Patient Information: Shoulder Impingment
Shoulder is constituted of several joints combined with tendons and muscles that allow a great range of motion and provide strength.
The rotator cuff ( group of muscles helping in shoulder movement) is a common source of pain in the shoulder. Pain can be the result of:
- Tendinitis. The rotator cuff tendons can be irritated or damaged.
- Bursitis. The bursa can become inflamed and swell with more fluid causing pain.
- Impingement. When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or "impinge" on) the tendon and the bursa, causing irritation and pain.
Young athletes who use their arms overhead for cricketing activities like bowling, swimming, baseball, and lawn tennis are particularly vulnerable. It is alos an occupational injury in those who do repetitive lifting or overhead activities using the arm, such as paper hanging, construction, or painting are also susceptible.In some patients, pain may develop secondary to minor injury. Sometimes, it occurs without any apparent cause.
Presentation/ Symptoms
Rotator cuff pathology usually causes pain in the front of the shoulder, accompanying swelling is ususally uncommon. Pain and stiffness is common when one lifts his arm. There may also be pain when the arm is lowered from an elevated over head position( thus called painful arc of movement).
Initial symptoms may be mild and may include:
- Minor pain that is present both with activity and at rest
- Pain radiating from the front of the shoulder to the side of the arm
- Sudden pain with lifting and reaching movements
- Athletes in overhead sports may have pain when throwing or serving a tennis ball
As the problem progresses, the symptoms increase:
- Pain at night
- Loss of strength and motion
- Difficulty doing activities that place the arm behind the back, such as buttoning or zippering
If the pain comes on suddenly, the shoulder may be severely tender. All movement may be limited and painful.
Treatment: The initial treatment in most cases is conservative i.e Non surgical. Depending on one's progress and degree of symptoms and clinical loss of function, surgical inetervention may be contemplated.The goal of treatment is to reduce pain and restore function. While planning the treatment, Orthopedic surgeon considers the age, activity level, and general health of the patient.
Nonsurgical Treatment
Rest. Your doctor may suggest rest and activity modification, such as avoiding overhead activities.
Non-steroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling.
Physical therapy. A physiotherapist will initially focus on restoring normal motion to your shoulder. Stretching exercises to improve range of motion are very helpful. If you have difficulty reaching behind your back, you may have developed tightness of the posterior capsule of the shoulder (capsule refers to the inner lining of the shoulder and posterior refers to the back of the shoulder). Specific stretching of the posterior capsule can be very effective in relieving pain in the shoulder.
Once your pain is improving, your therapist can start you on a strengthening program for the rotator cuff muscles.
Steroid injection. If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine. Injecting it into the bursa beneath the acromion can relieve pain.
Surgical Treatment is Subacromial Decompression.
When nonsurgical treatment does not relieve pain, surgery may be the next choice.The goal of surgery is to create more space for the rotator cuff. To do this, procedure is carried out to remove the inflamed portion of the bursa and if required refashion excess bone also called an anterior acromioplasty (in which part of the acromion is removed). The procedures can be performed using either an arthroscopic or open technique.
Arthroscopic technique. In arthroscopy, thin surgical instruments are inserted into the shoulder and the shoulder is examined through a fiberoptic scope connected to a television camera. .
Open surgical technique. A small incision is made in the front of theshoulder. This allows the doctor to see the acromion and rotator cuff directly and carry out the desired intervention.
Rehabilitation. After surgery, the arm is ususally be placed in a sling for a short period of time. This allows for early healing. As soon as your comfort allows, you can remove the sling to begin exercise and use the arm.Rehabilitation program based on your needs and the findings at surgery includes exercises to regain range of motion of the shoulder and strength of the arm. It typically takes 2 to 4 months to achieve complete relief of pain, but it may take up to a year.