Thread by @hjluks

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#Shoulder pain in the adult ....
We still use the phrase "Impingement Syndrome" .. WHY?
Focus ...
The Acromion ... hooked or flat. Does it matter?
Short answer: Time to leave our little friend the acromion alone. 1/?

The Villain.
The acromion is most superior, anterior part of the scapula ... It serves as the attachment for the Deltoid, the ACJ ligaments, the the CA lig. 2/?

In the beginning ...
On certain X-rays it may appear to be flat, or hooked.
In the early 1970s, in a non-peer reviewed citation it was held that the acromion was the cause of rotator cuff pain and pathology. ncbi.nlm.nih.gov/pubmed/5054450
3/?

The Neer impingement test/theory was borne. The thought was simple... the acromion causes pinching of the rotator cuff under the CA arch (spur) in maximal forward elevation ... therefore remove that "spur" and the cuff will not tear, and pain will be relieved. 4/?

In medicine and especially in orthopedics it's very easy to think mechanically... so this theory was easy to grasp and it made sense.
A decompression (SAD) became the standard Tx for Impingement Syndrome .. and the acromion was burred and thinned across the globe. 5/?

It had always amazed me that the Orthopedic community had accepted that the Patella, quad, achilles and ECRB tendons were the likely cause of pain around the knee/ankle and elbow.. yet in the shoulder we held it was a "spur" that was the cause. #seriously ? 6/?

As the years went by studies showed that the distance between the greater tuberosity and the acromion actually becomes larger in maximal FE or ABD. The decompression was still being performed routinely... 7/?

Gerber and others tried to create an impingement model in the rat by thickening the anterior acromion... it led to bursal sided cuff fraying. 8/?

Yet we know that the vast majority of "age appropriate changes" in the rotator cuff originate on the articular side of the cuff in the anterior SST. The acromial theory of shoulder pain etiology was still never proven. 9/?

"But the CA lig is frayed in some people" Sure-- the humeral head rises up dynamically as the cuff is weakened. But taking the acromion out simply allowed that weakly supported head to rise higher. Long term results of SAD mostly show no sig benefit over PT 10/?

A decompression becomes the most widely performed procedure around the shoulder ... 11/?

In 2008 a Cochrane review shows that the lit does not support SAD over active non-op mgmt. ncbi.nlm.nih.gov/m/pubmed/18254… 12/?

Certainly an acromionplasty would improve the results of a rotator cuff repair?
Nope ... ncbi.nlm.nih.gov/m/pubmed/22261… 12/?

Certainly all PT-RCTs progress so we need to take the spur out to prevent that progression ... nope. Some PT-RCTs actually heal. Some don't. Only some progress.
ncbi.nlm.nih.gov/pubmed/28949249 13/?

Despite more than a decade of evidence showing little if any effect of a SAD on rotator cuff tear causation, repair integrity, etc we are still debating its effectiveness. 14/?

JBJS 2017 ... No advantage of SAD over active non-op mgmt in patients with cuff tendinopathy ... 10 yr follow-up. ncbi.nlm.nih.gov/m/pubmed/28566… 15/?

This Lancet article shows no benefit of SAD over bursectomy or PT in managing "Subacromial Pain" ncbi.nlm.nih.gov/m/pubmed/29169…
16/?

There is now a significant collection of data showing that a SAD or spur removal is of little benefit over that of a placebo. It is not protective either. To assist our patients... we put this on our blog. howardluksmd.com/shoulder-pain/… 17/?

The cause of subacromial pain is still hotly debated. Many pain mediators are found in bursa / cuff of folks with shoulder pain... Nociceptive vs more central pain issues are being debated too... it's all very confusing. 18/?

We need to be able to say that we are not quite sure what causes subacromial pain. We know that #PT works to shoulder alleviate pain in many. Surgery is "necessary" in some cases... but we are not sure why it works yet. 19/?

Time to stop using the term Impingement Syndrome ...
Time to start a friend of the acromion club :-)
#Thread_done #PT #shoulder