Management of Shoulder Impingement
Liz Morris, ATC
Hughston Athletic Training Fellowship
What is shoulder impingement?
The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The rotator cuff connects the humerus to the scapula. The rotator cuff consists of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles cover the head of the humerus and work together to lift and rotate the shoulder. As the arm is raised, the rotator cuff also keeps the humerus tightly in its socket. The upper part of the scapula that makes up the roof of the shoulder is called the acromion. A bursa (lubricated sac that cuts down on friction) is located between the acromion and the rotator cuff tendons. In this case, the bursa protects the acromion and the rotator cuff from grinding against each other. The word impingement basically means rubbing or catching. In this context, we refer to structures within the shoulder. As the arm is lifted, the acromion rubs, or "impinges" on, the surface of the rotator cuff. This causes pain and limits movement.
Who gets it?
Impingement is common in athletes, where overhead activity is a major part of their sport, particularly throwing athletes. Athletes who use their arms overhead for swimming and tennis are also vulnerable. In-fact, the condition is sometimes called "Throwers Shoulder" or "Swimmer's Shoulder" for this reason. Adults who continuously engage in overhead activities may also suffer from impingement.
Causes
Impingement occurs to some degree in everyone's shoulder. Typically, there is enough room between the acromion and the rotator cuff so that the tendons move easily underneath the acromion as the arm is raised. However, each time you raise your arm, a bit of rubbing or pinching occurs between the tendons and the bursa. Raising the arm tends to force the humerus against the edge of the acromion. With overuse, this can cause irritation and swelling of the bursa. Daily activities that involve raising the arm above shoulder level can even cause impingement. This usually does not lead to prolonged pain while continuous overhead activity, repeated throwing activity, or other repetitive actions of the shoulder can be problematic. Impingement becomes problematic when it causes irritation or damage to the rotator cuff tendons. If any other condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement may get worse. Pain may also develop as the result of minor trauma or appear with no cause.
Symptoms
Early symptoms may be mild but often include:
- Stiffness when the arm is lifted.
- Minor pain that is present with activity and at rest
- Pain radiating from the front of the shoulder to the side of the arm
- Sudden pain with lifting and reaching movements
- Athletes in overhead sports may experience pain when throwing or serving a tennis ball
- Swelling and tenderness in the front of the shoulder.
- Pain when the arm is lowered from an elevated position.
Diagnosis
Impingement is usually diagnosed on clinical examination. Doctors will typically diagnose rotator cuff impingement syndrome just by talking with you and examining your shoulder.
Your doctor may also perform a special test when they examine your shoulder called the Neer Impingement Test. In this test they ask you to straighten your arm. They then raise your arm forward, keeping your palm pointing away from your body. If this test is painful, the test is positive and rotator cuff impingement syndrome is likely. Special tests such as an arthrogram may also be useful for diagnosis. This is a specific type of MRI scan in which a dye is injected into the joint space to allow tears in the labrum to be seen. Fluid around tendons and in the joint could also point to impingement as well as tears in the rotator cuff. Similar findings may also be discovered as a result of an ultrasound.
Treatment
Treatment consists of:
- Rest & Ice: Allows inflammation in the tendons, joint capsule and bursa to subside.
- NSAIDS and steroid injection: Help facilitate the decrease in inflammation, NSAIDs such as ibuprofen can be helpful, as can a steroid injection into the joint such as Kenalog.
- Strengthening program: Aimed at the rotator cuff muscles and other muscles of the shoulder and upper back.
- Sports / Job specific training: Rehab aimed at a specific area of performance; in this case it is likely to be throwing.
- Surgery: If rehab fails to provide satisfactory results or if the rotator cuff is badly damaged, then early repair must be considered. The goal of surgery is to remove the impingement and create more space for the rotator cuff. This allows the humeral head to move freely in the subacromial space and to lift the arm without pain.
References:
American Academy of Orthopaedic Surgeons. (October 2007). Impingement of the shoulder. Retrieved March 23, 2009 from http://orthoinfo.aaos.org/topic.cfm?topic=a00032
Orthogate: Internet Society of Orthopaedic Surgery & trauma. (July 2006). Impingement syndrome. Retrieved March 23, 2009 from http://www.orthogate.org/patient-education/shoulder/impingement-syndrome.html
Taylor, J., & Funk, L. (March 2009).Internal impingement. Retrieved on March 23, 2009 from http://www.shoulderdoc.co.uk/article.asp?article=1252
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Liz Morris, ATC is a second year graduate student and recipient of the Hughston Athletic Training Fellowship Program in Columbus, Georgia. She received her Bachelors of Science Degree in Athletic Training from Georgia College and State University in May of 2007, where she also minored in Dance. While at GC&SU Liz worked with men's and women's tennis, as well as softball, and completed a high school rotation with Tattnall Square Academy and First Presbyterian Day School both in Macon. She was a member of the Kinesiology club and received the Presidential Volunteer Service Award. She is an active member of the National Athletic Trainers Association (NATA) and the Georgia Athletic Trainers Association (GATA). Liz is responsible for the overall healthcare of the athletes at Glenwood School in Phenix City, Alabama. |
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