Impingement syndrome refers to the mechanical compression and/or wear of the rotator cuff tendons as they pass under the bony structure of the shoulder. This compression can cause inflammation of the subacrominal bursa and other structures of the joint, resulting in a persistent increase in pain, tenderness and loss of motion in the affected shoulder. Normally the rotator cuff glides smoothly and without irritation between the undersurface of the acromion and the humeral head. A healthy rotator cuff is essential to shoulder strength, flexibility and control. One potential outcome of impingement syndrome is a rotator cuff tear.
The rotator “cuff” is actually a collective or cohesion of a group of four musculoskeletal structures that share a common tendon. The muscles originate at different places on the shoulder blade and insert on the upper portion of the arm bone. This group of muscles attach on or near the humeral head humerus via a combined tendon.
- Common rotator cuff injuries that can occur in addition to impingement are: tendonitis, bursitis and tears of the rotator cuff.
- Impingement is more common in older adults, ages 40+.
- Activities frequently associated with this injury include, tennis, swimming, baseball, and football.
- Non-surgical treatment is effective therapy for cuff injuries that do not involve a tear.
- A full tear will require surgery as the torn or abraded tendons will not heal without surgical repair or augmentation.
Signs and Symptoms
- Pain or weakness is present with overhead arm activities or when the arm is held away from the body.
- Muscles may “catch” or “grate” when your arm is rotated or raised.
- There is an inability to sleep on the affected side due to pain.
- With a complete or partial rotator cuff tear resulting from impingement, you may be unable to raise or extend the arm.
Contact the Doctor if …
- The patient has the signs and symptoms indicating impingement syndrome.
- Non-surgical therapy has failed to control the pain and restore shoulder function.
- Unexpected side effects occur from over the counter or prescription medications.
Causes of Injury
- Impingement occurs when inflammation or bony spurs form in the shoulder joint.
- Rotator cuff injury can occur from the repetitive movement of the rotator cuff against the rough surface of an inflamed degenerative joint.
- Degenerative rotator cuff tear associated with impingement occurs most commonly in patients in their mid 40′s to late 60′s.
- Sports that involve repetitive overhead movement can lead to impingement.
- Sports commonly associated with symptoms of impingement include tennis, swimming, baseball, softball and volleyball.
- Heavy overhead lifting that places repetitive stress on the shoulder can lead to impingement and cause a tear in the rotator cuff.
- Poor posture may cause a shoulder, muscles or tendons to become pinched under the top of the shoulder (acromion) and lead to impingement.
Expectations of Recovery
- A successful recovery is dependent on the severity of the condition and level of physical therapy needed to rehabilitate the shoulder.
- Through non-surgical treatment, symptoms may diminish in several weeks, but a return to full activity may take several months.
- Factors effecting surgical recovery include your age, physical condition, the presence or absence of a rotator cuff tear and the size of the tear if one is present.
The shoulder is a complex and unique joint. The muscles which support and stabilize the shoulder literally hold the joint together, as opposed to the mechanics involved in the hinged joints of the elbow or knee. Shoulder impingement syndrome is categorized into four stages based on the severity of the injury.
Stage I: Swelling and Mild Pain
Stage II: Inflammation and Scarring
Stage III: Partial or Complete tears of the rotator cuff
Stage IV: Rotator Cuff Arthropathy
A detailed history and physical exam should be conducted by an orthopedic surgeon to confirm the symptoms of impingemet. Rotator cuff tears, impingement syndrome, frozen shoulder, shoulder arthritis or a nerve injury within the shoulder may present similar symptoms on initial examination. The physical exam may include movement and resistance tests that will help to determine stability, flexibility and strength in the shoulder and assist in the making of the diagnosis of impingement.
The clinical findings may indicate a shoulder impingement, but to make an accurate and complete diagnosis, radiographic imaging studies may also be ordered. These tests will provide the physician with highly detailed views of your shoulder’s muscles and tendons. Plain x-rays will be taken of the involved shoulder to evaluate the bones. An MRI (magnetic resonance imaging scan) may also be ordered. The images from the MRI will show if inflammation, tears or other conditions or problems with the muscles and tendons are present.
After review of the clinical findings by your orthopedic surgeon and shoulder impingement is confirmed, your physician will discuss surgical versus non-surgical treatment options. In patients over the age of 60 or with those who have increased health risks, surgical treatment is suggested only after a careful assessment of all risk factors.
- Pain or weakness is present with overhead arm activities.
- Muscles may “catch” or “grate” when your arm is rotated or raised.
- Pain is present when sleeping on the affected side.
Initial treatment for shoulder impingement should begin with and include rest and a reduction in activity. The avoidance of all overhead activities is recommended.
Non-Surgical Treatment: Conservative Treatment of Shoulder Impingement
- Rest and Activity Modification: Initial treatment for shoulder impingement should begin with and include rest and a reduction in activity. The avoidance of all overhead activities is recommended.
- Medication: Over the counter or prescription medications, including NSAIDs, will help to reduce the inflammation and swelling of the shoulder muscles.
- Icing: Ice applied to the injured shoulder is an excellent way to reduce inflammation and pain.
- Injections: Moderate to severe cases may be treated with an injection of a corticosteroid into the subacromial area.
- Physical Therapy: Specific rotator cuff stretches and strengthening exercises may be prescribed by your physician.
Non-Surgical Product Considerations
NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) are a group of drugs used to control pain. This category of medications includes both prescription and common over-the-counter painkillers such as ibuprofen. NSAIDs are effective for many types of pain that can occur because of inflammation of muscles, joints and bones. The drugs work quickly and people often notice some benefit within a few hours of taking the tablet. However, the complete effectiveness of the drug may not be realized for up to four weeks. For each individual, some varieties of NSAIDs are more effective than others. Often, patients will find that one or two varieties are helpful whereas others may not be as effective in controlling symptoms. It is usually necessary to try several brands and continue with the one that is most suitable. NSAIDs can be used to treat:
- Pain resulting from inflammation or swelling
- Pain after injury
- Joint pain and arthritis