Shoulder pain – Impingement Syndrome / Rotator Cuff Tendonitis / Bursitis
Impingement syndrome is a very common cause of shoulder pain. This problem is commonly referred to as BURSITIS or TENDONITIS.
What is wrong with my shoulder?
Your shoulder pain arises from a problem in the rotator cuff tendons. A tendon is a thick, cord-like structure that connects muscles to bones. The rotator cuff tendons pass between two bones in your shoulder, the acromion, and the humerus. This space is small and the tendons barely pass through as the arm is raised and rotated. With repeated overuse, a single injury, or even just wear and tear of age the tendons get pinched, or “impinged”, between the two bones and this can become painful.
How did this problem start?
Often the answer is obvious as the patient injured the tendon in an accident or remembers a specific injury. However, repeated use of the arm in the overhead position, weight lifting, tennis, or other use of the arm can also lead to impingement syndrome. Further, as we age our ability to repair the damage that results from normal activities of daily living decreases.
What are Tendonitis and Bursitis?
A bursa is a small sac of fluid that lies between tendons and bones and serves to act as a cushion for the tendons. In the shoulder, there is a bursa between the rotator cuff and the acromion. Like the tendon (tendonitis), the bursa may also become inflamed (bursitis) and increase in size which further decreases the space that is available for the cuff tendons to move. Pain results when this bursa is pinched as well. Most often the bursa and the tendons are both inflamed and painful.
- Rest the shoulder. Refrain from painful motions and activities. These motions can continue to irritate the inflamed tendons and can ultimately cause more damage.
- Medication. Anti-inflammatory medication can reduce the pain and inflammation in some patients and are part of the non-operative program.
- Physical Therapy. Physical therapy exercises are very beneficial. Exercises are designed to improve or maintain the amount of movement and strength in the shoulder muscles and can be performed at home. I will have you consult with a physical therapist to receive instructions on how to perform these exercises.
- Injections. The purpose of injections is to insert a strong anti-inflammatory medication(cortisone) into the space between the cuff tendons and the acromion. The cortisone will take a couple of days to reach its maximum effect, but will often have a dramatic effect on your symptoms. If you are diabetic, it is very important to monitor your blood sugar very carefully for several days following the injection as cortisone can cause it to rise. If your blood sugar does become difficult to control, you need to contact your medical doctor.
How do you know the tendon is not torn?
The only way to know for certain is to inspect the tendon during surgery. Plain X-rays like we take in the office only demonstrate bony anatomy and do not show tendons. Special studies like an MRI are needed to demonstrate a torn tendon. I will usually order these more expensive studies if you do not respond to the conservative measures that I outlined above.
Is surgery ever needed?
Although most people will recover from this problem with the treatment previously outlined, not everyone recovers from shoulder impingement. The indications for surgery are persistent pain interfering with your activities of daily living, work, and/or sports that have failed to respond to the conservative treatment program that I have outlined.
What if I have persistent pain and do not have surgery?
Based on current medical knowledge the problem will likely continue and may increase in severity. The possibility exists that the pressure on the tendon will cause further tendon damage such as a tear. Of course, the problem may remain the same or even improve with time.
What is the purpose of the surgery?
The purpose of the surgery is to create more space for the tendons to move by removing the inflamed bursa and the bone spur from the undersurface of the acromion. During the surgery, I also carefully inspect the shoulder joint, along with the ligaments and tendons for any damage. Any damage that is found is also repaired at the time of your surgery. The orthopedic literature shows that 85-90% of patients will have substantial relief of their symptoms following this procedure.
What is the surgery like?
The surgery is done arthroscopically. An arthroscope is an instrument about the size of a pen that has a video camera on its tip. The arthroscope is inserted into the joint through a 1⁄4” incision to allow me to see the inside of your joint on a television. Two or three other small incisions are made which allows me to place special arthroscopic instruments into your joint and repair the damage.
How long will the surgery take?
Depending on how much another damage is encountered in your shoulder, the surgery will take between one and two hours.
How long will I stay in the hospital?
Patients enter the hospital in the morning, have surgery, and go home the same day. This is called outpatient surgery.
How successful is surgery?
This type of surgery is successful about 85-90% of the time. No operation is 100% successful in every patient, but the procedures we perform are reliable and will help restore your shoulder’s function. The operation is most successful at relieving pain. It is more difficult to return to vigorous overhead use of the arm in work and/or sports. The success of your operation depends on many factors including the amount of damage, compliance with post-operative rehabilitation, how strenuous the activities are that you wish to participate in.
What are the potential complications of surgery?
Surgery is a complex and delicate process designed to repair damaged structures deep within the human body. Complications can occur, but fortunately are rare. The most common complication involves injury to the nerves around the shoulder and occurs in less than 1%. These are usually stretch injuries resulting from us manipulating the arm in an attempt to see the entire joint without doing damage to the cartilage. They are almost always temporary and the nerve recovers in 2-6 weeks. Permanent injury can occur but is exceedingly rare. Infection can occur (<1%) and may require antibiotics and repeat surgery.
When can I return to routine activities of daily living?
You will be able to use your fingers, wrist, and elbow immediately after surgery. It will be beneficial to acquire a “gripee” or another squeeze device for your hand and just carry it around with you. You may shower 48 hours after surgery as long as all of the incisions are completely dry. I encourage you to walk outdoors, write, and use your arm in front of your body as soon as possible. Basically, if it hurts—don’t do it. Apply an ice pack to your shoulder for most of the first couple of days. This will help reduce pain and swelling.
When can I return to work?
For most sedentary jobs, I recommend 3-4 days off work. When you return to work your arm will be sore but you should be able to manage as long as you do no heavy lifting, pushing, pulling, or carrying. You may begin to use your arm at waist level after the first week with a 5-10lb weight restriction. Heavier lifting, or above waist level will be started 1-2 months after surgery. Return to very heavy lifting or prolonged overhead work may require 6-12 months. These are merely guidelines and may need to be altered based on your individual recovery.
How is the shoulder rehabilitated?
Although you can usually perform the necessary exercises by yourself at home, I will have you see a physical therapist in order to receive individual instruction on an exercise program. Then they will see you once or several times per week to check your progress. I encourage you to start aerobic exercise as soon as possible. You may enjoy walking, riding a stationary bicycle within 1 week of surgery. Jogging, Stairmaster® and regular bicycle riding can start as soon as you are comfortable. Swimming, running, tennis groundstrokes, and gentle golf strokes start from 1-2 months depending on your progress. Return to overhead throwing and tennis strokes can require 3-6 months of rehabilitation. Return to weight lifting is less predictable and you may need one full year before performing the bench press. The primary goal of the procedure is to eliminate pain that occurs during activities of daily living.
What if I have more questions?
I encourage you to return to the office for further discussion at any time. You can also contact us.
To see more treatment options for impingement syndrome rotator cuff tendonitis, see our Treatments.