Shoulder Impingement – Subacromial Bursitis

What is shoulder impingement?

Shoulder Impingement Syndrome Treatment

Shoulder Impingement is a painful condition that is caused by squeezing or rubbing of the rotator cuff tendons in the space between the ball of the upper arm bone (humeral head) and the tip of the shoulder (acromion). When the tendons are compressed in the space, or squeezed on movement, the subacromial bursa, which is a fluid-filled sac, becomes inflamed and this leads to pain.

Shoulder impingement is one of the most common conditions I treat

What causes Shoulder Impingement?

Poor posture is a major contributor in shoulder impingement. If you spend hours sitting at a desk, hunched over staring at a computer screen, your muscles aren’t in the best position to work properly, and this puts extra stress on them, leading to pain.

Repetitive overhead activities (such as swimming, tennis and weightlifting) continuously load the rotator cuff tendons, particularly if your technique isn’t great, or if you have poor control of your shoulder girdle.

Sometimes, our individual anatomy means we may be predisposed to shoulder impingement because of the angle of the end of the acromion. Wear and tear within the joint above the rotator cuff tendons (the acromioclavicular joint) can also create rubbing or compression on the tendons.

What are the symptoms of Shoulder Impingement?

Shoulder impingement affects people in different ways, but commonly, you might experience pain down the side of you shoulder (and perhaps into your upper arm).

You might have pain when reaching your arm up over your head or away from your side.

You might have pain at night if you lie on that side, and you’ll probably find that overhead activities, such as serving in tennis, becomes really difficult. You might even find yourself avoiding giving your loved-ones a hug as it causes too much pain.

Some patients tell me that they struggle with putting a coat on comfortably, or if they suddenly jar their shoulder (e.g. when catching a heavy door that’s closing), it can be really painful and brings tears to their eyes.

How is Shoulder Impingement diagnosed?

When you come to clinic, I’ll be asking you lots of questions about your symptoms, how they are affecting you, and what’s important to you when it comes to being active. I might ask you about your sports, your technique, and what you may have tried in terms of treatment.

I’ll examine you, watching carefully how you move, and I may then recommend an MRI scan or ultrasound scan, to look at the structure of your shoulder joint and the soft tissues.

How is Shoulder Impingement treated?

If your shoulder is really painful, whilst we’re getting you better, you may need to temporarily adapt the activities that particularly aggravate your shoulder.

Most people with shoulder impingement will improve with good physiotherapy or osteopathy, but it’s important to see a therapist who really understands good shoulder movement and has particular expertise in shoulders.

Sometimes an ultrasound guided corticosteroid injection (to bathe the bursa) is needed to reduce the inflammation and pain, so that rehab can be more effective.

The right injection at the right time can restore your activity with very few risks.

Will my shoulder need surgery?

I always try to exhaust all non-operative options first but sometimes, despite excellent therapy, we may need to consider the option of surgery. It’s important to approach surgery with the right mindset. You need to be clear that having tried everything else, it’s the right decision for you, and for your lifestyle going forwards.

Shoulder Impingement Surgery (subacromial decompression).

The goal of the surgery is to reduce the pressure and loading on the rotator cuff tendons by making more space for them.

I perform the surgery usually as a day case operation, but sometimes if you have surgery in the afternoon, you may spend a night in hospital.

On the day of the operation, you’ll have a light general anaesthetic (so you’ll be asleep), but also we’ll numb the nerves in shoulder with a carefully placed injection in your neck. This means when you wake up after the surgery, you won’t feel any pain, so you can get on with life.

I’ll make two very small incisions to get access to the inside of your shoulder – one on the side, and one behind your shoulder. I then shave away any bony bumps or soft tissue that’s causing the impingement.

I’m really fussy about making the little incisions look very neat after surgery, and the stitches are placed under the edges of the skin, so there’s no stitches or staples to be removed. If you happen to have a tattoo, I’ll do my upmost to leave it looking as pristine as possible.

Before you return home, you’ll be given some painkillers for the next few days, and I’ll show you how to perform some gentle exercises to get the shoulder moving.  Your arm is going to be numb and floppy for a few hours after the surgery, so until it “comes back to life”, you will be provided with a sling to support it.  After that, I want you to engage in some really good physio rehab. You may find it easiest to sleep on your back with pillow lined up alongside you to rest your arm upon, especially in the first few days.

You can drive when you can confidently move your shoulder, which might take two to three weeks. (When patients ask me when they can drive again, I tell them “I ride a motorbike, and so if you were behind the wheel of your car, when were both on the road, I’d like to know that you could confidently swerve and stop if you had to, and not knock me off!”)

Physiotherapy is best started ten to fourteen days after surgery (giving time for the wounds to heal). I very much leave it to the individual therapist to work with you, but I will of course be liaising with them about your progress.

On average, six weeks is a typical amount of time you’ll need to spend seeing the physio.

Most of my patients are well on their way to recovery by six weeks, but returning to sport may take a little longer. It’s really important that you have regained good biomechanical movement and strength around the shoulder. Sport requires specific movement patterns, and so you will need to relearn these, or correct any less-than-perfect techniques.  So, if you’re a tennis player, take your racquet with you when you have your physio, and consider investing in time with a sports coach if you could do with a refresher on best form.

Thankfully most surgeries go smoothly, and the risk of serious complications (such as infection, or damage to the nerves, or blood vessels) is very rare.

Occasionally, some people may experience a frozen shoulder reaction to the surgery, which is when the shoulder becomes stiff and inflamed. If this were to happen, it can usually be rectified with injection treatment and good physio.

Post surgery FAQ

Make sure that your hand is above the level of your elbow, so that your arm is completely relaxed in the sling.

Yes.

Lying flat can be painful, so try propping yourself up on several pillows.

You can sit on a stationary bike straight away (as long as you keep your arm in your sling). You’ll be given more detailed instructions about other activities, when you are seen in clinic.

My secretary will arrange a follow up appointment approximately 10 days after surgery. At this appointment, I’ll remove your dressings, and check that the wound is OK. If you’ve had surgery for a fracture or joint replacement, we may need take an X-ray.

For the first three to four days, don’t wait for the pain to kick in, take them regularly (even if you’re not feeling pain – we want to keep it at bay).

Yes, unless you’ve had surgery for a frozen shoulder, or shoulder impingement surgery – in which case, you can take it in and out, as comfort allows.

Avoid baths until the dressings have been removed – typically at 10 days. Your wounds will have waterproof dressings on, so it’s ok to take a shower. It’s really important to keep your arm pits clean – so have a good scrub with a flannel!

It’s important to use the keyboard with your forearms supported on the desk. Wait till you’re comfortable and don’t overdo it?

Don’t rush back to work; try to take off at least a week.

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Ms Susan Alexander is recognised by all the UK’s major insurers