Shoulder ‘impingement’ syndrome

It’s got many names…. rotator cuff tendinitis, swimmers shoulder, throwers shoulder, subacromial impingement or subacromial bursitis. These are all smart, intelligent sounding names for pain that occurs deep in the anterolateral shoulder (anterior meaning front & lateral meaning side… so to the front and side)

Lets do a little anatomy recap: The shoulder is a ball and socket joint; likened to a golf ball on a golf tee. The humerus or upper arm bone sits against a small socket called the glenoid. It’s an inherently unstable joint which is why we are able to perform all the weird & wacky movements with our arms.

The rotator cuff are a group of 4 muscles: supraspinatus, infraspinatus, subscapularis and teres minor. Their role? to depress the head of the humerus essentially assisting the joint capsule and shoulder ligaments to hold it snug in its socket.shoulder

The supraspinatus tendon is usually the one of interest when it comes to rotator cuff ‘impingement’. It passes between the acromion and head of the humerus in the ‘subacromial space’. This space is perfectly designed for the tendon with not a hell of a lot of ‘breathing space’. So when the tendon gets inflamed, irritated and swollen a pinching occurs as this space becomes a little too narrow!

This can be an overuse injury due to repetitive or prolonged strain on the rotator cuff tendons such as with overhead activities, pulling/pushing, lifting or repetitive reaching. It can also be the result of a direct blow or fall onto the point of the shoulder forcing the head of the humerus upwards into the subacromial space creating a pinching effect on the rotator cuff tendon.

Both outcomes result in a painful arc of movement of the arm that can begin to impact on simple activities of daily living such as reaching behind for your seat belt, doing up your bra (ladies) and overhead reaching tasks.

Patients will generally report feeling a deep ache deep inside their shoulder that they can’t quite pinpoint. The severity can vary enormously from a small niggle that is quite hard to replicate with testing to those that can barely lift their shoulder above shoulder height due to pain.

A few key symptoms that indicate ‘impingement’ syndrome include the inability to sleep to the affected shoulder; associated neck stiffness as a result of compensatory movement patterns and pain on repetitive overhead movements… often people will struggle with hanging out the clothes or unpacking the dishwasher.

How is it diagnosed?

A skilled physio need only listen to your history and do a few key clinical tests to know diagnose an impingement syndrome.

Further investigation such as ultrasound or MRI can be organised to confirm this diagnosis if required.

Is physio necessary?

The short answer is yes. Why?

In both presentations of impingement whether it is an overuse problem or as the result of acute trauma physiotherapy is a pretty important management tool.

Treatment can include:

Soft tissue massage: to tight overactive muscles particularly at the back of the shoulder. The upper trapezius found at the top of the shoulder is also tight.

Advice regarding activity modification in terms of training & exercise but also avoiding day to day tasks that may be aggravating their condition.

Dry needling & acupuncture: this is a really useful way to release tight muscles whilst also encouraging blood flow to the region. Fresh blood is packed full of oxygen and essential nutrients to assist with the healing process.

Rehabilitation: once the inflammation is under control most people need to undertake a rotator cuff strengthening program to restore correct shoulder biomechanics, improve posture and prevent ongoing pain and dysfunction. Some common exercises include internal and external rotation as well as lots & lots of upper back strengthening. Think seated row, high row, and prone row! Muscly backs are incredibly attractive boys….

What happens if ‘conservative’ management fails?

DON’T panic most cases don’t get to this stage but sometimes conservative management of impingement syndromes can fail. In these circumstances there are more aggressive forms of treatment that can be explored such as cortisone injections, platelet injections and in very severe non responsive cases surgical intervention maybe required.

Impingement syndrome can be a very very debilitating problem. When it’s chronic it’s a frustrating condition to suffer but also to treat. It’s stubborn and slow. If you’re noticing a niggle don’t ignore it, the sooner you get treatment & appropriate management strategies are employed the sooner you will be back in the surf, on the tennis court or in the pool.

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