Shoulder Impingement Syndrome

Shoulder Impingement Syndrome treatment and information

Shoulder impingement syndrome is a common cause of shoulder pain, it occurs when the rotator cuff tendons (typically the supraspinatus muscle) or bursa inside your shoulder rub on the outer edge of your shoulder as they pass through the subacromial space, this occurs mostly when the arm is lifted. The rubbing can result in the presence of inflammation which can cause further narrowing of the subacromial space and lead to further impingement.

Overhead activity of the shoulder, especially repeated activities such as painting, lifting or overhead sports such as swimming and tennis, are common movements that can increase the risk for shoulder impingement syndrome. Other risk factors include bone and joint abnormalities.

With shoulder impingement syndrome, pain is normally constant and can affect everyday activities. Movements such as reaching up behind the back or reaching up overhead to put on a coat or blouse can be difficult to perform.

The typical symptoms of shoulder impingement syndrome include difficulty reaching up behind the back, pain with overhead use of the arm and weakness of muscles around the shoulder. The onset of symptoms are typically gradual, and pain can build up over weeks or months.

If there is repetitive impingement on the tendons, they can become thinner and tear resulting in a rotator cuff tear. This can go on to cause significant weakness in the shoulder and may make it difficult for the person to move his or her arm.

Diagnosis of shoulder impingement syndrome begins with a medical history and physical examination by your healthcare practitioner. Your healthcare provider will ask you some questions about your symptoms, daily habits and previous injuries. The physical examination will be characterized by the inspection and palpation of the shoulder as well as passive and active range of movements of your shoulder to assess the severity of your limitation. Usually with shoulder impingement syndrome the most affected movements are external rotation and abduction.

Depending on the severity of your symptoms your health care practitioner may suggest further imaging to understand the severity of the condition or to rule out any other conditions. X- rays may be taken to rule out arthritis and may show changes in the bone that indicate injury of the muscle. Bone spurs or changes in the normal contour of the bone may be present (Creech and Silver 2020). Magnetic resonance imaging (MRI) is usually recommended if there is no improvement in symptoms following 6 weeks of clinical intervention including physical therapy (Creech and Silver 2020). MRI is used to show the integrity of the tissues around the shoulder; it can also show signs of inflammation in the muscles of the shoulder and around the subacromial bursa.

Shoulder rehabilitation exercises play a huge role in the management of shoulder impingement syndrome. Physiotherapy for shoulder impingement syndrome will include the use of exercises where the aim is to strengthen the rotator cuff, trapezius and serratus anterior muscles. Exercises to correct strength imbalances in the upper limb will also be used (Gebremariam et al., 2014).

The avoidance of repetitive activities with your injured arm, particularly activities where the elbow would move above shoulder level is recommended (Koester., et al 2005) in the beginning stages of the rehabilitation process.

Oral anti-inflammatory medications such as aspirin, naproxen, or ibuprofen, remain the most common treatment for helping with the pain associated with impingement syndrome. Before taking any new medication it is important to speak to your GP beforehand as they can advise you on which type is the best for you and your pain.

If you have persistent symptoms, despite the use of oral anti-inflammatory drugs, your doctor may consider a cortisone-type injection. Cortisone is a potent anti-inflammatory medication, which should be used only when necessary. This is because it can result in weakening of muscles and tendons if used repeatedly.

If there is known structural damage to the shoulder joint, bony abnormality or if there is failure of response to physical therapy then surgery may be recommended by your doctor or orthopedic consultant.

The vast majority of people who have impingement syndrome are successfully treated with medication, stretching exercises, and temporary avoidance of repetitive overhead activity until the condition settles down.

The length of time shoulder impingement syndrome lasts can vary from person to person. This is because the prognosis is dependent on the severity of the condition and if surgery is required.

With conservative treatment including physical therapy, rehabilitation exercises, NSAIDs, and cortisone injections research has shown that satisfactory results can be obtained within 2 years in 60% of people (Garving., et al 2017).

Not all shoulder impingement can be prevented this is because some causes of the syndrome are due to the anatomical shape of the bones in the shoulder. However there are a few factors that may help in reducing the risk of shoulder pain:

1. Adapt your training: if you are used to training frequently make sure to take rest days between training sessions. Warm up your muscles before starting your exercises and practise stretching at the end of the session. Make sure to start with simple exercises before moving on to more complex ones. This is to make sure that your shoulder is fully warmed up. Also focus your attention on building up all of the muscles of the shoulder joint, especially the muscles in the upper back and near the shoulder blade; shoulder blade stability is vital for a healthy shoulder.
2. Practice good posture: another thing that may aggravate shoulder pain is poor posture. Pay attention to your posture throughout the day. Slouching can have an effect on the shoulders as it can cause your shoulder to round forward.
3. Ice and rest: apply ice to your shoulder after a training session this can help with reducing inflammation. Also make sure to take rest days in between sessions to allow your shoulder muscles to repair.

Scapula retraction and depression: Roll your shoulders back, down and then hold for 5 seconds. In this position, you will be squeezing your shoulder blades together. Repeat 10 times. The purpose of this exercise is to engage the muscles around your shoulder blade. These muscles are important in helping stabilize your shoulder. Mobility of your shoulder blade is crucial for shoulder health and this exercise focuses on helping you develop shoulder blade mobility and motor control.

Shoulder blade push and pull up: Start with standing tall and pull your shoulder blades down. During this exercise you need your arms stretched out in front of you. Begin by moving your shoulder blade forward without engaging your back or your neck. This is achieved by gently pulling your hands forward. Then move your shoulders all the way back, this is achieved by pulling your hands backwards slightly. Hold the position for 5 seconds and repeat 10 times.

The advance movement of this exercise is performing it against a wall. As previously, hold the pulled position and rest your hands against a wall. After that, push your shoulders forward. This exercise simply adds resistance to help strengthen your muscles around your shoulder blade and your mid-upper back. Both of these exercises will help warm up your rotator cuff muscles.

Shoulder internal rotation in a side lying position: lay down on your side on top of your upper arm. Bend the elbow of the arm that is on the ground to 90 degrees. Then rotate your arm as if touching the opposite side of your chest. Keep your arm bent throughout the whole of this exercise. Repeat this exercise 10 times.

Shoulder external rotation in a side lying position: similar to the previous exercise, lay down on your side on top of your upper arm, bend your elbow that is not on the ground to 90 degrees. Then rotate your arm externally as far as you can. You should feel an engagement of your shoulder. Repeat this exercise 10 times. If pain is felt whilst doing the exercise you can reduce the range of movement or completely stop doing the exercise.

*It is recommended to get the go ahead from your GP or physical therapist before carrying out any of these exercises.

NHS

Creech, J.A. and Silver, S., 2020. Shoulder impingement syndrome. StatPearls

Garving, C., Jakob, S., Bauer, I., Nadjar, R. and Brunner, U.H., 2017. Impingement syndrome of the shoulder. Deutsches Ärzteblatt International, 114(45), p.765.

Gebremariam, L., Hay, E.M., van der Sande, R., Rinkel, W.D., Koes, B.W. and Huisstede, B.M., 2014. Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. British journal of sports medicine, 48(16), pp.1202-1208.

Koester, M.C., George, M.S. and Kuhn, J.E., 2005. Shoulder impingement syndrome. The American journal of medicine, 118(5), pp.452-455.