Common Shoulder Problems :: Shoulder Impingement
Shoulder pain is an extremely common cause of disability and patient visits to physicians. The causes of shoulder pain are many and the specific diagnoses are often somewhat blurred. A frequent diagnosis, in cases of shoulder pain, is shoulder impingement syndrome.The shoulder joint is the most mobile joint in the body. Unlike the hip, which is built for strength and stability, the shoulder socket is very shallow, to allow the shoulder to move in an extremely wide range of motion. This permits the upper extremity to position the hand to accomp lish all the various tasks which are necessary.
The trade-off for this mobility, however, is an inherent lack of joint stability. The stability of the very shallow bony socket of the shoulder is enhanced by a surrounding layer of cartilage tissue and then further surrounded by the tendons of the rotator cuff. The rotator cuff is comprised of four small muscles which originate from the shoulder blade, the tendons of which blend together, forming a solid cuff of tissue surrounding the head of the humerus or ball of the shoulder joint.
Above the rotator cuff lies a bony arch which is comprised of the overlying clavicle or collar bone, as well as by the acromion, which is a forward projection of the shoulder blade, which meets the end of the collar bone. The space between the bony arch and the rotator cuff is filled by loose fibrous tissue and is termed the bursa.
In shoulder impingement syndrome, the tissue of the bursa as well as the rotator cuff, are pinched between the ball of the shoulder joint and the overlying bony arch. This generally occurs in specific positions, especially with elevation of the arm above horizontal, and when attempting to do overhead work and activities.
This creates pain and irritation in the bursa, as well as in the rotator cuff. The rotator cuff then tends to function improperly, which in turn leads to further problems of impingement. All of this creates pain in the shoulder, which can radiate into the arm and down to the elbow. Patients often note they have difficulty using the arm for overhead activities and frequently complain of the inability to find comfortable positions in which to sleep.
The diagnosis of impingement syndrome is generally made after listening to the patient's description of symptoms and a careful physical examination. Often x-rays will be used to further evaluate the shoulder as well. Occasionally additional studies, such as an MRI, are used to verify the status of the rotator cuff.
Initial nonsurgical treatment of shoulder impingement syndrome includes activity modification, shoulder rehabilitation exercises and anti-inflammatory medications.
Activity modification basically refers to refraining from those activities known to increase the symptoms, but remaining as generally active as possible. Physical therapy is commonly employed in an attempt to rehabilitate the shoulder and especially the rotator cuff function. This generally is progressed to a home exercise program, which the patient is encouraged to perform on a regular basis.
Often, medications, to include oral anti-inflammatory mediations, either prescription or over-the-counter, are used as well as Tylenol for pain relief. If the symptoms fail to respond, an injection into the bursa, above the shoulder, can provide important diagnostic information and may be therapeutic as well. If a patient's symptoms persist after an adequate course of nonoperative treatment, it may be time to consider surgical treatment for the shoulder.
In most cases, shoulder impingement syndrome can be treated arthroscopically, which involves 2 or 3 small incisions around the shoulder, to allow insertion of the arthroscope (a small telescope which visualizes the inside of the shoulder), and the surgical instruments to remove the structures causing impingement. This may involve removal of some soft tissue, as well as the undersurface of the bony arch above the shoulder. This procedure also allows full visualization of the shoulder joint, as well as the rotator cuff tendons. If a rotator cuff tear is identified, it generally is repaired at the same surgery. After surgery, the patient's activity is increased progressively, depending on the exact surgical findings and the procedure performed.
While shoulder pain remains a very common problem, most cases can be adequately diagnosed and treated, either surgically or nonsurgically. We always emphasize a complete diagnostic evaluation, to include x-rays or other studies as needed, and then recommend a thorough course of nonoperative treatment. If this treatment course is unsuccessful, however, the surgical treatments of shoulder impingement syndrome are often very successful at returning patients to their activities and in relieving pain.
