Internal impingement of the shoulder

Case contributed by Andrew Dixon


Posterior shoulder pain in a high-level tennis player.

Patient Data

Age: 35 years
Gender: Male

There are a combination of findings suggestive of internal shoulder impingement consisting of cysts within the humeral head underlying the superior fibers of infraspinatus, undersurface fraying of the superior fibers of infraspinatus, tendinosis and intrasubstance delamination involving the posterior fibers of supraspinatus, and significant fraying of the posterosuperior glenoid labrum.  

There is mild thickening of the inferior glenohumeral ligament and anterior joint capsule.  Mild subcoracoid and rotator interval edema is evident. Normal appearance of the coracoacromial ligament.  Thickening / increased fluid within the subacromial / subdeltoid bursa. Early superficial chondral wear of the inferior portions of the glenohumeral joint.  Mild degenerative hypertrophy of the AC joint with mild capsular hypertrophy and adjacent marrow edema.

Annotated image

Constellation of findings in keeping with internal shoulder impingement. Posterior fiber supraspinatus tendinosis with intrasubstance delamination and overlying bursal fluid (black arrow). Humeral head cysts underlying the superior insertional fibers of infraspinatus which demonstrate undersurface fraying (white). Significant fraying of the posterosuperior glenoid labrum (grey arrow). 

Case Discussion

Features of internal impingement of the shoulder with humeral head cysts underlying infraspinatus, superior fiber infraspinatus and posterior fiber supraspinatus tendinosis and posterosuperior labral fraying. Subacromial bursal thickening and increased fluid indicating co-existing subacromial bursitis.

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