Escolar Documentos
Profissional Documentos
Cultura Documentos
Gordon Edelson, MD, and Cecile Teitz, PhD, Tiberias and Tel Aviv, Israel
Neer
19
popularized the concept of external impingement of the rotator cuff against the overlying acromion
as the principal cause of rotator cuff tears. This concept
superseded the previous theory, associated with Codman,3 which held that rotator cuff tears originated from
wear and tear changes on the underside of the cuff
rim rents at the tuberosity insertions. This debate as to
etiology has occasioned much comment and research
over the years.1,16,21 It is of more than simple academic interest because the notion of the acromion as the
main culprit in producing tears underpins the operation
of acromioplasty, the most common surgical procedure
performed in the shoulder today.
Sophisticated recent histologic studies of the cuff 9,18
substantiate the contention that the vast majority of tears
originate from the undersurface rather than from the
acromial side. Similarly, the bulk of recent arthroscopic
observation tends to support this view.8 However, no
cogent mechanism has yet been proposed to rival or
replace the presence of hooks and exaggerated
curves on the overlying acromion and the fact that the
humeral head rises up to meet the corocoacromial arch
in the end stages of rotator cuff disease.
This work, based on the study of a large number of
skeletal specimens, seeks to demonstrate that an underFrom the Department of Orthopaedics, Poriya Government Hospital, Tiberias (Dr Edelman), and the Department of Anatomy and
Anthropology, Sackler School of Medicine, Tel Aviv (Dr Teitz).
Reprint requests: Gordon Edelson, MD, Kibbutz Deganya Bet,
M.P. Jordan Valley, 15130, Israel.
Copyright 2000 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2000/$12.00 + 0 32/1/105449
doi:10.1067/mse.2000.105449
308
OBSERVATIONS
Bony evidence of rotator cuff pathosis was noted in
34% of specimens (419 humeri). This evidence consisted of the following: on the humeral head side, craterlike
areas and bone resorption in the rotator cuff sulcus5,24;
areas of appositional new bone formation and osteophytes surrounding the head,4 irregularity, pitting, and
spur formation at the tendon attachment zones30 and
rounding off and eburnation of the tuberosities from
early to end stage degree.7 These changes on the
humeral head side were accompanied by characteristic
osteophytic changes on the glenoid side, subsequently
to be described.
Table I documents the areas of impingement between
the humeral head vis-a-vis the glenoid and/or the
acromion, which were seen when the 30 shoulders tested quantitatively were taken through the ranges of
motion selected for this study.
Some highlights of the results, which are summarized in Table I, are as follows:
With the scapula perpendicular to the floor and the
humerus in neutral rotation (test 1, Table I), abduction in
the scapular plane was only possible to approximately
90 degrees (Figure 1). Further motion was blocked by
forceful impingement between the supraspinatus facet
of the greater tuberositythe area where rotator cuff
tears usually first appearand the superior glenoid at
or just posterior to the biceps anchor site. External rotation allowed additional abduction (test 2, Table I), but
this too was eventually blocked by supraspinatus facet
impingement further posterior on the glenoid face (Figure 2). External rotation in abduction was thus obligated not to clear the greater tuberosity from impingement
under the acromion but rather to release it from
impaction against the superior aspect of the glenoid.
Impingement against the acromion took place only at
the extremes of external rotation and flexion, usually
outside a normal physiologic range of motion.13 Furthermore, no acromion, with or without a hook, made
actual contact with the rotator cuff insertional areas of
the head. Contact with the acromion, when it did occur,
took place farther down, at the surgical neck area of the
309
humeral shaft, well beyond the rotator cuff insertion (Figure 3; test 3, Table I).
Of crucial importance in substantiating the reality of
internal impingement was the fact that a number of the
head specimens showing evidence of rotator cuff disease (118 of 419) also demonstrated a telltale geographic pattern of osteophyte formation on their superior surfaces (Figure 4). This pattern fit like pieces of a
jigsaw puzzle to adjacent areas of impingement on the
glenoid side, as demonstrated during the range-ofmotion portion of the study. The pattern was not seen
distinctly in every case of rotator cuff disease. In the
early stages of disease, it had evidently not yet been
impressed into the bone; in the end stages of disease,
it was obscured by osteophyte proliferation and wearing away of the tuberosity (Figure 5). Only because of
the opportunity afforded here to examine a very large
number of specimens, demonstrating all stages of bony
rotator cuff pathosis, did this pattern become evident.
Of the specimens demonstrating bony signs of rotator cuff disease on the humeral side, it was observed
that the glenoid side showed a characteristic osteophytic pattern in 126 specimens. This pattern consisted
of a ring of osteophyte that was most evident in the posterior superior quadrant (Figure 6). This was the area
where internal impingement by the head against the
glenoid was most often demonstrated during the rangeof-motion tests. This posterior glenoid osteophyte was
usually not large, but in a number of cases (18 specimens) it was extremely prominent (Figure 7).
The most superior portion of the glenoidthat part
of the bone protected from direct impact with the head
by the overlying biceps insertionusually presented a
hiatus in the superior ring of glenoid osteophyte (Figure
8). In front of this biceps hiatus, along the anterior
superior quadrant, the ring of glenoid osteophyte was
less prominent but tended to regain substance distally,
reflecting most probably the internal impingement
demonstrated on the range-of-motion studies to take
place in this area. For example, in the arm at the side
position, internal rotation (necessary to reach a pocket
behind the back) resulted in impingement between the
chondral margin of the head just medial to the lesser
tuberosity and the middle glenoid rim (Figure 9). With
the addition of extension (necessary to reach higher up
the back) of the humerus to 45 degrees, the lesser
tuberosity itself was forced against the anterior inferior
glenoid rim (Figure 10; test 11, Table I).
Consistent signs of roughness and wear were noted
on or adjacent to the lesser tuberosity in most cases
(176 specimens) of moderate to severe rotator cuff disease (Figure 5). These changes sometimes spilled over
into the area of the bicipital groove (31 specimens),
with roughening and osteophyte formation along its
medial wall and, less commonly, along its lateral wall
(Figure 5 and Figure 8, B).
The Hawkins Impingement Test (test 10, Table I) usu-
310
Table I Internal and external impingement: summary of positions tested and demonstrated areas of contact
Test
no.
Position of
transepicondylar elbow axis
Anatomic position
60 external rotation
Anatomic position
Anatomic position
10
11
DISCUSSION
Although this type of work would benefit from
additional clinical correlation and could also be
strengthened by dissection, biomechanical, and
imaging studies, it nonetheless gives valuable information that cannot be observed by other means. The
unique patterns of osteophyte formation on both the
humeral head and the glenoid side, exactly paralleling the areas of impaction demonstrated between the
two during simulated range-of-imotion maneuvers,
No contact
No contact
No contact
No contact
No contact within physiologic range
of rotation
No contact
Contact at 75 internal rotation
with glenoid at 12:30 oclock in
25 of 30 cases
No contact
311
No contact
No contact
No contact
No contact
No contact
No contact
No contact within physiologic range of motion
No contact
No contact
No contact
4
5
6
7
8
9
10
11
No. of specimens
30
30
30
30
26
26
18
18
18
1
29
30
30
30
30
30
No contact
No contact
25
25
15
15
30
0
Point of impingement
Minimum
Maximum
Mean
SD
G
C
G
C
G
C
L
C
A
L
A
L
L
C
L
C
85
11:00
94
10:00
108
11:00
108
9:00
114
120
100
40
1:00
50
12:30
96
1:00
113
1:00
128
1:00
117
11:00
128
178
125
64
2:30
75
3:00
93
12:00
100
11:00
118
11:30
112
10:00
120
130
146
115
52
1:30
64
2:00
2.673
0.468
4.313
0.547
3.439
0.477
3.219
0.589
4.098
7.880
5.151
5.451
0.401
4.769
0.493
L
C
G
C
L
C
64
12:00
64
2:00
64
4:30
95
1:00
95
5:00
95
5:30
75
12:30
81
3:00
79
5:00
5.251
0.485
5.151
0.796
5.436
0.527
G, Greater tuberosityhumeral elevation or rotation at contact, expressed in degrees; L, lesser tuberosityhumeral elevation or rotation
at contact, expressed in degrees; A, acromionhumeral elevation at contact, expressed in degrees; C, point of contact on simulated
right glenoid clock face, expressed in hours.
312
abduction is blocked at 108 degrees by a combination of two factors that appear to occur simultaneously: (1) internal impingement
in jigsaw puzzletype fit between lesser tuberosity (l) and superior
posterior glenoid at 10:30 oclock position, where glenoid osteophyte (o) has formed; and (2) external impingement between anterior lateral acromion and surgical neck of humerus (arrowhead) in
area of bicipital groove.
Figure 4 Characteristic pattern of osteophyte formation on anterior superior aspect of humeral head suggestive of internal
impingement. Arrowheads indicate areas of impingement adjacent to greater and lesser tuberosities. These areas interdigitated
in jigsaw-puzzle fashion with superior posterior and/or superior
anterior rim of glenoid during range-of-motion testing. Area covered by biceps tendon as it emerges from its groove is relatively
free of osteophyte during this stage of disease process.
313
Figure 7 Right scapulae from 2 different individuals. Arrows indicate more dramatic examples of posterior superior osteophyte formation in specimens demonstrating more advanced rotator cuff disease.
Figure 5 Later stage in evolution of humeral head osteophyte. Initial jigsaw-puzzle pattern (seen in Figure 4) has been superseded
by a more proliferative ring of osteophyte, which has spilled
across bicipital groove and extended onto lesser tuberosity. Note
also wearing away and rounding off of greater tuberosity.
Figure 6 Left scapulae from 2 different individuals. Arrows indicate characteristic posterior superior glenoid osteophyte reflecting
internal impingement of humeral head against this area.
Figure 8 A, Arrow indicates characteristic hiatus in glenoid osteophyte in area presumably protected by biceps anchor from direct
forces of internal impingement. B, Glenoid hiatus is articulated with
adjacent hiatus on humeral head side created by bicipital
groove (b), seen here in 90 degrees of humeral abduction.
314
Figure 12 Neer Sign (test 3, Table I) demonstrates imminent contact about to take place between lesser tuberosity and glenoid
(arrowhead indicates intemal impingement) and between anterior
lateral acromion and proximal humeral shaft (arrow indicates
external impingement).
Figure 10 Further extension, as would be required to reach higher up the back, jams lesser tuberosity into anterior inferior glenoid
(arrowhead), here illustrated in individual with bony evidence of
advanced rotator cuff disease.
315