Shoulder impingement is a condition that I see and treat regularly. It is a common cause of shoulder pain. The pain is usually located in the front and the side of the shoulder. It can radiate towards the side of the arm. The pain is made worse when trying to lift the arm. Any work above shoulder height causes discomfort. There is a painful arc of movement when elevating the arm. Often there is a history of overuse…
What is shoulder impingement?
Shoulder impingement refers to “pinching” on the tendons and tissues in the shoulder. Above the humerus lie the rotator cuff tendons. These allow you to lift your arm. Above these tendons is a bony part of the shoulder called the acromion. The acromion can be thought of as the roof of the shoulder joint.
Between the acromion and the rotator cuff tendons is a small amount of tissue called a bursa. This helps with gliding movements in the joint. The space between the top of the humerus and the acromion is very narrow. When you lift or rotate your arm this space can become even more narrow. Impingement occurs when the acromion starts to rub on the tissues in the shoulder (bursa and rotator cuff). This causes pain and further inflammation. An inflammation of the bursa results in a shoulder bursitis. For further reading on bursitis see: I have shoulder pain – could this be shoulder bursitis?.
If shoulder impingement continues this may cause a rotator cuff tear. A rotator cuff tear can cause weakness and loss of function in the arm. For further reading on rotator cuff tears see: Two signs that may mean you have a rotator cuff tear.
Investigating the cause of shoulder impingement
If you suspect that you may have shoulder impingement you should see an orthopaedic surgeon. This should ideally be a shoulder surgeon or someone who has training and experience in treating shoulder conditions. During the examination special tests are performed to determine if you may have impingement.
X-ray
After an examination you will need investigations. X-rays are taken to rule out any other causes of the shoulder pain. An x-ray will also show the shape of the bones in your shoulder. The undersurface of the acromion may either be flat or slightly curved. In some people who have a curve this may end in a sharp “hook” in the front area of the bone. These people are particularly prone to impingement and bursitis.
Ultrasound
An ultrasound scan is also recommended. This can be done while you move the arm in certain positions. If there is impingement it may be visible on the scan. Other abnormalities can be picked up at the same time such as a rotator cuff tear or a bursitis.
Surgery for shoulder impingement
Surgery to treat shoulder impingement may be necessary if it does not respond to non-operative measures. Initially physiotherapy can be tried to improve your posture and increase the space underneath your acromion. Anti-inflammatories and cortisone injections to the shoulder may also help. Surgery is performed when these interventions are not working.
Surgery for shoulder impingement is done arthroscopically. This is another term for “keyhole surgery” or “minimally invasive surgery”. It is done in the safe and controlled environment of a hospital operating theatre. You will need to be admitted to hospital and prepared for theatre. As with all operations you need to be starved for six hours before the surgery. You may sip clear fluids such as water, black tea and black coffee for up to 2 hours before the surgery.
You may take any chronic medications on the morning of the operation. The exception is any diabetic medications – these should not be taken. If you are a diabetic your glucose will be checked on admission to the ward. Insulin may be used to control your blood sugars during your hospital stay. You should also not be on any blood thinning agents like warfarin. The timing of stopping of these medications will have been discussed with you before the surgery.
The procedure
Arthroscopic view of the undersurface of the acromion after an acromioplasty
After you have been prepared in the ward a porter will take into the operating theatre. In the operating theatre a general anaesthetic will be administered by the anaesthetist. You will be lying comfortably on your back on the operating table. When you are asleep you are placed in an upright position. This is called the “beach chair position” and is the position that I prefer for doing this procedure.
A routine acromioplasty may only involve two small “stab” incisions on the back and side of the shoulder. The joint is filled with water and a camera is inserted. Inspection is made of the shoulder joint. A camera is then inserted into the tight space under the acromion.
The diagnosis of impingement can be confirmed by direct vision. A special arthroscopic shaver is inserted into the space. This is used to remove any inflamed tissue (bursa) which could be causing pain. The undersurface of the acromion is cleared of soft tissue. A specialised arthroscopic burr is inserted and used to flatten the undersurface of the bone.
The advantage of doing the procedure arthroscopically is that it is minimally invasive. It is associated with faster recovery times and minimal scarring. Another advantage is that it allows for a complete inspection of the joint. The benefit of this is that any undiagnosed abnormalities can be seen and treated the same time. The wounds are closed with a “dissolving” stitches and waterproof dressings applied.
After the surgery
After the anaesthetist has woken you up, you are transferred back to the ward. The physiotherapist will see you once you are fully awake and have had something to eat, drink and you do not have nausea. The physiotherapist will help you with basic exercises. They will also show you how to use your arm sling and assist you with advice on dressing and undressing.
You will need to wear the sling for 2 or 3 weeks but this may be removed as soon as you are comfortable to do so. It is usual to follow up with me in my consulting rooms for a wound check about 10 days after the surgery. At this stage I usually measure your range of movement and refer you for ongoing physiotherapy if necessary.
Success rates
Arthroscopic acromioplasty for shoulder impingement is usually a low-risk procedure and is associated with very good outcomes. There is usually no restriction in range of movement after the surgery, and you can begin using your arm normally as soon as comfort allows. Return to work is usually possible quite soon after the operation. Recurrence of symptoms is rare.
In conclusion
As an orthopaedic surgeon with a special interest in shoulder surgery, I see and treat many patients who have a shoulder impingement. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.
Yours in good health,
MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)
Orthopaedic Surgeon
(011) 304 6784
About the author…
I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.
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