European Journal of Radiology 27 (1998) S42 S48

Shoulder impingement syndromes

Folco Rossi *
Italian Olympic Committee Sports Science Institute, Via Campi Sporti6i 46, 00197 Rome, Italy

Abstract
Objective: Not all shoulder pain conditions are a consequence of rotator cuff injuries secondary to anterior subacromial
impingement. Additional causative forms have been identified and classified as posterosuperior glenoid rim, subcoracoid and
suprascapular nerve (at spinoglenoid notch) impingement syndromes. Material and methods: We reviewed 206 consecutive
magnetic resonance examinations carried out with conventional T1- and T2-weighted spin-echo and gradient-echo sequences in
patients complaining of shoulder pain. Adjunctive sequences were acquired with the involved arm positioned in abduction and
external rotation. Results: Anterior subacromial impingement is only one of the possible causes of shoulder disorders.
Posterosuperior glenoid rim impingement is the most frequent cause of shoulder pain in young throwers. Subcoracoid and
spinoglenoid notch suprascapular nerve impingement are additional forms that must be considered in the differential diagnosis
because of their frequent occurrence in routine clinical practice. Conclusion: Magnetic resonance imaging is the most useful
diagnostic modality for shoulder disorders. 1998 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Shoulder impingement; Soft tissue; Magnetic resonance imaging

1. Introduction
The shoulder impingement syndrome is usually a
painful condition in which the soft tissues of the
subcromial space (bursa, rotator cuff tendons, biceps
tendon) are chronically entrapped between the humeral
head and the coracoacromial arch (anterior acromion,
coracoacromial ligament, acromioclavicular joint).
However, this syndrome, suggested by Codman and
demonstrated by Neer, does not always account for the
whole of shoulder conditions and additional symptomatic impingement syndromes have been hypothesized, identified and finally classified.
The four main and most frequent types are: (1)
anterior subacromial impingement [1]; (2) posterosuperior glenoid rim impingement [2]; (3) subcoracoid impingement [3]; and (4) suprascapular nerve (at
spinoglenoid notch) impingement [4].
Various imaging modalities, especially magnetic resonance imaging (MRI), have yielded very good results in
* Present address: Via S. Agatone Papa 34, I-00165 Roma, Italia.
Tel.: + 39 6 634859.

the study of these different friction and impingement

disorders and this is the subject of our presentation.

2. Materials and methods

The images presented in the paper were selected from
206 consecutive MR examinations performed last year
in patients who had had shoulder pain for more than 3
months before the first consultation. The patients were
1670 years old (mean: 41).
MR studies were carried out with a .2T permanent
magnet and a solenoid collar-shaped receiver coil, the
patients positioned supine with the arm in neutral
position.
T1-weighted spin-echo (TR 500, TR 20) and T2weighted gradient-echo (TR 500, TE 25, FA 50) were
always acquired. The matrix was 256 256 and the
FOV 240 mm; slice thickness was 45 mm with no
interslice gap. The images were acquired on obliquecoronal, axial and oblique-sagittal planes.
The images with the arm totally abduced and extrarotated were acquired, on an axial scout image, on

0720-048X/98/$19.00 1998 Elsevier Science Ireland Ltd. All rights reserved.

PII S0720-048X(98)00042-4

F. Rossi / European Journal of Radiology 27 (1998) S42 S48

the sagittal plane. These 4-mm Tl-weighted SE sequences clearly depict and characterize supraspinatus
tendon partial tears, as well as labrum and bone injuries. All MR findings were confirmed surgically.
3. Diagnostic considerations and images

3.1. Anterior subacromial impingement syndrome [1,5,6]

The shape and orientation of the acromion process
and osteophyte at the acromioclavicular joint are usually considered favoring factors. The presence of ossification of the coracoacromial ligament or of an os
acromiale (Fig. 1) are unusual favoring factors.
Three progressive lesion stages have been classified:
Stage 1. Occurs in young patients. Histologically, it
exibits edema and hemorrhage in the rotator cuff tendons (especially the supraspinatus) and synovial reaction in the bursa (Fig. 2).
Stage 2. Generally occurs in patients 20 40 years
old. Disorders consist of fibrosis and thickening of the
bursa and rotator cuff tendons including microscopic
and partial tears (Fig. 3).

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Stage 3. Is common in patients over 40. It features

complete rotator cuff tears (small, moderate, large,
massive) and biceps tendon changes (Fig. 4).

3.2. Posterosuperior glenoid rim impingement syndrome

[2,7,8]
Humeral retrotorsion much lower than the normal
2530, seems to be a favoring pathogenetic factor.
This syndrome is frequently complained of by the
athletes who practice sports involving repeated forceful
overhead abduction and external rotation.
Mostly posterior shoulder pain is the main clinical
feature, while glenohumeral bone degeneration is seen
at radiography (Fig. 5); supraspinatus tendon deep
surface tears and posterosuperior glenoid rim and
labrum changes (Fig. 6), are also depicted.

3.3. Subcoracoid impingement syndrome [3,9,10]

The most important favoring factors are inherent
abnormalities in orientation and length of the coracoid
process and acquired bone changes in the coracohumeral space components resulting from lesser
tuberosity or coracoid process displaced fractures especially if healed in pseudoarthrosis (Fig. 7).
Anterior pain over the coracoid results from repeated
arm flexion and internal rotation.
The continous contact between the coracoid tip and
the most prominent part of the lesser tuberosity causes
progressive bone degeneration, inflammation of the
subscapularis bursa and substance damage of the subscapularis tendon that may develop and result in isolated partial or complete tear (Fig. 8).

3.4. Suprascapular ner6e (at the spinoglenoid notch)

impingement syndrome [4,11,12]

Fig. 1. Anterior subacromial impingement syndrome; favoring factors. (A) acromial hook; (B) acromioclavicular osteophyte; (C) coracoacromial ligament ossification; (D) os acromiale.

A calcified or hypertrophic spinoglenoid ligament

and excessive nerve angulation, when it curves entering
the infraspinatus fossa, are considered important
pathogenetic factors of this syndrome.
Nerve entrapment from ganglion cysts at the
spinoglenoid notch or consequent to local trauma has
been reported (Fig. 9).
This syndrome has been reported in volleyball players of both genders. Infraspinatus muscle atrophy, decreased strength in external rotation and pain in the
posterior and lateral dominant arm are found in 20%
of professional players.
The syndrome results from gradual frictional degeneration and stretching over the terminal branches of the
nerve against the base of the notch during service to try
to give the ball a floating trajectory (Fig. 10).

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F. Rossi / European Journal of Radiology 27 (1998) S42 S48

Fig. 2. Stage 1: (A) subacromial bursitis; (B) tendinitis; (C) subacromial subdeltoid bursitis; (D) advanced tendinitis.

Fig. 3. Stage 2: (A) bursal fibrosis; (B) tendinosis; (CE) rotator cuff partial tear: bursar surface, intratendinous, articular surface.

F. Rossi / European Journal of Radiology 27 (1998) S42 S48

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Fig. 4. Stage 3: Complete rotator cuff tears: (A D) small, moderate, large, massive (see geyser sign).

Fig. 5. Posterosuperior glenoid rim impingement syndrome; X-ray features. (A C) Degenerative glenohumeral bony changes shown in lateral
glenoid view.

4. Conclusion
Rotator cuff disorders, causing painful shoulder
disability, do not always result from the attritional
degeneration beneath the coracoacromial arch as described by Neer [1,5]. Other forms of impingement
have thus been suggested to try to explain the actual
cause of different symptomatic shoulder injuries.

These additional impingement syndromes are much

more frequent than it is commonly thought, especially
in the posterosuperior glenoid rim which is the most
frequent cause of shoulder pain in young sportsmen
and women in our experience.
MR high diagnostic accuracy has always been
confirmed.

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F. Rossi / European Journal of Radiology 27 (1998) S42 S48

Fig. 6. Coronal oblique and sagittal sequences in abduction and extrarotation demonstrate the partial tears of the articular surface of the
supraspinatus, the glenoid rim and labrum damage.

Fig. 7. Subcoracoid impingement syndrome favoring factors. (A,B) Inherent coracoid process abnormalities. (C,D) Reduced coracohumeral space
from lesser tuberosity and coracoid tip displaced fractures.

F. Rossi / European Journal of Radiology 27 (1998) S42 S48

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Fig. 8. (A,B) Tip coracoid osteophytes and traumatic geodes caused by repeated microtraumas. (C,D) Traumatic subscapularis tendon tear with
dislocation of the long biceps tendon (coracohumeral normal width 8.7mm).

Fig. 9. Suprascapular nerve impingement syndrome at spinoglenoid notch. (A) Infraspinatus muscle atrophy in a volleyball player. (B) Synovial
ganglion cyst at spinoglenoid notch. (C) Infraspinatus muscle and tendon tear.

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Fig. 10. Different degrees of infraspinatus muscle atrophy are shown by axial sequences.

References
[1] Neer CS. Anterior acromioplasty for the chronic impingement
syndrome in the shoulder: a preliminary report. J Bone Jt Surg
Ser A 1972;54:41 49.
[2] Walch G, Liotard JP, Boileau P, Noel E. Le conflit glenoidien
posterosuperieur: un autre conflit de lepaule. Rev Chir Orthop
1991;77:571 574.
[3] Goldthwait JE. An anatomic and mechanical study of the shoulder joint, explaining many of the cases of pain shoulder, recurrent dislocations and brachial neuralgias. Am J Orthop Surg
1909;6:579 606.
[4] Thomas A. La paralyse du muscle susepineux. La Presse Medic
1936;64:1283 1284.
[5] Neer CS. Impingement lesions. Clin Orthop 1983;173:71 77.
[6] Sartoris DJ. Principles of Shoulder Imaging. New York: McGraw-Hill, 1995.

[7] Rossi F, Ternamian PJ, Cerciello G, Walch G. Il conflitto

glenoideo posterosuperiore nellatleta: valve diagnostico della
radiologia tradizionale e della RM. Radiol Med 1994;87:2227.
[8] Tirman PFJ, Bost FW, Garvin GJ, et al. Posterosuperior glenoid
impingement of the shoulder: findings at MR imaging and MR
arthrography with arthroscopy correlation. Radiology
1994;193:431 436.
[9] Gerber C, Terrier F, Ganz R. The role of the coracoid process in
the chronic impingement syndrome. J Bone Jt Surg Ser A
1985;67B:703 708.
[10] Patte D. The subcoracoid impingement. Clin Orthop Rel Res
1990;254:55 59.
[11] Ferretti A, Cerullo G, Russo G. Suprascapular neuropathy in
volleyball players. J Bone Jt Surg Ser A 1987;69A:260263.
[12] Rossi F, Barile A. Nervous diseases: spinal and peripheral nerve
entrapments. In: Masciocchi C, editor. Radiological Imaging of
Sports Injuries. Berlin: Springer Verlag, 1998.