What is Shoulder Impingement?
Shoulder Impingement syndrome is a common cause of adult shoulder pain. Shoulder Impingement is also called subacromial bursitis, swimmer’s shoulder, tennis shoulder, or rotator cuff tendinitis.
When the impingement is caused by bursitis, space becomes too narrow to accommodate the tendons and the bursa. Shoulder Impingement occurs when the tendons or bursa catch, pinch or rub on the shoulder bones.
If Shoulder Impingement Is Untreated?
Over time, Shoulder Impingement can lead to inflammation of the rotator cuff tendons (tendinitis) and bursa (bursitis). If not treated appropriately, the rotator cuff tendons can start to thin and tear.
Causes of Shoulder Impingement
Normally, the rotator cuff tendons can easily slide under the acromion each time your arm is raised; however, it is normal to have some degree of rubbing or pinching of the tendons and bursa.
The insufficient room between the acromion and the rotator cuff can cause impingement. This results from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arms are lifted.
Overuse of the shoulder in an elevated position can cause the impingement to become a problem and can lead to ongoing pain or damage to the rotator cuff tendons.
- Using arms overhead
- Repetitive lifting
- Result of a minor injury
In some circumstances, a partial tear of the rotator cuff may cause impingement pain.
Who is Affected by Shoulder Impingement?
Shoulder Impingement is more likely to occur in young and middle-aged people who engage in physical activities that require repeated overhead arm movements.
The condition is common in
- A sport such as: tennis, golf, swimming, weight lifting, or throwing a ball.
- Work that requires repeated overhead lifting or work at or above shoulder height is also at risk of rotator cuff impingement.
The pain may be due to "bursitis" or inflammation of the bursa overlying the rotator cuff or a "tendonitis" of the cuff itself.
Shoulder Impingement can also be caused by age-related degeneration.
Symptoms of Shoulder Impingement
Individuals with shoulder impingement may experience severe pain at rest and during activities, weakness of the arm and difficulty in raising the hand overhead.
Sufferers of Shoulder Impingement may have the following symptoms:
- Minor pain, present with activity and rest
- Pain radiating from the front of the shoulder to the side of the arm
- Pain with lifting and reaching movements
- Pain at night
- Loss of strength and motion
Shoulder Impingement caused by bursitis may include:
- Pain around the outside or tip of the shoulder
- Pain when the shoulder is touched
- Reduced range of movement in the shoulder joint
- Swelling and redness around the shoulder
- Shoulder pain when the arm is raised, such as reaching shelves or washing hair
The pain may become worse at night, especially when lying on the affected shoulder. It may also get worse after the shoulder has been kept still for a while.
If the above symptoms are coupled with a fever, the bursa may be infected. This is called septic bursitis, and a doctor should investigate the situation.
Diagnosis of Shoulder Impingement
While not all of these diagnostic approaches or tests are required to confirm the diagnosis, the diagnostic process will allow your surgeon to review any possible risks or existing conditions that could interfere with the surgery or its outcome.
During this consultation, your surgeon will:
- take a medical history,
- physical examination by your surgeon - Often Shoulder Impingement can be identified during a physical exam by your surgeon. By examining the joint, the cause of symptoms can be pinpointed.
- assessment of the range of movements and strength of the affected shoulder, and
- look for other associated causes of shoulder pain.
In order to clearly understand the nature of any loss of the joint space or bone spur formation. If imaging scans are required they can include:
- Ultrasound – This is a useful first-line test to help assess the amount of subacromial bursitis or the presence of any rotator cuff tear
- X-rays – Since x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur. Occasionally you can see calcific deposits in the tendon, related to a condition called calcific tendinopathy. A special x-ray view called an "outlet view," sometimes will show a small bone spur on the front edge of the acromion.
- MRI - can create more detailed images of your shoulder’s soft tissues. An MRI can produce cross-sectional images of internal structures such as the labrum (link back to labral tear), cartilage and rotator cuff if the diagnosis is unclear.
Where appropriate an Arthroscopy may be performed.
Treatment for Shoulder Impingement
Treatment typically involves resting the affected joint and protecting it from further trauma. In most cases, bursitis pain goes away within a few weeks with proper treatment, but recurrent flare-ups of bursitis are common.
When deciding on the appropriate treatment for Shoulder Impingement Your surgeon will consider your age, activity level and general health.
- Non-steroidal anti-inflammatory medication
- Cortisone injection into your shoulder’s subacromial space
Shoulder Impingement Surgery
Shoulder Impingement surgery may improve function and reduce pain to the shoulder joint and prevent future pain.
Minimally Invasive Shoulder Surgery
Shoulder Impingement surgery can now be performed arthroscopically (‘key-hole’), depending on the patient’s particular situation, with much smaller incisions.
Occasionally, however, arthroscopic surgery may need to be converted to open surgery to properly repair the damage to internal structures.
Minimally invasive surgery involves:
- Two or three small incisions(portals) are made. Each incision is called a portal.
- In one portal, the arthroscope is inserted to view the shoulder joint. Along with the arthroscope, a sterile solution is pumped to the joint which expands the shoulder joint, giving the surgeon a clear view and room to work.
- With the images from the arthroscope as a guide, the surgeon can look for any pathology or anomaly. The large image on the television screen allows the surgeon to see the joint directly and to determine the extent of the injuries, and then perform the particular surgical procedure, if necessary.
- Most often for impingement syndrome, the surgery involves decompressing the space above the rotator cuff and bursa by using a burr to remove spurs from the acromion (the ‘roof of the shoulder’).
- The bursa is then excised and removed using a shaver through one of the portals. If there is an associated rotator cuff tear (link back to rotator cuff tear), this can be repaired arthroscopically at the same time
- After surgery, the shoulder, the portals (incisions) are closed by suturing or by tape.
Impingement Surgery Preparation
Once Your doctor decides that surgery is required, preparation is necessary to achieve the best results and a quick, problem free recovery.
Preparing mentally and physically for surgery is an important step toward a successful result.
- Your surgeon will create a treatment plan and
- patients will also need to understand the process and their role in it
Participating and completing a tailored exercise program before (ie. pre-hab) with a trained physiotherapist will achieve the best result after surgery.
Your doctor will also need to:
- discuss any medications being taken with your doctor or physician to see which ones should be stopped before surgery
- do not eat or drink anything, including water, for 6 hours before surgery
- stop taking aspirin, warfarin, anti-inflammatory medications or drugs that increase the risk of bleeding one week before surgery to minimise bleeding
- review blood replacement options (including banking blood) with your doctor
- stop or cut down smoking to reduce your surgery risks and improve your recovery
Post Shoulder Impingement Surgery
The patient will wake up in the recovery room and then be transferred back to their hospital room.
- Pain medication will be provided to keep the patient comfortable.
- A bandage will be around the operated shoulder and the arm will be in a sling or brace.
- The sling will be worn for about 2-6 weeks to facilitate healing.
Your surgeon will see the patient prior to discharge and explain the findings of the operation and what was done during Surgery.
- The bandage will usually be removed 24 hours post surgery and in place will be water-proof sterile dressings which should remain intact until your post-operative follow-up review in 2 weeks.
- It is normal for the shoulder to swell after the surgery. Placing Ice-Packs on the shoulder will help to reduce swelling. Ice packs should be applied to the area for 20 min 3-4 times a day until swelling has reduced.
The patient should keep a pillow under their elbow while lying in bed.
- The patient will not be allowed to lift anything over your head or anything greater than 1 kilo for the first 6 weeks.
- 10-14 days after surgery Your doctor will see the patient to monitor their progress and remove the sutures.
It is recommended that the patient not drive during the first 6 weeks while wearing a sling due to safety reasons and the risk of injury to the surgical site.
You will be given specific instructions regarding activity and a rehabilitation program of exercise and strengthening.
Eating a healthy diet and not smoking will promote healing.
Untreated Shoulder Impingement
Shoulder Impingement is not life-threatening but can severely impact a patient’s quality of life and function.
It can affect anyone: elite athletes and the active individual, manual labourers and office workers.
Shoulder Impingement can lead to
- Short Term Impact – inflammation of the rotator cuff tendons and bursa.
- Long Term Impact – rotator cuff tendons may start to thin and tear.
Impingement Surgery Risks
As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
It is important that the patient is informed of these risks before the surgery takes place.
Complications can be medical (general) or specific to Shoulder Resurfacing surgery.
Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:
- Allergic reactions to medications
- Blood loss requiring transfusion with its low risk of disease transmission
- Heart attacks, strokes, kidney failure, pneumonia, bladder infections.
- Complications from nerve blocks such as infection or nerve damage.
Serious medical problems can lead to ongoing health concerns, prolonged hospitalisation or rarely death. Specific complications for surgery are rare but may include:
- Infection - Infections can occur superficially at the incision or in the joint space of the shoulder, a more serious infection. Infection rates vary; if it occurs it can be treated with antibiotics but may require further surgery.
- Shoulder Stiffness - Shoulder stiffness with loss of range of motion is a common complication that can be greatly minimized with strict adherence to your occupational therapy program prescribed by your surgeon.
- Damage to nerves of Blood Vessels - Also rare but can lead to weakness or loss of sensation in part of the arm. Damage to blood vessels may require further surgery if bleeding is ongoing.
- Damage to the joint - Joint damage to the cartilage or other structures can occur during surgery and may require another operation to repair.
- Blood Clots (Deep Venous Thrombosis) - Blood Clots can form in the arm muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life-threatening. If the patient suffers arm pain, redness or swelling, or have shortness of breath at any stage, contact Your doctor
- Haemarthrosis - A condition caused by excess bleeding into the joint after the surgery is completed. This may require additional surgery to irrigate the joint. e surgery is completed. This may require additional surgery to irrigate the joint.
Your Next Step
If you are experiencing any of the above symptoms Dr Austin Vo can offer advice on a possible diagnosis, further investigations and suitable treatment.
We would advise that you see your general practitioner to obtain a referral to see Dr Vo at Melbourne Shoulder & Knee and arrange an appointment now for peace of mind and body.
Dr Austin Vo is a specialist orthopaedic surgeon in Melbourne who is focused on conditions and treatments for the Shoulder and Knee.