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Arthroscopic subacromial decompression: Two- to seven-year follow-up
Arthroscopic
Subacromial Decompression: Two- to Seven-Year Follow-up
Robert P. Roye, M.D., William
A. Grana, M.D., and Carlan K. Yates, M.D.
Summary: Arthroscopic subacromial decompression (ASD) was performed in 88 patients (90 shoulders) with stage II or early III impingement syndrome of the shoulder unresponsive to nonoperative treatment. The purpose of this retrospective study was to evaluate the follow-up an average of 41 months (range 24 to 82 months) after surgery. We wished to compare results in (1) patients with and without rotator cuff tears, (2) in athletes and nonathletes, and (3) in throwers and nonthrowers. Patients were evaluated by (1) Neer’s Criteria for Satisfactory Result, (2) the UCLA Shoulder RAting Scale, (3) the Shoulder and Elbow Surgeons Rating Scale, (4) a detailed questionnaire, and (5) patient satisfaction. In the follow-up group (n = 90), 80% met Neer’s criteria for satisfactory result; 94% had satisfactory results by the UCLA Shoulder Scale; 95% had a satisfactory result by the Shoulder and Elbow Society Scale; and 93% of shoulder patients expressed satisfaction at follow-up. There were no statistically significant differences in function between the group without rotator cuff tear (n = 47) and the group with rotator cuff tear (n = 43). Satisfactory results were obtained in 68% of throwing athletes and in 90% of nonthrowing athletes (P < .05) by the Neer Rating, whereas only 50% of competitive baseball and softball pitchers had satisfactory results. Out impression is that ASD is an acceptable alternative to open anterior acromioplasty with comparable results for the treatment of the impingement lesion. There were no differences in result in patients who had a partial rotator cuff tear and those who had no tear. Throwing athletes do not have as good a prognosis to maintain high-caliber painfree shoulder activities as do nonthrowing athletes. Key Words: Shoulder impingement-subacromial decompression-Throwing athlete.
I
mpingement of the rotator cuff beneath the coracoacromial arch has been recognized as a cause of chronic shoulder pain.’ It is a common cause of shoulder pain in pitchers, swimmers, participants in racquet sports, and in those whose occupations involve repetitive overhead activities. Neer’%2clearly showed that the functional position of the shoulder is forward flexion, not abduction, as was previously through& because Private practice, Waxahachie, Texas (R.P.R.); from the Department of Orthopaedic, Surgery and Rehabilitation, University of Oklahoma, Health Sciences Center, Oklahoma City, Oklahoma, U.S.A. (W.A.G., C.K.Y.). Address corresuondence and renrint reauests to William A. Grana, M.D., Presbyterian Professional Buiding, 711 Stanton L. Young Blvd, Suite 310, Oklahoma City, OK 73104, U.S.A. 0 199.5 by the Arthroscopy Association of North America 0749~8063/95/1103-0975$3.00/O
Arthroscopy:
The
Journal
of Arthroscopic
and
Related
most upper-extremity activities are performed with the hand in front of the shoulder and not lateral to it. Impingement occurs against the undersurface of the anterior third of the acromion, and at times underneath the acromioclavicular joint.rX3 Wear is centered over the supraspinatus tendon, and may lead to permanent damage. Neer defined three stages of impingement syndrome. He felt this process was a continuum and, if untreated, would progress from stage I to stage III with eventual rotator cuff tear.2
DIAGNOSIS History Stage I patients are usually young and have pain with or following overhead activities. With stage II Surgery,
Vol
II,
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3 (June),
199.5:
pp 301-306
301
302
R. P. ROYE ET AL.
disease, pain is usually present even after the activity is stopped; these patients often have night pain. As the process progresses to stage III, these individuals have constant pain, stiffness, and sometimes weakness of their shoulder girdle. Physical Examination Kessel and Watson described a painful arc of motion in 1977.4 Pain can be elicited between 60” and 120” of abduction with passive range of motion. The classic impingement sign is elicited by passive forward flexion with the scapula stabilized until pain is reproduced over the anterior aspect of the shoulder. A second impingement sign is elicited by forward flexion at 90 of abduction with full passive internal rotation of the shoulder. The lidocaine impingement injection test is positive when an impingement sign is absent after injection of 10 mL of lidocaine in the anterior subacromial space. Radiographic Study Various imaging studies are important in the diagnosis of impingement. Plain radiographs may show a spur below the acromion process or below the acromioclavicular joint. Outlet or cephalic tilt views may improve visualization of the tip of the acromion and subacromial spurs.5 The arthrogram has long been the gold standard for the diagnosis of a complete rotator cuff tear. Ultrasound and magnetic resonance imaging studies are relatively new and have not proven to be significantly better or cheaper than the standard arthrogram technique for complete tear, but may be helpful for partial tear. Treatment Nonoperative treatment consists of activity modification, rotator cuff strengthening exercise, anti-inflammatory medication, and local corticosteroid injection. Good results have been reported even for patients with rotator cuff tear. An X- to 16-week trial is warranted in most patients6 Operative treatment, according to Neer,’ is to render the undersurface of the acromion flat without overhand. Neer reported that 15 of 16 patients achieved a satisfactory result after open acromioplasty.’ A variety of studies suggest that open anterior acromioplasty is an excellent procedure for relief of pain caused by impingement. Overall, these studies show an 86% to 95% success rate following open acromioplasty.7-g More recently, these operative objectives are effectively achieved arthroscopically.‘0-‘7 Gartsman et al,” in a cadaver study, were able to perform successful anterior acromioplasty on cadavera with division of
the coracroacromial ligament. The technqiue has been well described in several recent studies.12~15,18,1g Recent series of arthroscopic subacromial decompression (ASD) have reported 73% to 88% good and excellent results. 13-16 The purpose of our study was to analyze retrospectively our initial experience with ASD, and to compare the results in patients with and without rotator cuff tear. MATERIALS
AND METHODS
We reviewed retrospectively clinic charts, operative notes, and rehabilitation charts on all patients who had shoulder arthroscopy performed from March 1985 through May 1990. The operating surgeons were authors (W.A.G. and C.K.Y.) and Mark S. Pascale, M.D. We then excluded patients in whom the preoperative and postoperative diagnoses did not include the diagnosis of impingement syndrome, and who did not have ASD. Patients who had clinical and radiographic glenohumeral degenerative joint disease or who had shoulder instability were excluded. Classification and Stratification From the original 125 shoulder arthroscopic procedures, we identified 105 shoulders of 102 patients with ASD. We obtained follow-up data on 90 shoulders of 88 patients who had a telephone interview to confirm and supplement clinical and rehabilitation records. These patients were asked about qualitative symptoms, range of motion, and strength. In addition, 20 patients had an individual examination. All patients in the follow-up group had at least 24 months of follow-up with an average follow-up of 41 months (range 24 to 82). The patients who were contacted were divided into two groups; those without partial rotator cuff tears (GWOT) and one with tears (GWT). There were 46 patients (47 shoulders) in the GWOT. There were 42 patients (43 shoulders) in the GWT. Thirty-eight of these tears were partial thickness and 5 were full-thickness small (< 1 cm) rotator cuff tears. Fifty-six (62%) of the shoulders were of patients who considered themselves athletes. Our definition of an athlete was anyone in whom sports activities either caused or exacerbated symptoms. Eleven shoulders (12%) were in patients involved in worker’s compensation claims. Thirty-four throwing athletes (34 shoulders) were identified. A throwing athlete was anyone who performed repetitive overhand throwing motion during a sport. There were 12 pitchers, 8 baseball fielders, 5
ARTHROSCOPIC
SUBACROMIAL
303
DECOMPRESSION
TABLE 1. Shoulder and Elbow Surgeons Rating Scale:
TABLE 2. Questionnaire
Function/Subjective A. B. C. D. E. F. G. H. I. J. K. L. M. N. 0.
Use back pocket Perineal care Wash opposite axilla Eat with utensil Comb hair Use hand with arm at shoulder level Carry lo-15 pounds with arm at side Dress Sleep on affected side Pulling Use hand overhead Throwing Lifting Do usual work Do usual sport
NOTE. 4 = normal, 3 = mild compromise, 2 = difficulty, 1 = with aid, 0 = unable. Maximum score on function scale = 60.
tennis players, 4 swimmers, 2 racquetball players, 1 elite-level handball participant, 1 calf roper, and 1 quarterback. FOLLOW-UP
EVALUATION
Patients in the follow-up group were evaluated according to five clinical classifications: (1) Neer’s criteria (2) the UCLA Shoulder Rating Scale, (3) the Shoulder and Elbow Surgeons Rating Scale, (4) a questionnaire specifically designed for this study, which included (5) patient satisfaction. Neer’s criteria for satisfactory result are: no significant pain, no restrictions to activity, no more than 20” loss of forward flexion postoperatively, and the shoulder should have maintained at least 75% of normal strength. A patient who does not meet all criteria is rated as unsatisfactory. The UCLA Shoulder Rating Scale-the maximum score is 35 points. There is a total score of 10 points each for pain and function and a total of 5 points each for elevation, strength, and satisfaction. An excellent result is 34 to 35, a good result is 28 to 33, a fair result is 21 to 27, and a poor result is 20 or less. Satisfactory result is greater or equal to 28 points. The Shoulder and Elbow Surgeons Rating Scale is divided into subjective and objective criteria. There is a 5-point scale for pain with 5 points being given to a patient with no pain. Table 1 summarizes the functional evaluation for this rating scale. A questionnaire was developed by one of the authors, (R.P.R.) to evaluate pain, function, satisfaction and desire to have the surgery again (Table 2).
Frequency Positive
Percent
42 27 27 3
47% 30% 30% 3%
87 88 87 84
97% 98% 97% 93%
Any pain/discomfort at all? Pain overhead activities? Pain with sports Pain with every day use? Normal use of function of operated shoulder? Scars cosmetic? Would you have surgery again? Are you satisfied with result?
RESULTS Preoperative Findings (n = 90) The patients with shoulders reviewed had an average age of 35 years. Sixty-four shoulders (71%) were male and 67 shoulders (74%) were the dominant extremity. Rotator cuff weakness was evident in 68 shoulders (75%) preoperatively and in 32 shoulders (35%) there was a history of trauma. The duration of the symptoms averaged 17 months with a range of 1 to 120 months, and all patients had pain as their primary complaint. There were no significant differences in age, male:female ratio, dominant extremity involvement, duration of preoperative symptoms, or postoperative follow-up in the GWOT and the CWT. There were also no significant differences in the frequency of night pain, weakness, positive lidocaine impingement test, frequency of athletic participation, or frequency of worker’s compensation between the two groups (Table 3). Radiographic Findings (n = 90) Thirty-one shoulders (34%) had radiographically evident subacromial spurs preoperatively and 6 (7%) had evidence of acromioclavicular joint arthritis. TABLE 3. GWOT and GWT Comparisons Frequency
GWT (47 Shoulders)
GWT (43 Shoulders)
Age Male Dominant Duration of symptoms Follow-up Night pain Rotator cuff weakness Impingement sign Helped by injection Athlete Worker’s Comp
32.9 years 57% 77% 15.1 mos 42.9 mos 43% 70% 98% 70% 57% 11%
36.2 79% 77% 15.7 mos 38.3 mos 52% 82% 95% 61% 67% 9%
304
R. P. ROYE ET AL. TABLE 4. Satisfactory Results of Current Study
Overall, n = 90 No tear, n = 47 Tears, n = 43 Athletes, n = 56 Throwers, n = 18 Pitchers, n = 18
Shoulder/Elbow
Patient Satisfaction
85 (94%)
86 (95%)
84 (93%)
37 (79%)
44 (94%)
44 (94%)
43 (92%)
35 (81%)
41 (95%)
42 (97%)
41 (95%)
45 (80%)
48 (87%)
48 (86%)
51 (91%)
23 (68%)
27 (79%)
28 (82%)
29 (85%)
6 (50%)
8 (67%)
9 (75%)
8 (67%)
Neer
UCLA
72 (80%)
Eighty of the 90 shoulders were studied preoperatively with shoulder arthrogram imaging studies. Of the 80 shoulders, 56 were normal, in 19 a partial tear was suspected, and 4 had a full-thickness, tear shown by arthrogram. Surgical Findings (II = 90) In the follow-up group, the surgical findings confirmed that 47 shoulders had no evidence of a rotator cuff tear, 38 had a partial rotator cuff tear with 32 involving the supraspinatus, and 5 had a full-thickness small (< 1 cm) rotator cuff tear. There were 12 labral tears and 6 shoulders had evidence of glenoid and humeral chondromalacia, grade II or less. Two showed biceps tendon fraying and 1 had a full-thickness biceps tendon tear. One intra-articular loose body was identified. Follow-up Evaluation (n = 90) In the follow-up group, 72 shoulders (80%) had satisfactory results according to Neer’s criteria. Thirtyseven (79%) of the shoulders in GWOT were satisfactory while 35 shoulders (8 1%) in GWT were satisfactory. This was not a statistically significant difference. Eighty-five (94%) shoulders had satisfactory result according to the UCLA Shoulder Scale. In the GWOT, 44 (94%) of the shoulders had good to excellent results and 41 (95%) of the shoulders in the GWT had good to excellent results. This was not a statistically significant difference. By the subjective portion of the Shoulder and Elbow Surgeons Rating Scale, the shoulders in the GWOT had a mean pain score of 4.5; and in the GWT the mean pain score was 4.2. This was not a statistically significant difference. The maximum score for function was 60. The GWOT scored 57.2. The GWT had a mean of 54.3. Once again, there was no significant
difference. Eighty-six shoulders (95%) had a satisfactory result overall, with 44 shoulders (94%) in the GWOT and 42 (97%) in the GWT. Our questionnaire showed 42 shoulders (47%) had some pain or discomfort in the shoulder. Twenty-seven (30%) had pain with overhead activities and 20 shoulders (22%) had pain with sports. Only 3 shoulders (3%) had pain with everyday use and 87 shoulders (97%) had normal use and function of the operated shoulder. Eighty-eight shoulders (98%) had scars that were cosmetic and in eighty-seven (97%) shoulders the patients would have surgery again (Table 2). Athletes (n = 56) There were 27 athletes in the GWOT and 29 athletes in the GWT. Eighteen (67%) of the GWOT returned to sports postoperatively, whereas 16 (55%) of the GWT returned to sports postoperatively. Of the shoulders, 45 (80%) had a satisfactory result by Neer’s criteria, 48 (86%) by the UCLA Scale, and 48 (86%) by the Shoulder and Elbow Surgeon’s Scale. Throwers (n = 34) There were 17 overhand throwing athletes in each group and 10 (59%) recovered and returned to sport in the GWT. Two of these were reinjured after return to sports. Eight (47%) of the throwing athletes in the GWOT recovered and three were reinjured after return to sports. In the throwing athletes, 23 (68%) had a satisfactory result by Neer’s criteria, whereas 50 shoulders (90%) of the remainder of the follow-up group were satisfactory by these criteria. This was a significant difference (P < .05 at follow-up. In summary, the satisfactory results in throwers were: Neer 23 (68%) UCLA 27 (79%), and Shoulder and Elbow Society Scale 28 (82%). Pitchers (n = 12) Of the 12 pitchers, 6 were satisfied at long-term follow-up and 6 were unsatisfied. Of the 6 unsatisfied pitchers, all had pain, 3 had been reinjured, 1 was felt to have had an inadequate acromioplasty, and 1 had incomplete rehabilitation by his own admission. By the Neer criteria 6 (50%) UCLA 8 (67%), and the Shoulder and Elbow Society Scale 9 (45%), had satisfactory results. Table 4 summarizes all the results of this study. Workman’s Compensation (n = 8) Four (100%) worker’s compensation patients in the GWT returned to work an average of 2.5 months and three (75%) of worker’s compensation patients with
ARTHROSCOPIC
SUBACROMIAL
tear returned to work at an average of 4 months postoperatively. Range of Motion
(n = 90)
Postoperative range of motion was significantly improved over preoperative range of motion. Seventythree patients (49%) of the GWOT believed they had limited preoperative range of motion, whereas only two (4%) felt they had limited postoperative range of motion. Likewise 13 (30%) of the GWT had limited preoperative range of motion, whereas only two (5%) had limited postoperative range of motion. Return
to Daily Activity
(n = 90)
The interval from surgery to return to normal activities of daily living averaged 2 weeks. There was no statistically significant difference between the two groups in the mean time to return to activities of daily living: 1.6 weeks for the GWOT ant 2.3 weeks for the GWT. Examination
Group (n = 20)
Twenty of the follow-up group were able to come in and be examined. There were no statistical differences in this group from the whole follow-up group. Of the 20 examined, 10 had partial rotator cuff tears and 10 did not. Range of motion and strength were evaluated in 20 shoulders by examination. Functional range of motion was achieved postoperatively in both groups and strength was near 5 out of 5 in the supraspinatus, middle deltoid, anterior deltoid, and external rotation in the two groups postoperatively. There were no statistically significant differences between the two groups. Complications
(n = 90)
Complications occurred in 2 shoulders (2%) in patients with keloid scar formation at two portal sites. There were no neurovascular complications. DISCUSSION
Ellman13 published the first large series of ASD patients. Eight-eight percent (average age, 50 years) had satisfactory results. Esch et all4 reported 82% satisfactory results in stage II impingement patients with and without partial rotator cuff tears. In addition, they had 88% satisfactory results in the patients with stage III full-thickness rotator cuff tears. Hawkins et all6 reported 46% satisfactory results with ASD, while they had a concurrent series of open acromioplasty patients with 87% satisfactory results. Gartsman” had 95% sat-
DECOMPRESSION
305
isfactory results in his group without partial tears and 83% satisfactory results in his group with partial tears. Our subjective results by the three ratings and patients satisfaction compared favorably with these other published series of ASD (80% to 95% satisfactory). These results show an outcome as good as open anterior acromioplasty for the treatment of impingement syndrome. Our patients reported 92% patient satisfaction in the GWOT and 95% satisfaction in the GWT, for an overall satisfaction rating of 93.5%. While 91% of the athletes expressed satisfaction, only 85% of the overhand throwing athletes and 67% of the pitchers were satisfied. There were few complications, morbidity is low, and return to activity is rapid. Although the patients in the GWT fared as well as those in the GWOT, throwing athletes may not return to their preinjury level of functional activity (68% satisfactory by Neer’s criteria), reinjury is common, and pitchers have the poorest prognosis (50% satisfactory by Neer’s criteria). Rotator cuff problems in the overhand throwing athlete, especially a pitcher, may not result primarily from rotator cuff tear injury but, secondarily, from instability. To treat the rotator cuff problem adequately, the instability must be treated concomitantly or continued complaints may result. Further, complete understanding of the relationship between the rotator cuff and instability is in evolution. As that evolution unfolds, there will be a better understanding of how to treat the high performance throwing athlete.rgX2’ Acknowledgment: the cooperation R.P.T.
This study was made possible with of Mark S. Pascale, M.D. and David Ruhl,
REFERENCES 1. Neer CS II: Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg Am 1972;54:4150. 2. Neer CS II: Impingement lesions. Clin Orthop Rel Res 1983; 173:70-77. 3. Rathburn JB, Macnab I: The microvascular pattern of the rotator cuff of the shoulder. J Bone Joint Surg AMC 1970;56:540-553. 4. Kessel L, Watson M: The painful arc syndrome. J Bone Joint Surg Br 1977;59:166-172. 5. Zanca P: Shoulder pain: Involvement of the acromioclavicular joint. AJR 1971; 112:493-506. 6. Itoi E, Tabata S: Conservative treatment of rotator cuff tears. Clin Orthop 1972;275:165-173. 7. Penny JN, Welsh RP: Shoulder impingement syndromes in athletes and their surgical management. Am J Sports Med 1981;9:11-15. 8. Post M. Cohen J: Impingement syndrome: A review of late stage II and early stage III lesions. CZin Orthop Rel Res 1986;207:126-132. 9. Tibone JE, Jobe FW, Kerlan RK, Carter VS, Shields CL, Lom-
306
10. 11. 12. 13. 14.
R. P. ROYE ET AL. bardo SJ, Yocum LA. Shoulder impingement syndrome in athletes treated by an anterior acromioplasty. Clin Orthop Rel Res 1985; 198:134-140. Andrews JR, Schemmel SP: Arthroscopic acromioplasty. Surg Rounds Orthop 1989;45-50. Andrews JR, Broussard TS, CArson WG: Arthroscopy of the shoulder in the management of partial tears of the rotator cuff: A preliminary report. Arthroscopy 1985; 1:117-122. Caspari RB, Thal R: A technique for arthroscopic subacromial decompression. Arthroscopy 1992;8:23-30. Elhnan H: Arthroscopic subacromial decompression: Analysis of one- to three-year results. Arthroscopy 1987;3:173-181. Esch JC, Ozerkis LR, Helgager JA, Kane N, Lilliott N. Arthroscopic subacromial decompression: Results according to the degree of rotator cuff tear. Arthroscopy 1988;4:241249.
15. Gartsman GM: Arthroscopic acromioplasty for lesions of the rotator cuff. .J Bone Joint Surg Am 1990;72:169-180. 16. Hawkins RJ, Saddemis S, Moor J, Hawkins A, Tew M. Arthroscopic subacromial decompression: A two-year to four-year follow-up study. Presented at the Annual Meeting of the Arthroscopy Association of North America, April 1992. 17. Meyers JF: Arthroscopic management of impingement syndrome and rotator cuff tears. Adv Sports Med Fitness 1989;2:243-260. 18. Gartsman GM, Blair ME, Noble PC, Bennett JB, Tulles HS. Arthroscopic subacromial decompression: An anatomical study. Am J Sports Med 1988; 16:48-50. 19. Jobe l%, Tibone JE, Jobe CM, Kvitne RS: The shoulder in soorts. In: Rockwood CA Jr., Matsen FA III, ed. The shoulder. Phildelphia: Saunders, 1990:961-990. 20. Jobe FW: Impingement problems in the athlete. ICLS 1989;205209.
Subacromial Decompression: Two- to Seven-Year Follow-up
Robert P. Roye, M.D., William
A. Grana, M.D., and Carlan K. Yates, M.D.
Summary: Arthroscopic subacromial decompression (ASD) was performed in 88 patients (90 shoulders) with stage II or early III impingement syndrome of the shoulder unresponsive to nonoperative treatment. The purpose of this retrospective study was to evaluate the follow-up an average of 41 months (range 24 to 82 months) after surgery. We wished to compare results in (1) patients with and without rotator cuff tears, (2) in athletes and nonathletes, and (3) in throwers and nonthrowers. Patients were evaluated by (1) Neer’s Criteria for Satisfactory Result, (2) the UCLA Shoulder RAting Scale, (3) the Shoulder and Elbow Surgeons Rating Scale, (4) a detailed questionnaire, and (5) patient satisfaction. In the follow-up group (n = 90), 80% met Neer’s criteria for satisfactory result; 94% had satisfactory results by the UCLA Shoulder Scale; 95% had a satisfactory result by the Shoulder and Elbow Society Scale; and 93% of shoulder patients expressed satisfaction at follow-up. There were no statistically significant differences in function between the group without rotator cuff tear (n = 47) and the group with rotator cuff tear (n = 43). Satisfactory results were obtained in 68% of throwing athletes and in 90% of nonthrowing athletes (P < .05) by the Neer Rating, whereas only 50% of competitive baseball and softball pitchers had satisfactory results. Out impression is that ASD is an acceptable alternative to open anterior acromioplasty with comparable results for the treatment of the impingement lesion. There were no differences in result in patients who had a partial rotator cuff tear and those who had no tear. Throwing athletes do not have as good a prognosis to maintain high-caliber painfree shoulder activities as do nonthrowing athletes. Key Words: Shoulder impingement-subacromial decompression-Throwing athlete.
I
mpingement of the rotator cuff beneath the coracoacromial arch has been recognized as a cause of chronic shoulder pain.’ It is a common cause of shoulder pain in pitchers, swimmers, participants in racquet sports, and in those whose occupations involve repetitive overhead activities. Neer’%2clearly showed that the functional position of the shoulder is forward flexion, not abduction, as was previously through& because Private practice, Waxahachie, Texas (R.P.R.); from the Department of Orthopaedic, Surgery and Rehabilitation, University of Oklahoma, Health Sciences Center, Oklahoma City, Oklahoma, U.S.A. (W.A.G., C.K.Y.). Address corresuondence and renrint reauests to William A. Grana, M.D., Presbyterian Professional Buiding, 711 Stanton L. Young Blvd, Suite 310, Oklahoma City, OK 73104, U.S.A. 0 199.5 by the Arthroscopy Association of North America 0749~8063/95/1103-0975$3.00/O
Arthroscopy:
The
Journal
of Arthroscopic
and
Related
most upper-extremity activities are performed with the hand in front of the shoulder and not lateral to it. Impingement occurs against the undersurface of the anterior third of the acromion, and at times underneath the acromioclavicular joint.rX3 Wear is centered over the supraspinatus tendon, and may lead to permanent damage. Neer defined three stages of impingement syndrome. He felt this process was a continuum and, if untreated, would progress from stage I to stage III with eventual rotator cuff tear.2
DIAGNOSIS History Stage I patients are usually young and have pain with or following overhead activities. With stage II Surgery,
Vol
II,
No
3 (June),
199.5:
pp 301-306
301
302
R. P. ROYE ET AL.
disease, pain is usually present even after the activity is stopped; these patients often have night pain. As the process progresses to stage III, these individuals have constant pain, stiffness, and sometimes weakness of their shoulder girdle. Physical Examination Kessel and Watson described a painful arc of motion in 1977.4 Pain can be elicited between 60” and 120” of abduction with passive range of motion. The classic impingement sign is elicited by passive forward flexion with the scapula stabilized until pain is reproduced over the anterior aspect of the shoulder. A second impingement sign is elicited by forward flexion at 90 of abduction with full passive internal rotation of the shoulder. The lidocaine impingement injection test is positive when an impingement sign is absent after injection of 10 mL of lidocaine in the anterior subacromial space. Radiographic Study Various imaging studies are important in the diagnosis of impingement. Plain radiographs may show a spur below the acromion process or below the acromioclavicular joint. Outlet or cephalic tilt views may improve visualization of the tip of the acromion and subacromial spurs.5 The arthrogram has long been the gold standard for the diagnosis of a complete rotator cuff tear. Ultrasound and magnetic resonance imaging studies are relatively new and have not proven to be significantly better or cheaper than the standard arthrogram technique for complete tear, but may be helpful for partial tear. Treatment Nonoperative treatment consists of activity modification, rotator cuff strengthening exercise, anti-inflammatory medication, and local corticosteroid injection. Good results have been reported even for patients with rotator cuff tear. An X- to 16-week trial is warranted in most patients6 Operative treatment, according to Neer,’ is to render the undersurface of the acromion flat without overhand. Neer reported that 15 of 16 patients achieved a satisfactory result after open acromioplasty.’ A variety of studies suggest that open anterior acromioplasty is an excellent procedure for relief of pain caused by impingement. Overall, these studies show an 86% to 95% success rate following open acromioplasty.7-g More recently, these operative objectives are effectively achieved arthroscopically.‘0-‘7 Gartsman et al,” in a cadaver study, were able to perform successful anterior acromioplasty on cadavera with division of
the coracroacromial ligament. The technqiue has been well described in several recent studies.12~15,18,1g Recent series of arthroscopic subacromial decompression (ASD) have reported 73% to 88% good and excellent results. 13-16 The purpose of our study was to analyze retrospectively our initial experience with ASD, and to compare the results in patients with and without rotator cuff tear. MATERIALS
AND METHODS
We reviewed retrospectively clinic charts, operative notes, and rehabilitation charts on all patients who had shoulder arthroscopy performed from March 1985 through May 1990. The operating surgeons were authors (W.A.G. and C.K.Y.) and Mark S. Pascale, M.D. We then excluded patients in whom the preoperative and postoperative diagnoses did not include the diagnosis of impingement syndrome, and who did not have ASD. Patients who had clinical and radiographic glenohumeral degenerative joint disease or who had shoulder instability were excluded. Classification and Stratification From the original 125 shoulder arthroscopic procedures, we identified 105 shoulders of 102 patients with ASD. We obtained follow-up data on 90 shoulders of 88 patients who had a telephone interview to confirm and supplement clinical and rehabilitation records. These patients were asked about qualitative symptoms, range of motion, and strength. In addition, 20 patients had an individual examination. All patients in the follow-up group had at least 24 months of follow-up with an average follow-up of 41 months (range 24 to 82). The patients who were contacted were divided into two groups; those without partial rotator cuff tears (GWOT) and one with tears (GWT). There were 46 patients (47 shoulders) in the GWOT. There were 42 patients (43 shoulders) in the GWT. Thirty-eight of these tears were partial thickness and 5 were full-thickness small (< 1 cm) rotator cuff tears. Fifty-six (62%) of the shoulders were of patients who considered themselves athletes. Our definition of an athlete was anyone in whom sports activities either caused or exacerbated symptoms. Eleven shoulders (12%) were in patients involved in worker’s compensation claims. Thirty-four throwing athletes (34 shoulders) were identified. A throwing athlete was anyone who performed repetitive overhand throwing motion during a sport. There were 12 pitchers, 8 baseball fielders, 5
ARTHROSCOPIC
SUBACROMIAL
303
DECOMPRESSION
TABLE 1. Shoulder and Elbow Surgeons Rating Scale:
TABLE 2. Questionnaire
Function/Subjective A. B. C. D. E. F. G. H. I. J. K. L. M. N. 0.
Use back pocket Perineal care Wash opposite axilla Eat with utensil Comb hair Use hand with arm at shoulder level Carry lo-15 pounds with arm at side Dress Sleep on affected side Pulling Use hand overhead Throwing Lifting Do usual work Do usual sport
NOTE. 4 = normal, 3 = mild compromise, 2 = difficulty, 1 = with aid, 0 = unable. Maximum score on function scale = 60.
tennis players, 4 swimmers, 2 racquetball players, 1 elite-level handball participant, 1 calf roper, and 1 quarterback. FOLLOW-UP
EVALUATION
Patients in the follow-up group were evaluated according to five clinical classifications: (1) Neer’s criteria (2) the UCLA Shoulder Rating Scale, (3) the Shoulder and Elbow Surgeons Rating Scale, (4) a questionnaire specifically designed for this study, which included (5) patient satisfaction. Neer’s criteria for satisfactory result are: no significant pain, no restrictions to activity, no more than 20” loss of forward flexion postoperatively, and the shoulder should have maintained at least 75% of normal strength. A patient who does not meet all criteria is rated as unsatisfactory. The UCLA Shoulder Rating Scale-the maximum score is 35 points. There is a total score of 10 points each for pain and function and a total of 5 points each for elevation, strength, and satisfaction. An excellent result is 34 to 35, a good result is 28 to 33, a fair result is 21 to 27, and a poor result is 20 or less. Satisfactory result is greater or equal to 28 points. The Shoulder and Elbow Surgeons Rating Scale is divided into subjective and objective criteria. There is a 5-point scale for pain with 5 points being given to a patient with no pain. Table 1 summarizes the functional evaluation for this rating scale. A questionnaire was developed by one of the authors, (R.P.R.) to evaluate pain, function, satisfaction and desire to have the surgery again (Table 2).
Frequency Positive
Percent
42 27 27 3
47% 30% 30% 3%
87 88 87 84
97% 98% 97% 93%
Any pain/discomfort at all? Pain overhead activities? Pain with sports Pain with every day use? Normal use of function of operated shoulder? Scars cosmetic? Would you have surgery again? Are you satisfied with result?
RESULTS Preoperative Findings (n = 90) The patients with shoulders reviewed had an average age of 35 years. Sixty-four shoulders (71%) were male and 67 shoulders (74%) were the dominant extremity. Rotator cuff weakness was evident in 68 shoulders (75%) preoperatively and in 32 shoulders (35%) there was a history of trauma. The duration of the symptoms averaged 17 months with a range of 1 to 120 months, and all patients had pain as their primary complaint. There were no significant differences in age, male:female ratio, dominant extremity involvement, duration of preoperative symptoms, or postoperative follow-up in the GWOT and the CWT. There were also no significant differences in the frequency of night pain, weakness, positive lidocaine impingement test, frequency of athletic participation, or frequency of worker’s compensation between the two groups (Table 3). Radiographic Findings (n = 90) Thirty-one shoulders (34%) had radiographically evident subacromial spurs preoperatively and 6 (7%) had evidence of acromioclavicular joint arthritis. TABLE 3. GWOT and GWT Comparisons Frequency
GWT (47 Shoulders)
GWT (43 Shoulders)
Age Male Dominant Duration of symptoms Follow-up Night pain Rotator cuff weakness Impingement sign Helped by injection Athlete Worker’s Comp
32.9 years 57% 77% 15.1 mos 42.9 mos 43% 70% 98% 70% 57% 11%
36.2 79% 77% 15.7 mos 38.3 mos 52% 82% 95% 61% 67% 9%
304
R. P. ROYE ET AL. TABLE 4. Satisfactory Results of Current Study
Overall, n = 90 No tear, n = 47 Tears, n = 43 Athletes, n = 56 Throwers, n = 18 Pitchers, n = 18
Shoulder/Elbow
Patient Satisfaction
85 (94%)
86 (95%)
84 (93%)
37 (79%)
44 (94%)
44 (94%)
43 (92%)
35 (81%)
41 (95%)
42 (97%)
41 (95%)
45 (80%)
48 (87%)
48 (86%)
51 (91%)
23 (68%)
27 (79%)
28 (82%)
29 (85%)
6 (50%)
8 (67%)
9 (75%)
8 (67%)
Neer
UCLA
72 (80%)
Eighty of the 90 shoulders were studied preoperatively with shoulder arthrogram imaging studies. Of the 80 shoulders, 56 were normal, in 19 a partial tear was suspected, and 4 had a full-thickness, tear shown by arthrogram. Surgical Findings (II = 90) In the follow-up group, the surgical findings confirmed that 47 shoulders had no evidence of a rotator cuff tear, 38 had a partial rotator cuff tear with 32 involving the supraspinatus, and 5 had a full-thickness small (< 1 cm) rotator cuff tear. There were 12 labral tears and 6 shoulders had evidence of glenoid and humeral chondromalacia, grade II or less. Two showed biceps tendon fraying and 1 had a full-thickness biceps tendon tear. One intra-articular loose body was identified. Follow-up Evaluation (n = 90) In the follow-up group, 72 shoulders (80%) had satisfactory results according to Neer’s criteria. Thirtyseven (79%) of the shoulders in GWOT were satisfactory while 35 shoulders (8 1%) in GWT were satisfactory. This was not a statistically significant difference. Eighty-five (94%) shoulders had satisfactory result according to the UCLA Shoulder Scale. In the GWOT, 44 (94%) of the shoulders had good to excellent results and 41 (95%) of the shoulders in the GWT had good to excellent results. This was not a statistically significant difference. By the subjective portion of the Shoulder and Elbow Surgeons Rating Scale, the shoulders in the GWOT had a mean pain score of 4.5; and in the GWT the mean pain score was 4.2. This was not a statistically significant difference. The maximum score for function was 60. The GWOT scored 57.2. The GWT had a mean of 54.3. Once again, there was no significant
difference. Eighty-six shoulders (95%) had a satisfactory result overall, with 44 shoulders (94%) in the GWOT and 42 (97%) in the GWT. Our questionnaire showed 42 shoulders (47%) had some pain or discomfort in the shoulder. Twenty-seven (30%) had pain with overhead activities and 20 shoulders (22%) had pain with sports. Only 3 shoulders (3%) had pain with everyday use and 87 shoulders (97%) had normal use and function of the operated shoulder. Eighty-eight shoulders (98%) had scars that were cosmetic and in eighty-seven (97%) shoulders the patients would have surgery again (Table 2). Athletes (n = 56) There were 27 athletes in the GWOT and 29 athletes in the GWT. Eighteen (67%) of the GWOT returned to sports postoperatively, whereas 16 (55%) of the GWT returned to sports postoperatively. Of the shoulders, 45 (80%) had a satisfactory result by Neer’s criteria, 48 (86%) by the UCLA Scale, and 48 (86%) by the Shoulder and Elbow Surgeon’s Scale. Throwers (n = 34) There were 17 overhand throwing athletes in each group and 10 (59%) recovered and returned to sport in the GWT. Two of these were reinjured after return to sports. Eight (47%) of the throwing athletes in the GWOT recovered and three were reinjured after return to sports. In the throwing athletes, 23 (68%) had a satisfactory result by Neer’s criteria, whereas 50 shoulders (90%) of the remainder of the follow-up group were satisfactory by these criteria. This was a significant difference (P < .05 at follow-up. In summary, the satisfactory results in throwers were: Neer 23 (68%) UCLA 27 (79%), and Shoulder and Elbow Society Scale 28 (82%). Pitchers (n = 12) Of the 12 pitchers, 6 were satisfied at long-term follow-up and 6 were unsatisfied. Of the 6 unsatisfied pitchers, all had pain, 3 had been reinjured, 1 was felt to have had an inadequate acromioplasty, and 1 had incomplete rehabilitation by his own admission. By the Neer criteria 6 (50%) UCLA 8 (67%), and the Shoulder and Elbow Society Scale 9 (45%), had satisfactory results. Table 4 summarizes all the results of this study. Workman’s Compensation (n = 8) Four (100%) worker’s compensation patients in the GWT returned to work an average of 2.5 months and three (75%) of worker’s compensation patients with
ARTHROSCOPIC
SUBACROMIAL
tear returned to work at an average of 4 months postoperatively. Range of Motion
(n = 90)
Postoperative range of motion was significantly improved over preoperative range of motion. Seventythree patients (49%) of the GWOT believed they had limited preoperative range of motion, whereas only two (4%) felt they had limited postoperative range of motion. Likewise 13 (30%) of the GWT had limited preoperative range of motion, whereas only two (5%) had limited postoperative range of motion. Return
to Daily Activity
(n = 90)
The interval from surgery to return to normal activities of daily living averaged 2 weeks. There was no statistically significant difference between the two groups in the mean time to return to activities of daily living: 1.6 weeks for the GWOT ant 2.3 weeks for the GWT. Examination
Group (n = 20)
Twenty of the follow-up group were able to come in and be examined. There were no statistical differences in this group from the whole follow-up group. Of the 20 examined, 10 had partial rotator cuff tears and 10 did not. Range of motion and strength were evaluated in 20 shoulders by examination. Functional range of motion was achieved postoperatively in both groups and strength was near 5 out of 5 in the supraspinatus, middle deltoid, anterior deltoid, and external rotation in the two groups postoperatively. There were no statistically significant differences between the two groups. Complications
(n = 90)
Complications occurred in 2 shoulders (2%) in patients with keloid scar formation at two portal sites. There were no neurovascular complications. DISCUSSION
Ellman13 published the first large series of ASD patients. Eight-eight percent (average age, 50 years) had satisfactory results. Esch et all4 reported 82% satisfactory results in stage II impingement patients with and without partial rotator cuff tears. In addition, they had 88% satisfactory results in the patients with stage III full-thickness rotator cuff tears. Hawkins et all6 reported 46% satisfactory results with ASD, while they had a concurrent series of open acromioplasty patients with 87% satisfactory results. Gartsman” had 95% sat-
DECOMPRESSION
305
isfactory results in his group without partial tears and 83% satisfactory results in his group with partial tears. Our subjective results by the three ratings and patients satisfaction compared favorably with these other published series of ASD (80% to 95% satisfactory). These results show an outcome as good as open anterior acromioplasty for the treatment of impingement syndrome. Our patients reported 92% patient satisfaction in the GWOT and 95% satisfaction in the GWT, for an overall satisfaction rating of 93.5%. While 91% of the athletes expressed satisfaction, only 85% of the overhand throwing athletes and 67% of the pitchers were satisfied. There were few complications, morbidity is low, and return to activity is rapid. Although the patients in the GWT fared as well as those in the GWOT, throwing athletes may not return to their preinjury level of functional activity (68% satisfactory by Neer’s criteria), reinjury is common, and pitchers have the poorest prognosis (50% satisfactory by Neer’s criteria). Rotator cuff problems in the overhand throwing athlete, especially a pitcher, may not result primarily from rotator cuff tear injury but, secondarily, from instability. To treat the rotator cuff problem adequately, the instability must be treated concomitantly or continued complaints may result. Further, complete understanding of the relationship between the rotator cuff and instability is in evolution. As that evolution unfolds, there will be a better understanding of how to treat the high performance throwing athlete.rgX2’ Acknowledgment: the cooperation R.P.T.
This study was made possible with of Mark S. Pascale, M.D. and David Ruhl,
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