Shoulder Impingement

Shoulder impingement is common in both young athletes and middle-aged people. It can result from compression of the tendons of the rotator cuff between a part of the shoulder blade (acromion) and the head of the humerus (the upper arm), such as in young athletes who use their arms overhead for swimming, baseball and tennis. It can also become a chronic inflammatory condition that may lead to a weakening of the tendons of the rotator cuff, a situation that may result in a torn rotator cuff. Those who do repetitive lifting or overhead activities using the arm are susceptible to this. Pain may also develop as the result of minor trauma or spontaneously with no apparent cause.
Impingement commonly causes local swelling and tenderness in the front of the shoulder. As the arm is lifted above shoulder height, the acromion rubs or "impinges" on the surface of the rotator cuff. This causes pain and limits movement. There may also be pain when you lower the arm from an elevated position. Often the pain radiates to the outside “deltoid” part of the upper arm. As the problem progresses, pain at night may develop. Strength and motion may be lost. There may be difficulty with activities that place the arm behind the back, such as reaching in the back pocket or combing one’s hair. In advanced cases, loss of motion may progress to a "frozen shoulder."

Diagnosis
To diagnose shoulder impingement, an orthopaedic surgeon reviews the symptoms and physically examines the shoulder. X-rays are taken to view the acromion and to see if any bone spurs are present. The acromion is usually flat on one end. But, in some cases, it can be hooked. A hooked acromion is not necessarily abnormal, but it can increase the likelihood of impingement. An MRI can be performed if a rotator cuff tear is suspected, as well as to show fluid or inflammation in the bursa. Sometimes an injection of local anesthetic into the bursa can help to confirm the diagnosis.

Treatment Options
Initial treatment is conservative. Overhead (above horizontal) activities should be avoided. Non-steroidal anti-inflammatory medication is frequently prescribed. It is essential to maintain the strength in the muscles of the rotator cuff as these muscles help control the stability of the shoulder joint and strengthening these muscles can actually decrease the impingement of the acromion on the rotator cuff tendons and bursa. A stretching and/or rotator cuff strengthening program can be started under the supervision of a physical therapist. These programs are simply a set of exercise that will help keep the shoulder strong and flexible and help reduce the irritation from impingement.

Occasionally, an injection of cortisone may be helpful in treating this condition. Many patients benefit from injection of local anesthetic and a cortisone preparation to the affected area. The injection is into the bone, not the tendon. Improvement in symptoms may take several weeks to months. However, if no improvement has been made after three to six months, surgical intervention may be necessary.

Treatment Options: Surgical
When shoulder surgery is necessary, the surgical procedures used by doctors are designed to make more room for the tendons of the rotator cuff. The surgery is performed as an outpatient procedure. An acromioplasty is performed to remove bone spurs that the tendon rubs on in order to make more room for the tendon to glide normally. Additionally, a bursectomy (removal of the inflamed bursa) or rotator cuff repair can be performed at the same time. These procedures can be performed arthroscopically or open. With arthroscopic surgery tiny instruments are inserted through small incisions while an open repair involves making larger incisions. An open procedure involves a larger incision, but comparable results can be achieved.

After surgery, the arm may be placed in a sling for a short period of time which allows for early healing. Post-operative rehabilitation and therapy is a key component in healing. Early passive motion is started immediately after surgery and progresses to strengthening exercises and, depending on your level of sport, throwing exercises. It is essential to realize that complete healing doesn’t take place until months after surgery, but that most patients are able to return to their previous level of sport.

Editor’s Note: Dr. Robert S. Heidt, Jr., is Orthopedic Consultant to the Cincinnati Bengals and team physician for St. Xavier High School. The Cincinnati Bengals, the Western & Southern Financial Group Tennis Masters Series, Miami University and many other of the area’s most respected sports teams – including 16 local high schools – turn to the experts at Wellington Orthopaedic & Sports Medicine to keep their athletes in top competitive form. For more information logon to www.wellingtonortho.com or call 513-232-BONE.