Shoulder pain is a very common complaint. Your shoulder is made up of several joints, tendons and muscles that allow a wide range of motion of the joint and whole arm. Because the shoulder is so complex, it is vulnerable to a variety of problems. The rotator cuff is a frequent source of pain in the shoulder and this pain can be the result of shoulder impingement.
The word impingement basically means "rubbing" or "catching" of structures. In this context, we refer to structures within the shoulder. It is the impingement of the rotator cuff against other structures within the shoulder which form the basis of impingement syndromes.
When you raise your arm to shoulder height, the space between the rotator cuff and acromion decreases, this causes rubbing ("impingement") between the tendon and the bursa, leading to irritation and pain. This is a shoulder impingement.
Rotator cuff pain is common in both young athletes and middle-aged people. People who use their arms overhead for tennis, swimming and other overhead sports are particularly vulnerable. Those who do repetitive lifting or overhead activities/work using the arm (such as construction or painting) are also susceptible. Pain may also develop as the result of a minor injury. Sometimes, it occurs with no apparent cause.
A shoulder impingement may become a serious problem for some people and disturb their normal activities. This is when treatment is needed.
External impingement (also known as Subacromial Impingement, Trapped tendons, Tendinitis or Bursitis) is where the rotator cuff is impinged in a part of the shoulder known as the sub-acromial space.
There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm.
Any abnormality affecting the rotator cuff could lead to the humeral head riding upwards closer to the Acromion. This effect could lead to impingement. The following may be the cause for this type of shoulder impingement:
Rotator cuff pain commonly causes pain and swelling in the front of the shoulder. You may have pain and stiffness when you lift your arm. There may also be pain when the arm is lowered from an overhead position. Initially symptoms may be mild. Patients frequently do not seek treatment at an early stage.
These symptoms may include:
As the problem progresses, the symptoms increase:
If the pain comes on suddenly, the shoulder may be severely tender. All movement may be limited and painful and thus you should see Dr van der Berg.
After discussing your medical history and symptoms, your doctor will examine your shoulder. He will check to see whether it is tender in any area or whether there is a deformity. To measure the range of motion of your shoulder and arm strength, your doctor will have you move your arm in several different directions and do several specific tests.
Your doctor will also examine your neck to make sure that the pain is not coming from a "pinched nerve" and to rule out other conditions, such as arthritis.
Imaging tests such as the following may also be done to diagnose an external shoulder impingement:
The goal of treatment is to reduce pain and restore function. In planning your treatment, your doctor will consider several factors including your age, activity level, and general health.
In most cases, initial treatment of shoulder dislocations is nonsurgical. Although nonsurgical treatment may take several weeks to months, many patients experience a gradual improvement and return to function.
Subacromial bursitis and impingement http://www.youtube.com/watch?v=TcsJOLSYcHg
Subacromial decompression: http://www.youtube.com/watch?v=Yb2YsSbSdck
When nonsurgical treatment does not relieve pain, your doctor may recommend surgery to repair such a shoulder dislocation. The goal of surgery is to create more space for the rotator cuff. Your doctor will remove the inflamed portion of the bursa and perform an anterior acromioplasty (part of the acromion is removed). This is also known as a subacromial decompression. This procedure is done arthroscopically (keyhole surgery).
During arthroscopic shoulder surgery thin surgical instruments are inserted into 3 or 4 small puncture wounds around your shoulder. Your doctor examines your shoulder through a fiber-optic scope connected to a television camera. The surgeon guides the small instruments using a video monitor and removes bone and soft tissue. In most cases, the front edge of the acromion is removed (acromioplasty) along with some of the bursal tissue (bursectomy).
Your surgeon may also treat other conditions present in the shoulder at the time of surgery. These can include:
After surgery, your arm will be placed in a sling for a short period of time (if no rotator cuff repair was necessary). This allows for early healing and movement. As soon as your comfort allows, you may remove the sling to begin exercise and use of the arm. Your doctor will provide a rehabilitation program (guided by a specific physiotherapist) based on your needs and the findings at surgery. This will include exercises to regain range of motion of the shoulder and strengthen the arm. It typically takes three to six months to achieve complete relief of pain, but it may take up to a year.
Internal shoulder impingement involves other structures within the main shoulder joint itself (Glenohumeral joint). This condition is mainly seen in athletes, where overhead activity is a major part of their sport, particularly throwing athletes. In-fact, the condition is sometimes called "The Throwers Shoulder" and is also seen in the "Swimmer’s Shoulder". It is for this reason that it is mainly seen in a younger athletic population.
This picture shows how all the components of the shoulder come together during throwing.
The main symptom of an internal shoulder impingement is usually pain in the shoulder. This is made worse by over-head activity or throwing. There may also be shoulder instability as a result of the damage done to the labrum. The damage done to the rotator cuff may cause a weakness in the movements of the shoulder.
Internal impingement is usually diagnosed on clinical examination. Special tests such as a MR-arthrogram (MRI with contrast injected in the shoulder) may be useful. Similar things may also be picked up on an ultrasound scan.
When nonsurgical treatment does not relieve pain, your orthopaedic surgeon may recommend surgery. This is aimed at repairing rotator cuff damage or labral damage. If the rotator cuff is badly damaged, repair must be considered.