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Staging of Impingement Syndromes

- Stage I:
    - edema and hemorrhage:
    - reversible lesion usually seen in the second and third decade;
    - exam:
         - palpable tenderness over the greater tuberosity at supraspinitus insertion
         - palpalble tenderness along the anterior edge of the acromion;
         - painful arc of abduction between 60 and 120 deg increased with resistance at 90 deg;

- Stage II:
    - chronic inflammation or repeated episodes of impingement leads to fibrosis & thickening of supraspinatus, biceps, & subacromion bursa;
    - at this stage there is inability to reverse process by activity modification;
    - generally pts are between 25-40 years, however, age is less important than the duration of symptoms, which is usually years;
    - symptoms consist of an aching discomfort, often interfering w/ sleep & work, and may progress to interfere w/ activities of daily living
    - mild limitation to both passive and active range of motion;
    - arthroscopic acromioplasty & subacromial decompression do not require deltoid detachment & are assoc w/ cost savings & more rapid rehab;
    - arthroscopic acromioplasty is perhaps most suited for type II lesions (w/ partial tears), and is less useful for those with no tears or complete tears;

- Stage III:
    - rotator cuff tears, biceps ruptures, and bone changes;
    - following a prolonged history of refractory tendinitis, significant tendon degeneration is the hallmark of stage 3;
    - pts are usually in the 5th or 6th decade, and often admit to prolonged periods of pain, particularly at night;
         - weakness can be bothersome;
    - as further rotator cuff degeneration occurs:
         - limitation to shoulder motion;
         - infraspinatus atrophy;
         - weakness of shoulder abduction and external rotation;
         - biceps tendon involvement with rupture or degenerative changes occuring in a high percentage of pts with rotator cuff tears;
         - AC joint tenderness, esp if degenerative changes are present;
    - although pain related weakness can be present at any stage, injection of 1% lidocaine within the subacromial space in Stage 3 will not eliminate weakness and limitation of active motion;
    - radiographic changes:
         - cystic changes about the greater tuberosity
         - sclerotic changes beneath the anterior third of the acromion;
         - osteophytes along the undersurface of acromion often associated with the coracoacromial ligament;
         - AC joint changes;
         - late narrowing of the subacromial space

Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2).