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SHOULDER IMPINGEMENT

What is shoulder impingement?

Shoulder impingement, or shoulder impingement syndrome, is a very common cause of shoulder pain, where the supraspinatus tendon (one of the rotator cuff tendons) inside your shoulder joint rubs or catches on nearby tissue (bursa) and bone (acromion) as you lift your arm.

Shoulder impingement is an old term that gave the impression that pain was caused by the rotator cuff tendon and bursa being pinched between the humeral head and acromion and we now realise that this is an oversimplification, and that pain can happen with no mechanical problem, so it is now referred to as Subacromial Shoulder Pain.

It affects the rotator cuff tendon, which connects the muscles around your shoulder joint to the top of your arm. Problems with the rotator cuff tendon can cause pain, the subacromial bursa or both. Rotator cuff tendon problems that can cause subacromial pain include rotator cuff tendinopathy, partial-thickness rotator cuff tears, and calcific tendonitis. Subacromial bursitis is the main bursal problem.

Pain in the shoulder will often improve in a few weeks or months, especially with the right type of shoulder exercises, but occasionally it can be an ongoing problem.

What are the symptoms of shoulder impingement?

What is shoulder impingement Shoulder impingement can start suddenly or come on gradually. Patients mostly complain of pain on the outside of the shoulder over the deltoid muscle. Symptoms include:

  • pain in the top and outer side of your shoulder
  • pain that’s worse when you lift your arm, especially when you lift it above shoulder height
  • weakness in your arm
  • pain or aching at night, which can affect your sleep

The difference between frozen shoulder and impingement syndrome is that you will not experience stiffness with an impingement, if your shoulder is stiff you might have a frozen shoulder instead.

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When should you get medical help?

The first line of treatment for shoulder impingement should be non-operative. Over the counter pain killers such as an anti-inflammatory can help with pain and inflammation. In addition to pain killers icing the shoulder may help with inflammation. Gently hold an ice pack (or bag of frozen peas) wrapped in a towel on your shoulder for 15 to 20 minutes a few times a day.

Most patients with shoulder pain tend to rest their shoulder to avoid pain and this can quickly lead to weakness of the rotator cuff muscles, so it is important to exercise the shoulder to improve strength and posture for long term control of symptoms.

The British Elbow & Shoulder Society has produced a patient resource for patients with subacromial shoulder pain. This provides information and a good home exercise program to help rehabilitate the shoulder.

If these self-management options do not work, some patients may go on to need subacromial steroid injections for control of pain and inflammation, and formal exercise focused physiotherapy to work on strength and posture. Patients usually require at least 12 weeks of physical therapy to see long term improvements.

Patients with calcific tendonitis may require slightly different treatment. You can read more about this condition here. Shoulder impingement does not normally cause chest pain or numbness in fingers, this may be Thoracic Outlet Syndrome (TOS).

What not to do with shoulder impingement?

Avoid things that make the pain worse – avoid activities that involve repeatedly lifting or moving the arm above your head (such as swimming or playing tennis) for a few days or weeks. Don’t throw anything as this uses the upper arm, avoid weightlifting (especially over-head presses or pull-downs as this affects the biceps tendon) and avoid repetitive activities that keep your elbow from being aligned to your side.

Do not stop moving your arm completely – try to carry on with your normal daily activities as much as possible so your shoulder does not become weak or stiff. It’s usually best to avoid using a sling.

What is the non-operative management of shoulder impingement?

Having the right physiotherapy exercises will help to improve shoulder posture and further strengthen your muscles to improve your pain and range of movement. You may need to do these exercises with a physiotherapist at first so they can assess your range of motion and your medical history, but after a while, you’ll usually be able to continue doing them at home. If the exercises make your pain worse or your pain does not improve after a few weeks you may need a specialist review.

Steroid injections into your shoulder can help relieve pain by settling inflammation if rest and exercises on their own do not help. But it’s still important to do your shoulder exercises, as injections usually only have an effect for a few weeks and your pain may come back if you stop the exercises.

What if non-operative management does not work?

In some patients who fail to improve after steroids and physiotherapy and have persistent pain, surgery may be required. Any surgery required depends on the cause of the pain.

Most patients with persistent shoulder impingement may require an arthroscopic subacromial decompression. This operation is a key-hole, day-case, operation to clear out the subacromial bursa and shave the underside of the acromion. We recomend that this operation is performed with the patient awake under regional anaesthetic. You can find out more about awake shoulder surgery here.

Click here to download my post-operative rehab protocol for your physiotherapist.

Our instructions for post-op care and recovery after shoulder surgery can be found here.

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Nick Ferran @ Shoulder & Elbow London Ltd

Clinics in:

Chiswick – Harley Street – Harrow – St. Johns Wood