Med'', '''2003''', 31, 724-727.</ref><ref name=":69">J.L. Brasseur, O. Lucidarme, M. Tardieu, M. Tordeur, B. Montalvan, J. Parier, P. Le Goux, A. Gires, P. Grenier "Ultrasonographic rotator-cuff changes in veteran tennis players: The effect of hand dominance and comparison with clinical findings." ''Eur Radiol'', '''2004''', 14, 857-864.</ref> cystic changes in the  posterior aspect of the humeral head (Figure 26), posterosuperior labral pathology (Figure 27), possible presence of a spinoglenoid cyst (Figure 28) and mature periosteal glenoid formation. Jung et al. report a sensitivity of 85% and a specificity of 86% for superior labral tears.<ref name=":70">J.Y. Jung, Y.C. Yoon, S.H. Choi, J.W. Kwon, J. Yoo, B.K. Choe "Three-dimensional isotropic shoulder MR arthrography: Comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 t." ''Radiology'', '''2009''', 250, 498-505.</ref> Sequences with the shoulder in both the abducted and abducted and externally rotated position (ABER) appear to improve the diagnostic accuracy of soft tissue anterior and posterior labral tears, SLAP tears, and bony glenoid lesions.<ref name=":71">J.Y. Choi, S.H. Kim, H.J. Yoo, S.H. Shin, J.H. Oh, G.H. Baek, S.H. Hong "Superior labral anterior-to-posterior lesions: Comparison of external rotation and active supination CT arthrography with neutral CT arthrography." ''Radiology'', '''2012''', 263, 199-205.</ref><ref name=":72">C.S. Modi, S. Karthikeyan, A. Marks, A. Saithna, C.D. Smith, S.B. Rai, S.J. Drew "Accuracy of abduction-external rotation MRA versus standard MRA in the diagnosis of intra-articular shoulder pathology." ''Orthopedics'', '''2013''', 36, e337-342.</ref>
 [[File:Figure 26 jpeg.jpg|thumb|Figure 26. Coronal magnetic resonance arthrography (MRA) view showing a bony contusion on the greater tubercle caused by repeated impingement, as well as cysts and a partial-thickness articular rotator cuff lesion.]]
@@ Line 223: / Line 223: @@
 =====Conservative (Nonoperative) Treatment=====
-Conservative treatment should always be the first line of treatment for patients with posterosuperior impingement. Patients, athletes or not, will improve with cessation of activities and focused therapy modalities. Patients with new-onset impingement symptoms should be initially treated with activity modification, initiation of short-term routine NSAID use, and enrollment into a formal throwing therapy program. Rehabilitation should contain three key components: application of kinetic chain exercises, shoulder mobility, and shoulder strengthening.<ref>W.B. Kibler, J.E. Kuhn, K. Wilk, A. Sciascia, S. Moore, K. Laudner, T. Ellenbecker, C. Thigpen, T. Uhl "The disabled throwing shoulder: Spectrum of pathology-10-year update." ''Arthroscopy'', '''2013''', 29, 141-61 e26.</ref> All ranges of movement must be recovered, especially internal rotation at 90 degrees of abduction, by teaching the patient self-stretching exercises such as ‘sleeper-stretching’ (Figure 30).
+Conservative treatment should always be the first line of treatment for patients with posterosuperior impingement. Patients, athletes or not, will improve with cessation of activities and focused therapy modalities. Patients with new-onset impingement symptoms should be initially treated with activity modification, initiation of short-term routine NSAID use, and enrollment into a formal throwing therapy program. Rehabilitation should contain three key components: application of kinetic chain exercises, shoulder mobility, and shoulder strengthening.<ref name=":73">W.B. Kibler, J.E. Kuhn, K. Wilk, A. Sciascia, S. Moore, K. Laudner, T. Ellenbecker, C. Thigpen, T. Uhl "The disabled throwing shoulder: Spectrum of pathology-10-year update." ''Arthroscopy'', '''2013''', 29, 141-61 e26.</ref> All ranges of movement must be recovered, especially internal rotation at 90 degrees of abduction, by teaching the patient self-stretching exercises such as ‘sleeper-stretching’ (Figure 30).
 [[File:Figure 30 jpeg.jpg|thumb|Figure 30. The sleeper stretch is a range of motion exercise for the shoulder to improve shoulder internal rotation. The patient lies on his affected side. A pillow under the head can be used. The elbow is brought ring the straight out from the shoulder. The arm is kept bent in this L position. The other hand is used to push the forearm down toward the floor during 20 seconds.]]
@@ Line 229: / Line 229: @@
 Another tenet of nonoperative treatment is specific strengthening through restoration of scapular motor control, initiation of a scapular feedback program, and promotion of eccentric control through an increased number of repetitions throwing cycles. Strengthening of the external rotators should be concentric and eccentric using elastics or weights, as described in some protocols depending on the results of the isokinetic analysis (Figure 31). Proprioception can be worked on with ball exercises (Figure 32). If the patient fails in a 6-month range and cannot return to activities, then the patient may be considered for surgical intervention.
+[[File:Figure 31 jpeg.jpg|thumb|Figure 31. Strengthening of external rotators.]]
+[[File:Figure 32 jpeg.jpg|thumb|Figure 32. Proprioception exercises using a ball.]]
 =====Operative (Surgical) Treatment=====
-Depending on patient’s expectations and underlying conditions, surgical options include arthroscopic debridement, arthrolysis, posterosuperior glenoidplasty as described by Lévigne et al.<ref>C. Lévigne, J. Garret, F. Borel, G. Walch "Glénoplastie postérieure sous arthroscopie pour conflit glénoidien postérosupérieur." ''Rev Chir Orthop Reparatrice Appar Mot'', '''2007''', 93, 37.</ref><ref>C. Lévigne, J. Garret, S. Grosclaude, F. Borel, G. Walch "Surgical technique arthroscopic posterior glenoidplasty for posterosuperior glenoid impingement in throwing athletes." ''Clin Orthop Relat Res'', '''2012''', 470, 1571-8.</ref> (Figures 33) and derotational osteotomy (Figure 34). The later technique has largely been abandoned.
+Depending on patient’s expectations and underlying conditions, surgical options include arthroscopic debridement, arthrolysis, posterosuperior glenoidplasty as described by Lévigne et al.<ref name=":74">C. Lévigne, J. Garret, F. Borel, G. Walch "Glénoplastie postérieure sous arthroscopie pour conflit glénoidien postérosupérieur." ''Rev Chir Orthop Reparatrice Appar Mot'', '''2007''', 93, 37.</ref><ref name=":75">C. Lévigne, J. Garret, S. Grosclaude, F. Borel, G. Walch "Surgical technique arthroscopic posterior glenoidplasty for posterosuperior glenoid impingement in throwing athletes." ''Clin Orthop Relat Res'', '''2012''', 470, 1571-8.</ref> (Figures 33) and derotational osteotomy (Figure 34). The later technique has largely been abandoned.
+[[File:Figure 33 jpeg.jpg|thumb|Figure 33. (A) Arthroscopic view of a right shoulder through an anterolateral portal. Bone spicules on the posterosuperior glenoid rim. (B) Post glenoplasty result.]]
-Figure 35: (A) Arthroscopic view of a right shoulder through an anterolateral portal. Bone spicules on the posterosuperior glenoid rim. (B) Post glenoplasty result.
+<br />
+[[File:Figure 34 jpeg.jpg|thumb|Figure 34. Illustration of the principle of derotational osteotomy. Postoperatively, the repetitive contact between the posterior labrum and the rotator cuff is prevented.]]
+<br />
 ===Anterosuperior Impingement===
-Anterosuperior impingement was first described by Gerber and Sebesta who reported that repetitive friction led to partial articular subscapularis tendon and biceps pulley tears.[84] It is caused by entrapment of the subscapularis tendon between the anterior humeral head and anterior glenoid labrum with the arm in forward flexion, adduction, and internal rotation. It mirrors Walch’s posterosuperior impingement that involves the posterosuperior rotator cuff.<ref name=":17" /> It should not be mistaken with anterolateral impingement which is a synonym for the far more frequent subacromial impingement. Pain in anterosuperior impingement seems to be specifically located to the anterior aspect of the shoulder,<ref name=":24">C. Gerber, A. Sebesta "Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A preliminary report." ''J Shoulder Elbow Surg'', '''2000''', 9, 483-490.</ref><ref name=":25">S.S. Bath, S.S. Bath, J. Tehranzadeh "Anterosuperior glenoid impingement syndrome." ''Clin Med Insights Arthritis Musculoskelet Disord'', '''2012''', 5, 15-18.</ref><ref>P. Habermeyer, P. Magosch, M. Pritsch, M.T. Scheibel, S. Lichtenberg "Anterosuperior impingement of the shoulder as a result of pulley lesions: A prospectice arthroscopic study." ''J Shoulder Elbow Surg'', '''2004''', 13, 5-12.</ref> and has been frequently observed in patients with activities implying this repetitive movement, typically such as tennis players.<ref name=":18" /><sup>-</sup><ref name=":24" /><ref name=":25" />
+Anterosuperior impingement was first described by Gerber and Sebesta who reported that repetitive friction led to partial articular subscapularis tendon and biceps pulley tears.<ref name=":24" /> It is caused by entrapment of the subscapularis tendon between the anterior humeral head and anterior glenoid labrum with the arm in forward flexion, adduction, and internal rotation. It mirrors Walch’s posterosuperior impingement that involves the posterosuperior rotator cuff.<ref name=":17" /> It should not be mistaken with anterolateral impingement which is a synonym for the far more frequent subacromial impingement. Pain in anterosuperior impingement seems to be specifically located to the anterior aspect of the shoulder,<ref name=":24">C. Gerber, A. Sebesta "Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A preliminary report." ''J Shoulder Elbow Surg'', '''2000''', 9, 483-490.</ref><ref name=":25">S.S. Bath, S.S. Bath, J. Tehranzadeh "Anterosuperior glenoid impingement syndrome." ''Clin Med Insights Arthritis Musculoskelet Disord'', '''2012''', 5, 15-18.</ref><ref>P. Habermeyer, P. Magosch, M. Pritsch, M.T. Scheibel, S. Lichtenberg "Anterosuperior impingement of the shoulder as a result of pulley lesions: A prospectice arthroscopic study." ''J Shoulder Elbow Surg'', '''2004''', 13, 5-12.</ref> and has been frequently observed in patients with activities implying this repetitive movement, typically such as tennis players.<ref name=":18" /><ref name=":19" /><ref name=":20" /><ref name=":21" /><ref name=":68" /><ref name=":69" /><ref name=":70" /><ref name=":71" /><ref name=":72" /><ref name=":22" /><ref name=":23" /><ref name=":73" /><ref name=":74" /><ref name=":75" /><ref name=":24" /><ref name=":25" />
 ===Frayed Upper Edge Subscapularis Lesion with Impingement (FUSSI) and Subscapularis Abrasion from the Middle glenohumeral ligament (SAM) Lesions===

@@ Line 83: / Line 83: @@
 Table 1: Intrinsic factors responsible for shoulder impingement syndrome.
-=== Anamnesis ===
+===Anamnesis===
 Clinicians evaluating patients with acute or chronic shoulder pain should obtain a comprehensive history. Individuals will often present with atraumatic, insidious onset of pain upon lifting the arm or with lying on the affected side. Pain is commonly described as being located over the anterolateral aspect of the shoulder. As symptoms arise from bone and ligaments applying compressive forces to either the rotator cuff, the subacromial bursa, or both structures ("outlet-based" impingement), special attention should be made by the clinician to inquire about symptoms exacerbated by repetitive or overhead activities. Relief may be noted with rest, anti-inflammatory medications, but symptoms often recur upon return to activity.
@@ Line 185: / Line 185: @@
 ====Imaging====
-===== X-ray =====
+=====X-ray=====
 Simple radiographic examination is comprised of three views (anteroposterior, Lamy and Bernageau views) to assess for glenoid thrower’s exostosis (Figure 21)<ref name=":19">M.T. Freehill, S. Mannava, L.D. Higgins, A. Lädermann, A.V. Stone "Thrower's exostosis of the shoulder: A systematic review with a novel classification." ''Orthop J Sports Med'', '''2020''', 8, 2325967120932101.</ref> and bone cyst (Figure 22).
 [[File:Figure 21 jpeg.jpg|thumb|Figure 21. The type 1 is the classic Bennett lesion.<ref name=":20">G.E. Bennett "Elbow and shoulder lesions of baseball players." ''Am J Surg'', '''1959''', 98, 484-492.</ref> Type 2 corresponds to posterior exostosis. The type 3 is an exostosis occurring in the region of the posterosuperior glenoid rim. Reproduced from Freehill and al., with permission.<ref name=":19" />]]
@@ Line 202: / Line 201: @@
 [[File:Figure 24 jpeg.jpg|thumb|Figure 24. Posterior impingement can be suspected when a partial thickness lesion of the articular surface of the infraspinatus tendon (arrow) is associated with cortical erosions of the humeral head (arrow head). Adapted from Pesquer et al., with permission.<ref name=":21" />]]
-===== Computed tomography (CT) arthrography =====
+=====Computed tomography (CT) arthrography=====
 Computed tomography using intra-articular injection of a contrast is reliable to visualize labral lesions, articular rotator cuff lesions and glenoid bone formation (Figure 25).
 [[File:Figure 25 jpeg.jpg|thumb|Figure 25. Computer tomography (CT) arthrogram showing labral tears (blue arrow) and bone spur (red arrow).]]
-===== Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA) =====
+=====Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA)=====
 Magnetic resonance imaging (MRI), enhanced or not with gadolinium contrast to
 increase the diagnostic value, is the most utilized imaging modality to confirm posterosuperior impingement. This modality will confirm articular-sided rotator cuff tears found in up to 40% of professional baseball pitchers<ref name=":68" /> and in up to 60% of professional tennis players,<ref name=":18" /><ref name=":19" /><ref name=":20" /><ref name=":21" /><ref name=":68">P.M. Connor, D.M. Banks, A.B. Tyson, J.S. Coumas, D.F. D'Alessandro "Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5-year follow-up study." ''Am J Sports Med'', '''2003''', 31, 724-727.</ref><ref>J.L. Brasseur, O. Lucidarme, M. Tardieu, M. Tordeur, B. Montalvan, J. Parier, P. Le Goux, A. Gires, P. Grenier "Ultrasonographic rotator-cuff changes in veteran tennis players: The effect of hand dominance and comparison with clinical findings." ''Eur Radiol'', '''2004''', 14, 857-864.</ref> cystic changes in the  posterior aspect of the humeral head (Figure 26), posterosuperior labral pathology (Figure 27), possible presence of a spinoglenoid cyst (Figure 28) and mature periosteal glenoid formation. Jung et al. report a sensitivity of 85% and a specificity of 86% for superior labral tears.<ref>J.Y. Jung, Y.C. Yoon, S.H. Choi, J.W. Kwon, J. Yoo, B.K. Choe "Three-dimensional isotropic shoulder MR arthrography: Comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 t." ''Radiology'', '''2009''', 250, 498-505.</ref> Sequences with the shoulder in both the abducted and abducted and externally rotated position (ABER) appear to improve the diagnostic accuracy of soft tissue anterior and posterior labral tears, SLAP tears, and bony glenoid lesions.<ref>J.Y. Choi, S.H. Kim, H.J. Yoo, S.H. Shin, J.H. Oh, G.H. Baek, S.H. Hong "Superior labral anterior-to-posterior lesions: Comparison of external rotation and active supination CT arthrography with neutral CT arthrography." ''Radiology'', '''2012''', 263, 199-205.</ref><ref>C.S. Modi, S. Karthikeyan, A. Marks, A. Saithna, C.D. Smith, S.B. Rai, S.J. Drew "Accuracy of abduction-external rotation MRA versus standard MRA in the diagnosis of intra-articular shoulder pathology." ''Orthopedics'', '''2013''', 36, e337-342.</ref>
-Figure 26: Coronal magnetic resonance arthrography (MRA) view showing a bony contusion on the greater tubercle caused by repeated impingement, as well as cysts and a partial-thickness articular rotator cuff lesion.
+[[File:Figure 27 jpeg.jpg|thumb|Figure 27. Axial T1 fat saturation magnetic resonance arthrography (MRA) sequence revealing humeral head cysts and a posterosuperior labral lesion.]]
+[[File:Figure 28 jpeg.jpg|thumb|Figure 28. Magnetic resonance arthrography (MRA) coronal sequence showing a large spinoglenoid cyst.]]
 ====Isokinetic assessment====
 Isokinetic studies (Figure 29) now permit objective quantification of internal and external rotational forces, and especially the definition of ratios for comparative purposes.<ref name=":22">P. Codine, P.L. Bernard, M. Pocholle, C. Herisson "[Isokinetic strength measurement and training of the shoulder: Methodology and results]." ''Ann Readapth Med Phys'', '''2005''', 48, 80-92.</ref><ref name=":23">G. Gozlan, L. Bensoussan, J.M. Coudreuse, J. Fondarai, V. Gremeaux, J.M. Viton, A. Delarque [Isokinetic dynamometer measurement of shoulder rotational strength in healthy elite athletes (swimming, volley-ball, tennis): Comparison between dominant and nondominant shoulder]." ''Ann Readapt Med Phys'', '''2006''', 49, 8-15.</ref> Such assessment, while not perfectly simulating throwing conditions, does ensure a reliable, reproducible method for analyzing ratios and their imbalance, with linear tracking over time (to track progress, etc.).<ref name=":22" /><ref name=":23" /> It is of major interest because it must be standardized, just as the articular amplitudes must be perfectly symmetrical before considering surgery or return to sports (with or without surgery).
+[[File:Figure 29 jpeg.jpg|thumb|Figure 29. Isokinetic shoulder assessment.]]
 ====Treatment====
-===== Conservative (Nonoperative) Treatment =====
+=====Conservative (Nonoperative) Treatment=====
 Conservative treatment should always be the first line of treatment for patients with posterosuperior impingement. Patients, athletes or not, will improve with cessation of activities and focused therapy modalities. Patients with new-onset impingement symptoms should be initially treated with activity modification, initiation of short-term routine NSAID use, and enrollment into a formal throwing therapy program. Rehabilitation should contain three key components: application of kinetic chain exercises, shoulder mobility, and shoulder strengthening.<ref>W.B. Kibler, J.E. Kuhn, K. Wilk, A. Sciascia, S. Moore, K. Laudner, T. Ellenbecker, C. Thigpen, T. Uhl "The disabled throwing shoulder: Spectrum of pathology-10-year update." ''Arthroscopy'', '''2013''', 29, 141-61 e26.</ref> All ranges of movement must be recovered, especially internal rotation at 90 degrees of abduction, by teaching the patient self-stretching exercises such as ‘sleeper-stretching’ (Figure 30).
 Another tenet of nonoperative treatment is specific strengthening through restoration of scapular motor control, initiation of a scapular feedback program, and promotion of eccentric control through an increased number of repetitions throwing cycles. Strengthening of the external rotators should be concentric and eccentric using elastics or weights, as described in some protocols depending on the results of the isokinetic analysis (Figure 31). Proprioception can be worked on with ball exercises (Figure 32). If the patient fails in a 6-month range and cannot return to activities, then the patient may be considered for surgical intervention.
 Figure 31: Strengthening of external rotators.
@@ Line 241: / Line 236: @@
 Figure 32: Proprioception exercises using a ball.
-===== Operative (Surgical) Treatment =====
+=====Operative (Surgical) Treatment=====
 Depending on patient’s expectations and underlying conditions, surgical options include arthroscopic debridement, arthrolysis, posterosuperior glenoidplasty as described by Lévigne et al.<ref>C. Lévigne, J. Garret, F. Borel, G. Walch "Glénoplastie postérieure sous arthroscopie pour conflit glénoidien postérosupérieur." ''Rev Chir Orthop Reparatrice Appar Mot'', '''2007''', 93, 37.</ref><ref>C. Lévigne, J. Garret, S. Grosclaude, F. Borel, G. Walch "Surgical technique arthroscopic posterior glenoidplasty for posterosuperior glenoid impingement in throwing athletes." ''Clin Orthop Relat Res'', '''2012''', 470, 1571-8.</ref> (Figures 33) and derotational osteotomy (Figure 34). The later technique has largely been abandoned.

@@ Line 83: / Line 83: @@
 Table 1: Intrinsic factors responsible for shoulder impingement syndrome.
 Clinicians evaluating patients with acute or chronic shoulder pain should obtain a comprehensive history. Individuals will often present with atraumatic, insidious onset of pain upon lifting the arm or with lying on the affected side. Pain is commonly described as being located over the anterolateral aspect of the shoulder. As symptoms arise from bone and ligaments applying compressive forces to either the rotator cuff, the subacromial bursa, or both structures ("outlet-based" impingement), special attention should be made by the clinician to inquire about symptoms exacerbated by repetitive or overhead activities. Relief may be noted with rest, anti-inflammatory medications, but symptoms often recur upon return to activity.
@@ Line 183: / Line 184: @@
 ====Imaging====
 Simple radiographic examination is comprised of three views (anteroposterior, Lamy and Bernageau views) to assess for glenoid thrower’s exostosis (Figure 21)<ref name=":19">M.T. Freehill, S. Mannava, L.D. Higgins, A. Lädermann, A.V. Stone "Thrower's exostosis of the shoulder: A systematic review with a novel classification." ''Orthop J Sports Med'', '''2020''', 8, 2325967120932101.</ref> and bone cyst (Figure 22).
-Figure 22: Images showing bone cysts (short white arrows) or condensation (long white arrows) or on the greater tubercle and glenoid rim, indicating a previous posterosuperior impingement. From Pesquer et al., with permission.<ref name=":21">L. Pesquer, N. Poussange, M.-H. Moreau-Durieux, P. Meyer, B. Dallaudiere, P.H. Flurin, A. Lädermann, P. Abadie "Le conflit postéro-supérieur de l'épaule." ''Journal de Radiologie Diagnostique et Interventionelle'', '''2017''', 98, 296-302.</ref>
+[[File:Figure 22 jpeg.jpg|thumb|Figure 22. Images showing bone cysts (short white arrows) or condensation (long white arrows) or on the greater tubercle and glenoid rim, indicating a previous posterosuperior impingement. From Pesquer et al.,<ref name=":21">L. Pesquer, N. Poussange, M.-H. Moreau-Durieux, P. Meyer, B. Dallaudiere, P.H. Flurin, A. Lädermann, P. Abadie "Le conflit postéro-supérieur de l'épaule." ''Journal de Radiologie Diagnostique et Interventionelle'', '''2017''', 98, 296-302.</ref> with permission.]]
-====Ultrasound====
+=====Ultrasound=====
 Posterior internal impingement occurs often in overhead athletes and involves pinching of the supra- and infraspinatus tendons with the posterosuperior portion of the glenoid labrum when the shoulder is in abduction/external rotation/hyperextension (Figure 23 and 24). Dynamic imaging of this pathological impaction is carried out with the patient’s arm adducted and making external and internal rotation movements.
-Figure 23: Glenohumeral joint line, posterior labrum and spinoglenoid notch (containing the suprascapular neurovascular bundle). Ultrasonography image (a) with superimposed anatomy (b) and patient/probe position (c). From Plomb-Holmes et al., with permission.<ref name=":13" />
+<br />
+[[File:Figure 24 jpeg.jpg|thumb|Figure 24. Posterior impingement can be suspected when a partial thickness lesion of the articular surface of the infraspinatus tendon (arrow) is associated with cortical erosions of the humeral head (arrow head). Adapted from Pesquer et al., with permission.<ref name=":21" />]]
-Figure 24: Posterior impingement can be suspected when a partial thickness lesion of the articular surface of the infraspinatus tendon (arrow) is associated with cortical erosions of the humeral head (arrow head). Adapted from Pesquer et al., with permission.<ref name=":21" />
+===== Computed tomography (CT) arthrography =====
 Computed tomography using intra-articular injection of a contrast is reliable to visualize labral lesions, articular rotator cuff lesions and glenoid bone formation (Figure 25).
-Figure 25: Computer tomography (CT) arthrogram showing labral tears (blue arrow) and bone spur (red arrow).
+===== Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA) =====
 Magnetic resonance imaging (MRI), enhanced or not with gadolinium contrast to
-increase the diagnostic value, is the most utilized imaging modality to confirm posterosuperior impingement. This modality will confirm articular-sided rotator cuff tears found in up to 40% of professional baseball pitchers[74] and in up to 60% of professional tennis players,<ref name=":18" /><ref name=":19" /><ref name=":20" /><ref name=":21" /><ref>P.M. Connor, D.M. Banks, A.B. Tyson, J.S. Coumas, D.F. D'Alessandro "Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5-year follow-up study." ''Am J Sports Med'', '''2003''', 31, 724-727.</ref><ref>J.L. Brasseur, O. Lucidarme, M. Tardieu, M. Tordeur, B. Montalvan, J. Parier, P. Le Goux, A. Gires, P. Grenier "Ultrasonographic rotator-cuff changes in veteran tennis players: The effect of hand dominance and comparison with clinical findings." ''Eur Radiol'', '''2004''', 14, 857-864.</ref> cystic changes in the  posterior aspect of the humeral head (Figure 26), posterosuperior labral pathology (Figure 27), possible presence of a spinoglenoid cyst (Figure 28) and mature periosteal glenoid formation. Jung et al. report a sensitivity of 85% and a specificity of 86% for superior labral tears.<ref>J.Y. Jung, Y.C. Yoon, S.H. Choi, J.W. Kwon, J. Yoo, B.K. Choe "Three-dimensional isotropic shoulder MR arthrography: Comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 t." ''Radiology'', '''2009''', 250, 498-505.</ref> Sequences with the shoulder in both the abducted and abducted and externally rotated position (ABER) appear to improve the diagnostic accuracy of soft tissue anterior and posterior labral tears, SLAP tears, and bony glenoid lesions.<ref>J.Y. Choi, S.H. Kim, H.J. Yoo, S.H. Shin, J.H. Oh, G.H. Baek, S.H. Hong "Superior labral anterior-to-posterior lesions: Comparison of external rotation and active supination CT arthrography with neutral CT arthrography." ''Radiology'', '''2012''', 263, 199-205.</ref><ref>C.S. Modi, S. Karthikeyan, A. Marks, A. Saithna, C.D. Smith, S.B. Rai, S.J. Drew "Accuracy of abduction-external rotation MRA versus standard MRA in the diagnosis of intra-articular shoulder pathology." ''Orthopedics'', '''2013''', 36, e337-342.</ref>
+increase the diagnostic value, is the most utilized imaging modality to confirm posterosuperior impingement. This modality will confirm articular-sided rotator cuff tears found in up to 40% of professional baseball pitchers<ref name=":68" /> and in up to 60% of professional tennis players,<ref name=":18" /><ref name=":19" /><ref name=":20" /><ref name=":21" /><ref name=":68">P.M. Connor, D.M. Banks, A.B. Tyson, J.S. Coumas, D.F. D'Alessandro "Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5-year follow-up study." ''Am J Sports Med'', '''2003''', 31, 724-727.</ref><ref>J.L. Brasseur, O. Lucidarme, M. Tardieu, M. Tordeur, B. Montalvan, J. Parier, P. Le Goux, A. Gires, P. Grenier "Ultrasonographic rotator-cuff changes in veteran tennis players: The effect of hand dominance and comparison with clinical findings." ''Eur Radiol'', '''2004''', 14, 857-864.</ref> cystic changes in the  posterior aspect of the humeral head (Figure 26), posterosuperior labral pathology (Figure 27), possible presence of a spinoglenoid cyst (Figure 28) and mature periosteal glenoid formation. Jung et al. report a sensitivity of 85% and a specificity of 86% for superior labral tears.<ref>J.Y. Jung, Y.C. Yoon, S.H. Choi, J.W. Kwon, J. Yoo, B.K. Choe "Three-dimensional isotropic shoulder MR arthrography: Comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 t." ''Radiology'', '''2009''', 250, 498-505.</ref> Sequences with the shoulder in both the abducted and abducted and externally rotated position (ABER) appear to improve the diagnostic accuracy of soft tissue anterior and posterior labral tears, SLAP tears, and bony glenoid lesions.<ref>J.Y. Choi, S.H. Kim, H.J. Yoo, S.H. Shin, J.H. Oh, G.H. Baek, S.H. Hong "Superior labral anterior-to-posterior lesions: Comparison of external rotation and active supination CT arthrography with neutral CT arthrography." ''Radiology'', '''2012''', 263, 199-205.</ref><ref>C.S. Modi, S. Karthikeyan, A. Marks, A. Saithna, C.D. Smith, S.B. Rai, S.J. Drew "Accuracy of abduction-external rotation MRA versus standard MRA in the diagnosis of intra-articular shoulder pathology." ''Orthopedics'', '''2013''', 36, e337-342.</ref>
@@ Line 229: / Line 227: @@
 ====Treatment====
 Conservative (Nonoperative) Treatment
 Conservative treatment should always be the first line of treatment for patients with posterosuperior impingement. Patients, athletes or not, will improve with cessation of activities and focused therapy modalities. Patients with new-onset impingement symptoms should be initially treated with activity modification, initiation of short-term routine NSAID use, and enrollment into a formal throwing therapy program. Rehabilitation should contain three key components: application of kinetic chain exercises, shoulder mobility, and shoulder strengthening.<ref>W.B. Kibler, J.E. Kuhn, K. Wilk, A. Sciascia, S. Moore, K. Laudner, T. Ellenbecker, C. Thigpen, T. Uhl "The disabled throwing shoulder: Spectrum of pathology-10-year update." ''Arthroscopy'', '''2013''', 29, 141-61 e26.</ref> All ranges of movement must be recovered, especially internal rotation at 90 degrees of abduction, by teaching the patient self-stretching exercises such as ‘sleeper-stretching’ (Figure 30).
@@ Line 242: / Line 241: @@
 Figure 32: Proprioception exercises using a ball.
-Operative (Surgical) Treatment
+===== Operative (Surgical) Treatment =====
 Depending on patient’s expectations and underlying conditions, surgical options include arthroscopic debridement, arthrolysis, posterosuperior glenoidplasty as described by Lévigne et al.<ref>C. Lévigne, J. Garret, F. Borel, G. Walch "Glénoplastie postérieure sous arthroscopie pour conflit glénoidien postérosupérieur." ''Rev Chir Orthop Reparatrice Appar Mot'', '''2007''', 93, 37.</ref><ref>C. Lévigne, J. Garret, S. Grosclaude, F. Borel, G. Walch "Surgical technique arthroscopic posterior glenoidplasty for posterosuperior glenoid impingement in throwing athletes." ''Clin Orthop Relat Res'', '''2012''', 470, 1571-8.</ref> (Figures 33) and derotational osteotomy (Figure 34). The later technique has largely been abandoned.

@@ Line 158: / Line 158: @@
 Posterosuperior impingement occurs when the supraspinatus and infraspinatus become entrapped between the greater tuberosity and posterosuperior aspect of the glenoid labrum. The precise causes for this impingement remained unclear, but certain surgeons made theories, stating that repetitive contact,<ref name=":16">C.M. Jobe "Posterior superior glenoid impingement:Expanded spectrum." ''Arthroscopy'', '''1995''', 11, 530-536.</ref><ref name=":17">G. Walch, P. Boileau, E. Noel, S.T. Donell "Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study." ''J Shoulder Elbow Surg'', '''1992''', 1, 238-245.</ref> glenohumeral instability,<ref name=":16" /> scapular orientation,<ref>S.S. Burkhart, C.D. Morgan, W.B. Kibler "The disabled throwing shoulder: Spectrum of pathology part iii: The sick scapula, scapular dyskinesis, the kinetic chain, and rehabilitation." ''Arthroscopy'', '''2003''', 19, 641-691.</ref><ref>J.B. Myers, K.H. Laudner, M.R. Pasquale, J.P. Bradley, S.M. Lephart "Scapular position and orientation in throwing athletes." ''Am J Sports Med'', '''2005''', 33, 263-271.</ref><ref>J.B. Myers, S. Oyama, E.E. Hibberd "Scapular dysfunction in high school baseball players sustaining throwing-related upper extremity injury: A prospective study." ''J Shoulder Elbow Surg'', '''2013''', 22, 1154-1159.</ref><ref>M.K. Timmons, A.D. Lopes-Albers, L. Borgsmiller, C. Zirker, J. Ericksen, L.S. Michener "Differences in scapular orientatiom, subacromial space and shoulder pain between the full can and empty can tests." ''Clin Biomech (Bristol, Avon)'', '''2013''', 28, 395-401.</ref> rotator cuff dysfunctions,<ref>A.M. Cools, G. Declercg, B. Cagnie, D. Cambier, E. Witvrouw "Internal impingement in the tennis player: rehabilitation guidelines." ''Br J Sports Med'', '''2008''', 42, 165-171.</ref> posteroinferior capsular contracture with resultant glenohumeral internal rotation deficit (GIRD)<ref>S.S. Burkhart, C.D. Morgan, W.B. Kibler "The disabled throwing shoulder: Spectrum of pathology part i: Pathoanatomy and biomechanics." ''Arthroscopy'', '''2003''', 19, 404-420.</ref> may play a role in the development of symptomatic impingement.
-==== Walch’s theory ====
+====Walch’s theory====
 Walch et al. developed the theory of isolated posterosuperior impingement by publishing a series of 17 arthroscopies performed in athletes who demonstrated pain in the cocking phase but lacked concomitant instability.<ref name=":17" /> He explain this symptomatology by mechanical impingement repeated at 90 degrees of abduction, maximum external rotation and retropulsion (maximum extension), between the greater tubercle and the posterosuperior glenoid rim, causing partial tears in the posterosuperior rotator cuff and the facing glenoid labrum (Figure 17). The appeal of this theory is that it is validated by simple observation when reproducing cocking and retropulsion movements under arthroscopic control, revealing the tears by repeated contact.
-Figure 17: Walch’s theory of repeated mechanical impingement at 90 degrees of abduction, maximum external rotation and retropulsion (maximum extension), between the greater tubercle and the posterosuperior glenoid rim, causing partial-thickness tears in the posterosuperior rotator cuff and the facing glenoid labrum (which is ‘pinched’).
+====Frank Jobe’s Theory====
 For Frank Jobe, lesions observed in throwing athletes are related to subtle anterior instability (Figure 18).<ref>F.W. Jobe, C.E. Giangarra, SR.S. Kvitne, R.E. Glousman "Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports." ''Am J Sports Med'', '''1991''', 19, 428-434.</ref>
-Figure 18: Frank Jobe’s Theory. Lesions in throwing athletes are related to subtle anterior instability.
+====Christopher Jobe’s Theory====
 Christopher Jobe, Frank’ son, postulated that posterosuperior impingement was mainly due to hyperextension of the humerus relative to the scapula (Figure 19). In 1995, Davidson et al. took up this theory and showed how hyper-rotation (hyperabduction) and anterior humeral translation act as the trigger mechanism for pain, and explain how the shoulder relocation test reduces pain by releasing the internal impingement.<ref>P.A. Davidson, N.S. Elattrache, C.M. Jobe, F.W. Jobe "Rotator cuff and posterior-superior glenoid labrum injury associated with increased glenohumeral motion: A new site of impingement." ''J Shoulder Elbow Surg'', '''1995''', 4, 384-390.</ref>
-Figure 19: Christopher Jobe’s theory. The impingement is mainly due to hyperabduction of the humerus relative to the scapula.
+====Burkhart’s Theory====
 Burkhart et al. proposed a posteroinferior capsular contracture occurs in throwers, associated or not to a stretching of the anterior structures. This essential lesion secondarily results in increased external rotation. When the posterior capsule shortens, the glenohumeral contact point shifts posterosuperiorly (static posterosuperior glenohumeral instability), allowing hyperexternal rotation and repetitive hypertwisting of the rotator cuff fibers and of the long head of the biceps. Furthermore, a torsional force known as the peelback phenomenon is applied to the biceps anchor during the late cocking phase of throwing, leading to the development of lesion of the deep surface of the posterosuperior rotator cuff and to superior labral anterior posterior (SLAP) lesion.
@@ Line 182: / Line 180: @@
 ====Clinical Examination====
 The shoulder can exhibit increased external rotation and decreased internal rotation compared to the contralateral side. In abduction and maximal external rotation, the patient can experience the feeling of a dead arm. The Jobe test (empty can test), performed by placing the patient's arms at 90 degrees of abduction within the scapular plane, maximally internally rotating the arms and resisting further abduction by the patient is usually negative but results in pain. Similarly, an anterior apprehension maneuver is negative for instability but reproduces pain and the disagreeable feeling known by the patient. Finally, the relocation test (Figure 20) has the tendency to relieves the patient's symptoms.
+[[File:Figure 20 jpeg.jpg|thumb|Figure 20. Shoulder relocation test. Pain is experienced during cocking (A) and recedes when anteroposterior pressure applied by the examiner releases the internal impingement (B).]]
 ====Imaging====

@@ Line 110: / Line 110: @@
 ====Magnetic Resonance Imaging (MRI) / Magnetic Resonance Arthrography (MRA)====
 Consideration for advanced imaging with magnetic resonance imaging with or without arthrography is always recommended before planning for a surgery. It will allow for a detailed evaluation of bony and soft tissue structures and will confirm the isolated character of the impingement (Figures 12 and 13). Relevant bursitis can be defined as 3 mm or more of fluid above the rotator cuff (Figure 14).<ref>E.A. White, M.E. Schweitzer, A.H. Haims "Range of normal and abnormal subacromial/subdeltoid bursa fluid." ''J Comput Assist Tomogr'', '''2006''', 30, 316-320.</ref>
-Figure 12: Magnetic resonance arthrography (MRA) of a left subacromial impingement. Note the important compression done by the acromion and the coracoacromial ligament on the supraspinatus tendon.
+=== Treatment of Subacromial and Subclavicular Impingements ===
 ====Arthroscopic Acromioplasty====
 A clear distinction has to be made between isolated acromioplasty performed for subacromial impingement syndrome (pain, impingement, rotator cuff tendinopathy, snapping) and acromioplasty realized as an adjuvant procedure to rotator cuff repair, acromioclavicular joint osteoarthritis, or biceps pathology. An indication for isolated acromioplasty is rare, representing around 0.5 to 1% of shoulder surgeries in our experience. For such surgical indication, an acromioplasty with detachment of the coracoacromial ligament is indicated. Acromioplasty associated with rotator cuff repair serves a completely different purpose, dealing with working space necessary for arthroscopic repair or access to acromioclavicular joint, decreasing load on repaired tendons,<ref name=":5">C. Gerber, S. Catanzaro, M. Betz, L. Ernstbrunner "Arthroscopic correction of the critical shoulder angle through lateral acromioplasty: A safe adjunct to rotator cuff repair." ''Arthroscopy'', '''2018''', 34, 771-780.</ref> and perhaps aiding the healing process by providing growth factors from bleeding bone, etc. In the rotator cuff repair scenario, a more lateral acromioplasty with preservation of the acromioclavicular ligament is emphasized.<ref name=":5" /><ref>???</ref><ref>A. Lädermann, S. Chagué, D. Preissmann, F.C. Kolo, O. Zbinden, B. Kevelham, H. Bothorel, C. Charbonnier "Acromioplasty during repair of rotator cuff tears removes only half of the impinging acromial bone." ''JSES Int'', '''2020''', 4, 592-600.</ref><ref>A. Lädermann, S. Chagué, D. Preissmann, F.C. Kolo, O. Rime, B. Kevelham, H. Bothorel, C. Charbonnier "Guided versus freehand acromioplasty during rotator cuff repair. A randomized prospective study." ''Orthop Traumatol Surg Res'', '''2020''', 106, 651-659.</ref>

@@ Line 71: / Line 71: @@
 Swimmers
+|
-* Age, sex, genetics
+*Age, sex, genetics
-* Exogenous substances / factors (alcohol, tobacco)
+*Exogenous substances / factors (alcohol, tobacco)
-* Medication (fluoroquinolone antibiotics)
+*Medication (fluoroquinolone antibiotics)
-* Metabolic syndrome (dyslipidemia, hypertension, hyperglycemia, abdominal obesity)
+*Metabolic syndrome (dyslipidemia, hypertension, hyperglycemia, abdominal obesity)
-* Systemic diseases (thyroid disorders, diabetes, inflammatory arthritides)
+*Systemic diseases (thyroid disorders, diabetes, inflammatory arthritides)
-* Intratendinous space occupying lesions (i.e. calcifying tendinopathy)
+*Intratendinous space occupying lesions (i.e. calcifying tendinopathy)
-* Scapular morphology (critical shoulder angle)
+*Scapular morphology (critical shoulder angle)
 |Critical zone
 |}
@@ Line 98: / Line 98: @@
 ====X-ray====
 Standard plain radiographs should be obtained. An anteroposterior view in neutral rotation is used to analyze the acromiohumeral distance (normal range is 7-14 mm, a lower distance suggests rotator cuff pathology) and the critical shoulder angle, and to rule out other pathologies such as calcific tendinitis, arthritic changes or abnormal bone morphology such as malunion (Figures 9-10).<ref>A. Lädermann, P.J. Denard, S.S. Burkhart "Arthroscopic management of proximal humerus malunion with tuberoplasty and rotator cuff retensioning," ''Arthroscopy'', '''2012''', 28, 1220-1229.</ref> The scapular Y view allows for the assessment of the humeral head on the glenoid and the shape of the acromion. The axial view is necessary to rule out an os acromiale (Figure 11).
-Figure 9: Anteroposterior X-ray of a left shoulder after (A) a malunion of the proximal humerus creating subacromial impingement and (B) an uniplanar valgisation osteotomy by plate of the proximal humerus.
+[[File:Figure 11 jpeg.jpg|thumb|Figure 11. Axial view of a right shoulder demonstrating an os acromiale (preacromion).]]
 ====Ultrasound====

@@ Line 57: / Line 57: @@
 The table 1 summarize the different intrinsic factors responsible for shoulder impingement syndrome.
 Table 1: Intrinsic factors responsible for shoulder impingement syndrome.
 Clinicians evaluating patients with acute or chronic shoulder pain should obtain a comprehensive history. Individuals will often present with atraumatic, insidious onset of pain upon lifting the arm or with lying on the affected side. Pain is commonly described as being located over the anterolateral aspect of the shoulder. As symptoms arise from bone and ligaments applying compressive forces to either the rotator cuff, the subacromial bursa, or both structures ("outlet-based" impingement), special attention should be made by the clinician to inquire about symptoms exacerbated by repetitive or overhead activities. Relief may be noted with rest, anti-inflammatory medications, but symptoms often recur upon return to activity.
 ===Physical Examination===
-Physical examination should begin with inspection. Swelling may be observed in the case of subacromial bursitis (Figure 8). Passive and active range of motion are compared bilaterally and should normally be symmetrical and unlimited. A painful arc of motion, appreciated with abduction of the arm between 70 and 120 degrees and forced overhead movement, is frequently noted in the setting of subacromial impingement.
+Physical examination should begin with inspection. Swelling may be observed in the case of subacromial bursitis (Figure 8).
 The Jobe test (empty can test) is performed by placing the patient's arms at 90 degrees of abduction within the scapular plane, maximally internally rotating the arms and resisting further abduction by the patient. In the case of subacromial or subclavicular impingement, a negative test occurs (the patient is able to resist as the tendon is in continuity, there is no weakness) but results in localized pain to the anterolateral shoulder. Special tests (Hawkins test, Neer sign) have low specificity and are not exclusively relied upon by the authors.
-Figure 8: Superior view of both shoulders. Observe the swelling of right one in a 57 year old male who has right subacromial bursitis.
+[[File:Figure 8 jpeg.jpg|thumb|Figure 8. Superior view of both shoulders. Observe the swelling of right one in a 57 year old male who has right subacromial bursitis.]]
 ===Imaging===