Seventeen patients with a painful arc syndrome and tenderness over the coracoacromial ligament were selected to demonstrate the changes in the coracoacromial ligament in the impingement syndrome. Plain X-ray examination was normal and a preoperative subacromial bursogram demonstrated impingement in only three out of 17 patients. However, at operation the subacromial space under the coracoacromial ligament, which normally admits the tip of the little finger, appeared unusually tight and barely accessible in 15 out of 17 patients. Histological examination of the biopsied ligament showed degenerative changes but no increase in fibrous tissue. We conclude that in the absence of bony overgrowth the initial change is an increased volume of the soft tissues in the subacromial space. Consequently, the space is compromised by the swelling of its contents, which exert abnormal pressure on the overlying coracoacromial ligament and cause degenerative changes in the ligament. The symptoms of impingement appear because of the unyielding nature of the coracoacromial ligament. Subacromial bursography may not be a reliable test when the coracoacromial ligament is the site of impingement.

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Nonvisualization of the gallbladder by ultrasound in a fasting patient usually indicates calculous gallbladder disease. However, a number of other less common conditions can prevent gallbladder visualization or recognition. The latter occurs when the location or the morphology of the gallbladder is so altered that the gallbladder is difficult to identify. These conditions can be classified as: (1) congenital anomalies, (2) gallbladder contraction not due to stones, (3) conditions that cause shadowing or reverberation from the near wall of the gallbladder, and (4) the solid gallbladder pattern. Their distinction is important to proper patient management.

To determine the outcome predictors of single-dose intramuscular methotrexate therapy for tubal pregnancy. Materials and Methods: This retrospective study was approved by our institutional review board. Fifty-five consecutive women (mean