216 AJR:187, July 2006

AJR 2006; 187:216220

0361803X/06/1871216
American Roentgen Ray Society
M
E D I C A L

I M A G I N G
A
C E N
T
U
R Y O
F
Bureau et al.
Sonography
of Shoulder
Impingement
Syndrome
Mus cul os kel et al I magi ng Cl i ni cal Obs er vat i ons
Dynamic Sonography Evaluation of
Shoulder Impingement Syndrome
Nathalie J. Bureau
1
Marc Beauchamp
2,3
Etienne Cardinal
1
Paul Brassard
4
Bureau NJ, Beauchamp M, Cardinal E,
Brassard P
Keywords: dynamic sonography, impingement,
musculoskeletal imaging, shoulder, supraspinatus tendon
DOI:10.2214/AJR.05.0528
Received March 24, 2005; accepted after revision
May 30, 2005.
1
Radiology Department, CH Universit de Montral, Hpital
Saint-Luc, 1058 Saint-Denis St., Montreal, QC, H2X 3J4
Canada. Address correspondence to N. J. Bureau
(nathalie.bureau@umontreal.ca).
2
Orthopedic Department, CH Universit de Montral, Htel
Dieu de Montral, Montreal, QC, H2W 1T8 Canada.
3
Present address: Mdiclub, Montreal QC, H3S 2W1
Canada.
4
Division of Clinical Epidemiology, McGill University Health
Center, Royal Victoria Hospital, Montreal, QC, H3A 1A1
Canada.
OBJECTIVE. Our aim was to characterize shoulder impingement syndrome using dy-
namic sonography.
CONCLUSION. Dynamic sonography allows direct visualization of the relationships be-
tween the acromion, humeral head, and intervening soft tissues during active shoulder motion
and can provide useful information regarding potential intrinsic and extrinsic causes of shoul-
der impingement syndrome.
ubacromial impingement syndrome
is a clinical entity that was pro-
posed by Neer in 1972 [1]. This
syndrome is the result of chronic
irritation of the supraspinatus tendon against
the undersurface of the anterior one third of
the acromion, the coracoacromial ligament,
and the acromioclavicular joint. It is often
difficult to diagnose because the clinical pre-
sentation may be confusing and clinical tests
lack specificity [2].
Although the morphology of the acromion
has been shown to be an important factor in the
occurrence of subacromial impingement and
rotator cuff tears [3], assessment of the shape
of the acromion on radiography is sensitive to
minor changes in radiographic technique and
to the MR section viewed on MRI and shows
high interobserver variability [4, 5].
MRI is a reliable technique for the evalua-
tion of the rotator cuff tendons, but it provides
only a static evaluation of the shoulder joint
and can only indirectly suggest the diagnosis
of subacromial impingement because most
findings are nonspecific. Studies have inves-
tigated the value of dynamic MR evaluation
of the shoulder with open MRI [6, 7]. The ma-
jor limiting factors of dynamic MRI are the
restricted availability of open magnets and the
fact that the MR technology, at this time, only
allows sequential imaging of single-plane
shoulder motions that do not entirely repro-
duce physiologic shoulder motion.
In 1990, Farin et al. [8], using dynamic
sonography, described bursitis, fluid disten-
tion, and pooling of fluid lateral to the subdel-
toid bursa as signs of early-stage subacromial
impingement. In our experience, a wider
range of abnormalities can be observed on dy-
namic sonography in the presence of subacro-
mial impingement.
The purpose of this study was to describe a
method of dynamic sonography evaluation
and to characterize the spectrum of abnormal-
ities of subacromial impingement using dy-
namic sonography.
Subjects and Methods
Our institutional ethics committee approved
this study, and written informed consent was ob-
tained from all patients. Sonography examination
of both shoulders was performed prospectively in
a convenience sample of 13 patients (six men,
seven women; mean age, 46 years; age range,
3758 years) presenting with a clinical diagnosis
of subacromial impingement. The diagnosis of
subacromial impingement was established by an
orthopedic surgeon specializing in upper extrem-
ity management. Patients were selected from the
surgeons clinical practice over a period of 6
months on the basis of strict inclusion criteria (age
range, 3060 years; shoulder pain of more than 6
months duration; positive impingement test) and
exclusion criteria (shoulder surgery, history of ac-
romioclavicular joint dislocation, fracture to the
shoulder girdle, glenohumeral instability, osteoar-
thritis of the glenohumeral joint, inflammatory ar-
thritis, diabetes, congenital anomaly, tumor of the
shoulder girdle, radiation therapy to the shoulder)
and after standardized clinical evaluation of both
shoulders that included the Jobe, Neer, Hawkins,
and Speed tests [9]. In addition, the orthopedic
surgeon performed a subacromial injection test
(impingement test) using 10 mL of lidocaine hy-
S
Sonography of Shoulder Impingement Syndrome
AJR:187, July 2006 217
drochloride 2% (Xylocaine, Abbott Laboratories).
The marked relief of pain and an almost total im-
provement in passive or active shoulder range of
motion 10 min after the subacromial injection
were considered positive findings for subacromial
impingement [10].
The sonography examinations were performed
independently by either of two musculoskeletal ra-
diologists with 9 and 10 years experience in mus-
culoskeletal sonography, using either a 7.5-MHz or
a 513-MHz high-resolution transducer (Sonoline
Elegra, Siemens Medical Solutions). First, a com-
plete standard comparative sonography evaluation
of both shoulders was performed with the patient
sitting on a stool. A dynamic sonography examina-
tion was also performed in all patients. The position
in which the dynamic sonography evaluation was
performed was based on the MR study by Bross-
mann et al. [11] that used cadavers and showed that
subacromial impingement was best seen at 60 for-
ward flexion, 60 abduction, and internal rotation.
This maneuver is also similar to the impingement
test described by Neer [10].
Hence, during the dynamic sonography evalua-
tion, the patient was instructed to elevate the arm
halfway between flexion and abduction with the
hand in pronation and the elbow extended while the
ultrasound probe was positioned in the coronal
plane along the long axis of the supraspinatus ten-
don, between the acromion and the greater tuberos-
ity of the humerus. The active movement could be
repeated a few times.
The relationships between the acromion, the hu-
meral head, and the intervening soft tissues
namely, the subacromial bursa and supraspinatus
tendonwere assessed during active shoulder mo-
tion. All dynamic sonography examinations were
videotaped (Fig. S1, available at www.ajronline.org),
and static images were obtained from the cine loop
showing impingement when it occurred.
There was no evidence of impingement if the hu-
meral head passed easily and freely underneath the
acromion during shoulder motion (Fig. 1A). Soft-
tissue impingement was described when pooling of
fluid in the lateral aspect of the subacromialsub-
deltoid bursa occurred or when alteration of the
normally convex surface of the subacromial bursa
alone or of the subacromial bursa and of the su-
A
Fig. 1Sonograms of normal shoulder and shoulders with impingement. (See also
Figs. S1AS1C, videos, in supplemental data online.)
A, 37-year-old man with normal dynamic sonography evaluation. Coronal
sonography view of left asymptomatic shoulder, during active elevation of arm
halfway between flexion and abduction with hand in pronation, shows unobstructed
passage of greater tuberosity (T) of humeral head and supraspinatus tendon (S)
underneath acromion (A).
B, 49-year-old man with soft-tissue impingement during dynamic sonography
evaluation of shoulder. Coronal sonography view of left shoulder with subacromial
impingement, during active elevation of arm halfway between flexion and abduction
with hand in pronation, shows pooling of fluid in lateral aspect of
subacromialsubdeltoid bursa (arrow) and mild impingement of supraspinatus
tendon (arrowhead) as greater tuberosity (T) of humeral head approximates anterior
one third of acromion (A). Note that humeral head remains in anatomic position,
below acromion.
C, 43-year-old man with upward migration of humeral head during dynamic
sonography evaluation of shoulder. Coronal sonography view of left shoulder with
shoulder impingement syndrome, during active elevation of arm halfway between
flexion and abduction with hand in pronation, shows abnormal upward migration of
humeral head (H) in regard to acromion (A), preventing its passage underneath
acromion. There is mild distention of subacromial bursa (arrowhead).
S = supraspinatus tendon.
B C
Bureau et al.
218 AJR:187, July 2006
praspinatus tendon occurred when the greater tu-
berosity of the humeral head passed underneath the
acromion (Fig. 1B). Osseous impingement was re-
ported when the greater tuberosity of the humeral
head migrated upward and prevented its passage
underneath the acromion (Fig. 1C).
All dynamic sonography studies were retrospec-
tively reviewed by the two radiologists who per-
formed the studies, and the type of impingement
was determined by consensus. In addition, during
the dynamic sonography examination, the patient
was asked to report whether the movement was
painful or not. Based on the sonography findings
and the presence or absence of pain felt by the pa-
tient during the dynamic sonography examination,
we created a four-grade classification system to
characterize subacromial impingement on dynamic
sonography (Table 1).
Results
Twenty-six shoulders in 13 patients were
examined. There were 12 asymptomatic
shoulders and 14 shoulders with the clinical
diagnosis of subacromial impingement. In the
group of shoulders with a clinical diagnosis of
subacromial impingement, 14% (2/14) were
diagnosed on dynamic sonography examina-
tion as a case of grade 0 impingement; 29%
(4/14), grade 1; 7% (1/14), grade 2; and 50%
(7/14), grade 3. By contrast, in the group of
asymptomatic shoulders, 75% (9/12) were
grade 0 cases; 17% (2/12), grade 1; 0% (0/12)
grade 2; and 8% (1/12), grade 3.
Discussion
The acromiohumeral outlet is limited by
the humeral head below and is formed supe-
riorly by the coracoacromial arch, which con-
sists of the acromion, the coracoid process,
and the coracoacromial ligament, and medi-
ally by the acromioclavicular joint. During
the arc of motion of the shoulder, especially
forward flexion, the supraspinatus tendon and
subacromial bursa may be subjected to degen-
erative changes because of the close relation-
ship with these structures. In a concepts
review about subacromial impingement, Big-
liani and Levine [12] described intrinsic and
extrinsic causes of this syndrome.
Radiographic evaluation may give valuable
anatomic information such as the presence of
osteoarthrosis of the acromioclavicular joint or
os acromiale and evidence of prior gleno-
humeral joint dislocation or calcific tendinosis.
The supraspinatus outlet radiograph is used to
determine the shape of the acromion according
to the classification suggested by Bigliani et al.
[3]. Acromial shape, including the lateral tilt of
the acromion, can also be determined on MR
studies. In addition, MRI can show the pres-
ence of rotator cuff and subacromial bursa ab-
normalities, degeneration of the acromiocla-
vicular joint, and evidence of glenohumeral
instability. Although this anatomic informa-
tion is essential for evaluation of the patient, it
does not provide information about the func-
tional kinematics of the shoulder.
Sonography has proved useful in the diag-
nosis of rotator cuff tears [13], rotator cuff
tendinosis, calcific tendinosis, and subacro-
mial bursitis and has become an accepted
method of investigation of shoulder pathol-
ogy. Dynamic sonography can provide direct
visualization of the relationships between the
anterior one third of the acromion, subacro-
mial bursa, supraspinatus tendon, and greater
tuberosity of the humeral head during active
shoulder motion. In the absence of subacro-
mial impingement, the motion of forward
flexion of the arm halfway between flexion
and abduction with pronation of the hand
does not elicit any pain, and at sonography,
the greater tuberosity of the humeral head
glides easily beneath the anterior one third of
the acromion (Fig. 2).
We have found patients with grade 1 shoul-
der impingement who felt pain during the dy-
namic evaluation but in whom no evidence of
anatomic impingement was shown on sonog-
raphy. We hypothesize that in patients with
grade 1 subacromial impingement, pain can
result from impingement occurring medially
on a hypertrophic degenerative acromiocla-
vicular joint or from contact with the cora-
TABLE 1: Dynamic Sonography Classification of Subacromial Impingement
Grade Clinical Finding Sonography Finding
0 No pain elicited during shoulder motion No evidence of anatomic impingement
1 Pain elicited during shoulder motion No evidence of anatomic impingement
2 Pain elicited during shoulder motion Evidence of soft-tissue impingement
3 Pain elicited during shoulder motion Evidence of upward migration of the humeral head
coacromial ligament. Sonography does not
permit direct visualization of the relation-
ships between the supraspinatus tendon and
the acromioclavicular joint because of the os-
seous structures blocking the ultrasound
beam. In addition, some degree of proximal
migration of the humeral head may possibly
occur in grade 1 subacromial impingement
without provoking any visible anatomic sub-
acromial impingement but nevertheless caus-
ing pain from irritation of inflamed tissues.
Grade 2 subacromial impingement is asso-
ciated with encroachment of the soft tissues
between the acromion and greater tuberosity
and may result from intrinsic soft-tissue abnor-
malities, such as tendinosis with thickening of
the tendon, the presence of calcific deposits
that create focal thickening of the tendon, or in-
flammation and distention of the subacromial
bursa (Fig. 3). Primary bursitis, which is seen
in inflammatory arthritis, gout, infections, and
other synovial diseases, must be excluded be-
fore subacromial impingement can be impli-
cated as the cause of soft-tissue impingement.
The shape of the acromion can also cause soft-
tissue impingement. Failure of humeral head
depression during shoulder motion may also
cause grade 2 subacromial impingement.
In grade 3 subacromial impingement, there
is failure of humeral depression resulting in
upward migration of the humeral head
(Fig. 4). The causes of this abnormal kine-
matics of the shoulder could be rotator cuff
muscle fatigue, tendon tear or tendinosis, or
shoulder joint instability, as described in the
article by Bigliani and Levine [12]. Adhesive
capsulitis, which presents with limited range
of motion of the glenohumeral joint, espe-
cially abduction and external rotation, should
be recognized and easily differentiated from
grade 3 subacromial impingement.
In this study, the majority (75%) of asymp-
tomatic shoulders were classified as grade 0,
but two shoulders (17%) were classified as
grade 1 and one shoulder (8%) as grade 3 sub-
acromial impingement. This may be the result
of a selection bias because patients who suffer
from subacromial impingement syndrome in
one shoulder may be more at risk of having
shoulder abnormalities on the contralateral
side. Dynamic shoulder sonography in a cohort
of subjects with both shoulders free of abnor-
malities might have provided different results.
In the group of symptomatic shoulders, the
majority (86%) were classified as grade 1, 2,
or 3, but two shoulders (14%) were classified
as grade 0. This should not be interpreted as
two false-negative cases because this study
Sonography of Shoulder Impingement Syndrome
AJR:187, July 2006 219
did not use a gold standard. These two cases
merely reflect a disparity between the diagno-
sis of subacromial impingement made at clin-
ical examination and the findings on dynamic
sonography evaluation and emphasize the
fact that this diagnosis is difficult to establish.
In conclusion, dynamic sonography eval-
uation of subacromial impingement must be
regarded as a subacromial impingement im-
aging test that can provide useful informa-
tion to the clinician and that can be easily in-
tegrated into a routine sonography shoulder
examination protocol. Sonography can show
which structure is being impinged and can
show upward migration of the humeral head,
thus providing valuable information about
the potential intrinsic and extrinsic causes of
this syndrome.
Fig. 2Subjective drawing (not based on cadaveric model) of normal dynamic
shoulder evaluation. Drawing (coronal plane, cut section) of left shoulder during
active elevation of arm halfway between flexion and abduction with hand in
pronation shows normal relationships between acromion (A), greater tuberosity (T)
of humeral head, and intervening soft tissuesnamely, supraspinatus tendon (S)
and subacromialsubdeltoid bursa (arrow). D = deltoid muscle.
Fig. 3Subjective drawing (not based on cadaveric model) of subacromial
impingement with soft-tissue involvement. Drawing (coronal plane, cut section) of
left shoulder during active elevation of arm halfway between flexion and abduction
with hand in pronation explicitly depicts pooling of fluid in lateral aspect of
subacromialsubdeltoid bursa (arrow) and alteration of normally convex surface of
supraspinatus tendon (arrowhead) as arm is elevated. Supraspinatus tendon is not
always involved in grade 2 subacromial impingement. There is also evidence of
supraspinatus tendinosis and inflammatory changes in bursa.
Fig. 4Subjective drawing (not based on cadaveric model) of subacromial
impingement with upward migration of humeral head. Drawing (coronal plane, cut
section) of left shoulder during active elevation of arm halfway between flexion and
abduction with hand in pronation shows upward migration of humeral head in
relation to glenoid cavity, which prevents passage of greater tuberosity (T) and soft-
tissue structures of supraspinatus outlet beneath acromion.
Bureau et al.
220 AJR:187, July 2006
References
1. Neer CS 2nd. Anterior acromioplasty for the
chronic impingement syndrome in the shoulder: a
preliminary report. J Bone Joint Surg Am 1972;
54:4150
2. Calis M, Akgun K, Birtane M, Karacan I, Calis H,
Tuzun F. Diagnostic values of clinical diagnostic
tests in subacromial impingement syndrome. Ann
Rheum Dis 2000; 59:4447
3. Bigliani LU, Morrison DS, April EW. Morphology
of the acromion and its relationship to rotator cuff
tears. (abstr) Orthop Trans 1986; 10:459460
4. Haygood TM, Langlotz CP, Kneeland JB, Iannotti
JP, Williams GR Jr, Dalinka MK. Categorization of
acromial shape: interobserver variability with MR
imaging and conventional radiography. AJR 1994;
162:13771382
5. Peh WCG, Farmer THR, Totty WG. Acromial arch
shape: assessment with MR imaging. Radiology
1995; 195:501505
6. Beaulieu CF, Hodge DK, Bergman AG, et al. Gle-
nohumeral relationships during physiologic shoul-
der motion and stress testing: initial experience with
open MR imaging and active imaging-plane regis-
tration. Radiology 1999; 212:699705
7. Graichen H, Bonel H, Stammberger T, Englmeier
KH, Reiser M, Eckstein F. Subacromial space width
changes during abduction and rotation: a 3-D MR
imaging study. Surg Radiol Anat 1999; 21:5964
8. Farin PU, Jaroma H, Harju A, Soimakallio S. Shoul-
der impingement syndrome: sonographic evalua-
tion. Radiology 1990; 176:845849
9. McFarland EG, Selhi HS, Keyurapan E. Clinical
evaluation of impingement: what to do and what
works. J Bone Joint Surg Am 2006; 88:432441
10. Neer CS 2nd. Impingement lesions. Clin Orthop
Relat Res 1983; 173:7077
11. Brossmann J, Preidler KW, Pedowitz RA, White
LM, Trudell D, Resnick D. Shoulder impingement
syndrome: influence of shoulder position on rotator
cuff impingementan anatomic study. AJR 1996;
167:15111515
12. Bigliani LU, Levine WN. Current concepts review:
subacromial impingement syndrome. J Bone Joint
Surg Am 1997; 79:18541868
13. Teefey SA, Hasan A, Middleton WD, Wright RW,
Yamaguchi K. Ultrasonography of the rotator cuff.
J Bone Joint Surg Am 2000; 82:498504
F O R Y O U R I N F O R M AT I O N
A data supplement for this article can be viewed in the online version of the article at: www.ajronline.org.