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Shoulder Impingement

by Boyd W. Haynes III, MD
Shoulder pain can be caused by many factors, such as disease, injury or overuse.  A common problem that I treat in my practice is shoulder impingement, which happens when the bursa or the Rotator Cuff tendon (or both) of the shoulder get pinched or “impinged upon” by the bones (usually the acromion) of the shoulder.  This pinching causes pain.

Common causes of shoulder impingement are reaching overhead, either during work, exercise or because you have a minor shoulder bone or joint abnormality that makes you more prone. If this overhead motion is repeated often enough, the rotator cuff tendon can become inflamed and/or the shoulder bursa can swell and become irritated.  If left untreated, the rotator cuff tendon can become worn and may tear.  In more extreme cases, the biceps muscle can also rupture, compounding the problem.

For athletes, impingement is more common in swimmers, baseball and tennis players.  For workers, wall paper hangers, painters or construction team members are most often affected.  Sometimes, there is no injury and no known reason for its development, called idiopathic impingement.  It is seen most often in young people and in middle-aged folks, but it can happen to almost anyone.  It may happen suddenly or gradually develop over time.

Symptoms are persistent pain, especially when reaching overhead or behind, like when fastening a necklace or putting on a coat.  Lifting your arm to the side or front may also be painful.  Pain is often felt intensely at night, causing the patient to shift around trying to find a comfortable position. The shoulder muscles also weaken, because using them causes pain and not using them causes them to atrophy.

If you suspect you have shoulder impingement, you should be seen by a qualified Orthopaedic specialist, like me, for treatment.  I will first do a physical exam, asking you to show me what arm and shoulder movements cause pain.  I will also order simple x-rays to rule in or out arthritis or bone spurs.

Treatment will start with anti-inflammatories, either over the counter or if those have been tried, prescription anti-inflammatories.  Instead, I may administer an injection of cortisone to the shoulder to reduce inflammation.  Avoidance/ modification of overhead activities will be suggested, as well as stretching exercises and/or Physical Therapy.  Most patients will recover after this regimen over several weeks to months.

If this treatment does not get us the desired recovery or if you show increasing levels of weakness in your arm and shoulder, I may order an MRI to rule out any other issues, such as a torn Rotator Cuff.

Surgery is recommended when conservative treatments fail.  It is performed as outpatient arthroscopic surgery, using tiny incisions and a camera to help me visualize the rotator cuff.  My aim is to make more room for the Rotator Cuff to move freely and I may remove a portion of the inflamed bursa and a small bit of the acromion (bone).  If the rotator cuff is torn, I will repair it.  I can also repair any other issues seen in the shoulder at the same time.

After surgery, you are discharged home with your arm in a sling, which you will wear for several days to several weeks, depending on the extent of the surgery.   You will be sore for a few days after surgery and I will prescribe pain medication for you to take as needed.  I will recommend icing your shoulder several times a day for the first few days.  I will also give you passive gentle movements to complete to start the rehabilitation of your shoulder.

After your follow-up visit, I will determine if you are healed enough to begin Physical Therapy, which will be ordered to help you increase your strength and range of motion.  Full recovery can take several months, again depending on how extensive the damage to your shoulder was and how much surgical repair had to be done.  Your full compliance with the Physical Therapy regimen prescribed will help you to heal and regain full use of your shoulder in less time.

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