Fig 1. On left is a Coronal PD MRI with red circle showing subacromial impingement. Fig 2. On right is a Coronal PD fat sat MRI showing partial thickness rotator cuff tear (green arrow) and subacromial bursitis (blue arrow) in the same patient experiencing shoulder impingement.
Fig 2. Overhead work can increase the risk of shoulder impingement.
Fig 3. Anatomical variants of the acromion can cause impingement in the shoulder. The Bigliani classification can be used to describe the acromion type. Type 3 acromion is associated with increased risk of shoulder impingement.
Fig 4. Sleeper stretch is a commonly used stretch for the posterior capsule of the shoulder. It may be recommended for shoulder impingement. Check with your provider if this stretch is useful for you.
Impingement
What is it? And why does it happen?
Impingement occurs when there is excessive friction between tissues. In the shoulder, it often happens when the space between the acromion (shoulder blade) and a group of tendons called the rotator cuff increases, leading to excessive rubbing.
Shoulder impingement is often a result of overuse. Frequently using the shoulder can cause the tendons of the rotator cuff to swell, decreasing the joint space. This makes the cuff rub against the acromion, leading to pain, irritation, and inflammation. Shoulder impingement can also be caused by bursitis (inflammation of the bursa). Bursa provides the lubrication for the cuff to slide freely during motion, so inflammation of this tissue leads to issues.
Risk factors for shoulder impingement
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Overhead athletes
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Jobs with overhead lifting
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Age related (Increasingly common after age 50)
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Previous injuries or structural issues of the shoulder
Sports like volleyball, swimming, tennis, and baseball, as well as occupations like construction, painting, and window washing may increase the risk of this injury. Inflammation or structural issues such as an abnormally shaped acromion can also contribute to impingement.
What are the symptoms of impingement? And how can my doctor tell if I have this condition?
If you have pain, weakness, and stiffness at the shoulder joint, you may be experiencing impingement. This pain may be present during a variety of overhead activities, and may even ache at night. Impingement is related to a variety of conditions of the shoulder including bursitis and rotator cuff tendonitis. Dr. Urband will consider these other conditions in the diagnosis of your pain.
Your provider will take your medical history and provide a physical exam including assessing your range of motion. Additional imaging with X-ray, US or MRI may be useful to determine the underlying pathology. In some cases, an anesthetic injection into the acromioclavicular or bicipital groove may be used to provide additional diagnostic information of the underlying source of pain.
How is impingement treated?
Treatment of impingement depends on three majors factors: the underlying pathology, the level or sport/activity and the severity of impingement.
Most patients with impingement symptoms can be treated non-operatively with activity modification, OTC topical and oral analgesics and anti-inflammatories and physical therapy. Other non-operative modalities such as therapeutic ultrasound, electrical stimulation, cold laser therapy and transcutaneous nerve stimulation may also be used.
Injury prevention through stretching and strengthening are the mainstay of treatment for athletes with impingement due to rotator cuff or biceps tendon pathology.
Surgical management may be considered after prolonged failure of non-operative measures or if instability of the shoulder is present. Diagnostic and therapeutic arthroscopy can be performed. Common surgical procedures that may be performed may include subacromial decompression, bursectomy or rotator cuff repair.
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How can I prevent this injury?
To prevent this injury, avoid overhead lifting and perform exercises that strengthen the rotator cuff. Stretching can decrease the pinching of tissues in the shoulder, while good posture or sleeping with a taller pillow can also help.
Surgical Treatment
There are a few methods of surgery for this condition. Surgeons may widen the subacromial space so the rotator cuff no longer catches on bone. Your provider may also remove an inflamed part of the bursa, or perform an anterior acromioplasty, where part of the shoulder blade is removed. Surgery can be performed arthroscopically or via open surgery.
References
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https://my.clevelandclinic.org/health/diseases/7079-shoulder-impingement-syndrome
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https://shoulderelbow.org/2017/07/19/terrible-triad-elbow-fracture-dislocation/
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https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-impingementrotator-cuff-tendinitis
Attribution for Images
1. Freygant M, Dziurzy ńska-Białek E, Guz W, Samojedny A, Gołofit A, Kostkiewicz A, Terpin K - Polish journal of radiology. Polish Medical Society of Radiology (2014). f1-poljradiol-79-391.
OpenStax College. “Shoulder Joint”. Wikimedia Commons, 19 May 2013, https://commons.wikimedia.org/wiki/File:914_Shoulder_Joint.jpg.
2. RSatUSZ. “Subacromial Impingement with Supraspinatus Rupture”. Wikimedia Commons, 1 February 2017, https://commons.wikimedia.org/wiki/File:Subacromial_Impingement_with_Supraspinatus_Rupture.jpg.
3. Nasch92. “Neer Test”. Wikimedia Commons, 10 August 2018, https://commons.wikimedia.org/w/index.php?search=neer+test&title=Special:MediaSearch&go=Go&type=image.
4. Fatih İlker Can, et al. "The stages of subacromial impingement (Stage 1-3)". Jt Dis Relat Surg, 2022 Apr, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9057549/figure/F1/.
Stretching
Surgery
