What it is and how we treat it!
Shoulder impingement syndrome is a common cause of shoulder pain. Shoulder impingement is a “pinching” of the rotator cuff tendon(s) underneath a bony projection of the shoulder blade that attaches to the collar bone, called the acromion. This usually happens due to a rounded, slouched shoulders (a forward-flexed and internally rotated position). Also, when you raise your arm to shoulder height, the space between the acromion and rotator cuff tendons narrows. The acromion can rub against (or “impinge” on) the tendon and the bursa, causing irritation and pain. Over time, if not treated appropriately, the rotator cuff tendons can start to thin-out and tear.
With shoulder impingement syndrome, pain is persistent and affects everyday activities. Motions such as reaching overhead (to put on a coat or shirt, for example) or up behind the back (the motion used to scratch behind your neck), may cause pain.
The shoulder is one of the largest and most complex joints in the body. There are two joints in the shoulder. The glenohumeral joint is the main joint and is a flexible ball-and-socket type joint. The top part of the arm bone, the humerus (the ball part) forms a joint with the shoulder blade, the scapular (the socket part). The humerus fits relatively loosely into the shoulder joint because the socket is not that deep. This gives the shoulder a wide range of motion, but also makes it vulnerable to injury. The acromioclavicular (AC) joint is a gliding joint located on the top of the shoulder. This joint is formed by a part of the shoulder blade called the acromion and the collar bone (clavicle).
The rotator cuff, which is a collection of muscles and tendons that surround the shoulder and holds the head of the humerus (ball) into the Scapula (socket), giving it support and allowing a wide range of motion.
The bursa is a small sac of fluid that cushions and protects the tendons of the rotator cuff.
The labrum, which is a cuff of cartilage attached to the scapula (socket) t0 make it less shallow. This allows for a better attachment to the head of the humerus (ball) to fit into.
The human shoulder is the most mobile joint in the body. This mobility provides the upper extremity with tremendous range of motion. The trade off is this also makes the shoulder joint unstable and susceptible to overuse injuries.
Stages Of Shoulder Impingement
Stage 1: commonly affecting patients younger than 25 years, is depicted by acute inflammation, edema, and hemorrhage in the rotator cuff. This stage usually is reversible with non-operative treatment such as physiotherapy.
Stage 2 usually affects patients aged 25-40 years, resulting as a continuum of stage 1. The rotator cuff tendon progresses to fibrosis and tendonitis. This can be treated with physiotherapy , though on occasion may not response to conservative treatment and may require an operation.
Stage 3 commonly affects patients older than 40 years. As this condition progresses, it may lead to disruption of the rotator cuff tendon and cause an arthritic change called osteophytosis along the acromion. Physiotherapy is recommended as a conservative treatment option, though may require surgery (anterior acromioplasty and a rotator cuff repair)
Causes of Shoulder Impingement
Rotator cuff pain is common in both young athletes and middle-aged people. Young athletes who play sports requiring their arms to be moved overhead repeatedly such as swimming, baseball (particularly pitching), and tennis are especially vulnerable. Those who do repetitive lifting or overhead activities using the arm, such as paper hanging, construction, or painting are also susceptible. Keeping the arm in the same position for long periods, such as doing computer work or hairstyling, and poor posture over many years are also risk factors.
Pain often develops as the result of a minor injury, though sometimes, it occurs with no apparent cause, which is often the result of cumulative repetitive micro-trauma (gradual wear and tear)
Signs and Symptoms of Shoulder Impingement
- Gradual increase in shoulder pain with overhead activities
- Pain usually is reported over the lateral, superior, anterior shoulder; occasionally refers to the deltoid region.
- Pain during sleep, in various sleeping positions, especially over affected shoulder.
- Progressive loss of active range of motion and strength
- Difficulty with overhead activities such as grooming one’s hair, reaching for a seatbelt overhead, reaching for a back pocket or bra strap
Our Physiotherapy Approach For Shoulder Impingement Treatment
Step 1 – Thorough History & Assessment
The key to an effective treatment plan is to have the correct diagnosis. We start every management plan with a thorough history of your condition followed by a physical exam to ensure the correct diagnosis is made and to rule out any medical condition for which further evaluation may be required. We then discuss our findings and treatment options and together decide on a treatment plan. Once this is agreed upon, treatment typically starts on the first visit. On occasion, a referral to your doctor will be necessary for further testing (ex. blood work or x-rays) prior to treatment.
Step 2 – Pain Management and Decreasing Swelling
Managing pain and swelling is usually the main goal for patients with shoulder impingement. Our Physiotherapist will choose the most appropriate from a variety of modalities for your particular case. These modalities may include electrotherapy (interferential current, TENS), heat therapy, and manual techniques to help improve your pain.
Step 3 – Restoring Range of Motion and Strength
Increasing range of motion is the most important part of the rehabilitation process. Manual therapy techniques (passive range of motion, joint mobilization, muscle energy technique, and facilitation techniques) in addition to an exercise routine, including stretching and range of motion exercises will help you to restore shoulder flexibility and range of motion. Once you range of motion is restored, an individualized strengthening exercise program, targeting specific muscles will help to increase your strength, and overall function.
Step 4 – Restoring Function
Most patients with shoulder impingement experience difficulty with certain activities, such as grooming one’s hair, reaching overhead, and reaching back. Restoring function is the ultimate goal of the physiotherapy treatment. As part of your rehabilitation process, a functional exercise program is designed to help you improve your function and facilitate your daily activities.
When rest, medications, and physiotherapy do not relieve your pain, our Physiotherapist may recommend to follow-up with your doctor to discuss other treatment options. An injection of a local anesthetic and/or a cortisone preparation may be helpful. Therapeutic injections (lidocaine plus a corticosteroid) are useful both because they are therapeutic and also because they can help the physician differentiate impingement from other problems.
When nonsurgical treatment does not relieve pain, your doctor may recommend surgery. Most patients with impingement and rotator cuff tears actually do well without surgery. However, surgery might be considered in a patient who has failed to improve after six months of conservative treatment or in a patient less than 60 years of age with a debilitating tear that impairs function.
Step 5 – Education
We believe understanding your condition is the first step in your recovery. We focus on educating you about your condition, what to expect and giving you the tools to self-manage is a fundamental part of the rehabilitation process. Good communication with your physiotherapist is key to have positive outcomes.
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“My first meeting with Dr. Nick helped to put the pain in context. Finally, an explanation and some real answers.”
– Jeff Smith, Sackville, NS