Shoulder impingement revisited: evolution of diagnostic understanding in orthopedic surgery and physical therapy

Abstract

"Impingement syndrome" is a common diagnostic label for patients presenting with shoulder pain. Historically, it was believed to be due to compression of the rotator cuff tendons beneath the acromion. It has become evident that "impingement syndrome" is not likely an isolated condition that can be easily diagnosed with clinical tests or most successfully treated surgically. Rather, it is likely a complex of conditions involving a combination of intrinsic and extrinsic factors. A mechanical impingement phenomenon as an etiologic mechanism of rotator cuff disease may be distinct from the broad diagnostic label of "impingement syndrome". Acknowledging the concepts of mechanical impingement and movement-related impairments may better suit the diagnostic and interventional continuum as they support the existence of potentially modifiable impairments within the conservative treatment paradigm. Therefore, it is advocated that the clinical diagnosis of "impingement syndrome" be eliminated as it is no more informative than the diagnosis of "anterior shoulder pain". While both terms are ambiguous, the latter is less likely to presume an anatomical tissue pathology that may be difficult to isolate either with a clinical examination or with diagnostic imaging and may prevent potentially inappropriate surgical interventions. We further recommend investigation of mechanical impingement and movement patterns as potential mechanisms for the development of shoulder pain, but clearly distinguished from a clinical diagnostic label of "impingement syndrome". For shoulder researchers, we recommend investigations of homogenous patient groups with accurately defined specific pathologies, or with subgrouping or classification based on specific movement deviations. Diagnostic labels based on the movement system may allow more effective subgrouping of patients to guide treatment strategies.

Shoulder impingement syndrome: a systematic review of clinical trial participant selection criteria

“…Many studies highlight the difficulty in differentiating impingement from other shoulder pathologies, where shoulder pain can be indicative of other conditions such as joint instability, cervical radiculopathy, calcific tendinitis, adhesive capsulitis, degenerative joint disease, acromioclavicular osteoarthrosis and nerve compression. 2,[5][6][7] Consequently, the use of the term SIS as a diagnostic label has been the subject of debate, as it has been used for a spectrum of other shoulder and cervical conditions 5,6,[8][9][10][11] Diagnosis of SIS often relies upon a combination of physical examinations and further radiological investigations. However, the literature contains no suitable definition for the diagnosis of SIS using ultrasound and magnetic resonance imaging where such investigations play only a supporting role in the exclusion of other conditions.…”

Shoulder biomechanics and the success of translational research

“…As pointed out by Braman et al [6], epidemiological literature clearly identifies greater risks for shoulder pathologies in certain occupations and overhead athletes. The papers presented in this issue, dealing with impingement, rotator cuff tears, glenohumeral instability, shoulder prostheses, and muscle synergies, as well as enhanced measurement and estimation techniques by biomechanical models, directly impact issues within these two groups of subjects.…”

“…The contributions of Braman [6] and de Witte [12], for instance, suggest that the diagnostic label "impingement syndrome" is misleading and uninformative. Is it time for its discontinuation, and definition of alternatives, in the interest of patient care?…”

“…This increases the risk of misunderstandings and suboptimal patient care. Braman et al [6] follow along this line and, based on a thorough examination of the literature, provide historical and practice-rated explanations for the divergence between professionals in the use of the label "shoulder impingement syndrome". Through a review of recent findings, they advocate the discontinuation of the term and the specific analysis of "mechanical impingement" and movement-related impairments.…”

Clinical assessment of subacromial shoulder impingement – Which factors differ from the asymptomatic population?

“…Multiple types of subacromial shoulder impingement (SSI), (intrinsic, extrinsic and internal), each with different underlying pathomechanical causes, have been proposed (Braman, Zhao, Lawrence, Harrison, & Ludewig, 2013; Jeremy. S Lewis, Green, & Dekel, 2001;Michener, McClure, & Karduna, 2003).…”