Shoulder Impingement Syndrome

Click here for printer friendly PDF file.



Shoulder impingement is a condition that results from the rotator cuff and the bursa pushing upward against a portion of the shoulder blade called the acromion

This area of the shoulder is referred to as the point of the shoulder or the upper outer aspect of the shoulder.

The shoulder impingement syndrome is a complex situation that involves a number of structures and processes. These would include inflammation of the bursa, which sits on top of the tendons and inflammation in the tendons of the rotator cuff themselves.

Inflammation in this area can be caused by injury or perhaps more commonly by wear and tear of the shoulder tissues.

A tear in the rotator cuff tendons is usually the result of impingement existing over a period of time.

Signs and Symptoms

There is no single initiating event in the cause of shoulder impingement syndrome. It can come on slowly and result only in some occasional soreness usually in the front part of the shoulder. Mild weakness in the shoulder is often ignored, as is loss of range of motion and the ability to lift the arm overhead. Movement of the shoulder may be mildly or severely painful.

A tear of the rotator cuff can be part of the shoulder impingement syndrome complex. This is often characterized by sufficient weakness that the arm cannot be held outward from the shoulder against any resistance. However, shoulder impingement can exist without a tear in the rotator cuff. A tear in the rotator cuff may be thought of as an end stage of impingement syndrome.

It is usually not possible to have tendonitis in the shoulder without bursitis also being present as the tendon and bursa structures are intimately related to one another. (See Online Orthopaedics web site articles pertaining to shoulder pain and the rotator cuff).

Almost anyone can get shoulder impingement syndrome. You do not have to be an athlete or industrial worker to have the problem. People develop these problems at home more frequently than they do in sports or at work.

Bursitis is common in persons who excessively use the shoulder, for example, while pitching a baseball; however, it is also common in people who are painting or washing windows. Those in middle age or older are more prone to develop bursitis.

Tendonitis seems to develop over time in persons whose muscles are not in good condition or in younger persons who have over used the arm and shoulder.

Treatment

  • Rest is the recommended initial treatment.
  • Ice to the affected area can be very helpful as well as anti-inflammatory medications.
  • Sometimes the physician will prescribe physical therapy
  • Sometimes the physician will suggest a steroid injection in the shoulder.
Symptoms from tendonitis, which very frequently accompany bursitis, are treated in a very similar way.

Diagnosis of Torn Rotator Cuff

Currently a torn rotator cuff is diagnosed in one of two ways. A shoulder arthrogram is sometimes done in which a contrast agent is injected into the shoulder, followed by a period of gentle exercises and plain x-rays of the shoulder.

MRI studies of the shoulder can also diagnose a rotator cuff tear and the study is sometimes done with or without a contrast injection. This would be at the discretion of the ordering physician or the radiologist. Sometimes the addition of MRI contrast material (Gadolinium) can greatly increase diagnostic accuracy.

More Advanced Treatment

If the initial attempts at treatment including rest, physical therapy, injection and medication are not successful, surgery is sometimes suggested.

In some cases, arthroscopic surgery can be done to relieve the condition and even possibly repair ligaments. This can be done perhaps one third of the time. In the other two thirds surgery is usually required in the traditional way of open surgery to decompress the shoulder and/or repair torn rotator cuff tendons.

In my experience, surgery for this type of shoulder problem has been very helpful in relieving the patient's symptoms. I think it is one of the more successful types of surgery done by most orthopaedic surgeons. This is true whether the surgery is open or arthroscopic.

The Future

If someone has been improved with conservative treatment or has required surgery, certain adjustments need to be made for maintenance of improvement in the future.

It may take several months to improve sufficiently to resume some activities. Whether the person would be able to successfully resume any and all activities that they wish to participate in is frequently uncertain.

In my experience successful shoulder surgery of this type is accompanied by the patient making certain adjustments in their expectations of what the shoulder can do and what they can participate in. This is not to say they have to give up all activities to maintain their improvement. This would depend on the overall success of the treatment and how strenuous the activities are that the person wishes to participate in.

In most cases, the outlook is favorable and the patient is satisfied with the treatment.