Shoulder impingement: imaging and treatment

1. What is seen on plain film with impingement? Chronic rotator cuff tear?
2. What is the gold standard for rotator cuff tears? For labral tears?
3. What is the utility of arthrogram for rotator cuff tears?
4. What is the conservative treatment for rotator cuff injury in the acute phase (first 4 weeks)?
5. What is the conservative treatment for the first 6 months? After the first 6 months?
6. What are the indications for surgery?

Answers:
1. With impingement, there are cystic changes in the greater tuberosity. In chronic rotator cuff tear, there is superior migration of the proximal humerus, flattening of the greater tuberosity, and subacromial sclerosis.
2. MRI for rotator cuff, add gadolinium for labral assessment.
3. Can assess full thickness tears but can't tell size of tear or partial thickness tear.
4. Relative rest, pain management, modalities, reestablish nonpainful ROM, retard muscle atrophy.
5. In first 6 months, improve ROM, improve rotator cuff strength and scapular stabilizers. After the first 6 months, continue strengthening, do activity-specific training, conticosteroid injections.
6. Surgical indications include tears that fail conservative treatment. In athletes, surgical repair may be done within first 3 weeks for better return of function.