FAQ - Shoulder Impingement Syndrome and Joint Arthritis

Q :		What is impingement syndrome?
A :		This type of shoulder pain arises from a problem in the rotator cuff tendons. A tendon is a thick, cord-like structure that connects muscles to bones. In the shoulder these tendons are called the rotator cuff. The rotator cuff tendons pass between two bones, the acromion and the humerus (hopefully, I pointed these out to you on your x-rays). The space is small and normally the tendons barely fit through as the arm is raised and rotated. If the tendon increases in size, there is not enough space, and movement can be painful. With repeated overuse, a single injury, or even just with the wear and tear of age, the tendon increases in size and gets pinched or impinges between the bones.

Q :		How did this problem start?
A :		Often the answer is obvious as the patient injured the tendon in an accident or remembers a specific injury. Lifting a heavy object or even a small weight in an awkward or unusual position can also cause tendonitis. Repeated use of the arm in the overhead position, weight lifting, tennis, golf (grounding the club especially), or even aerobic dancing can cause damage. Commonly, no specific reason is found. As we age, our ability to repair the damage that occurs during the normal activities of daily living decreases. What we could do in our 20's is not possible now.

Q :		Do I have bursitis or tendinitisor both?
A :		"itis" is Latin for inflammation. When you see that on the end of any word a doctor uses it means that this structure is inflamed. Tendonitis then means inflammation of the tendon and bursitis means inflammation of the bursa. A bursa is a small sac of fluid that serves to cushion the impact of tendons as they pass over bones. These bursae occur in many sites around the body: elbow, knee, hip, shoulder, etc. Like the tendon, the bursa may become inflamed and increase in size. The shoulder bursa lies on top of the rotator cuff tendon and it too can be pinched between the shoulder bones. Most commonly with impingement syndrome the tendon and the bursa become inflamed together and most often you have both bursitis and tendonitis together as a result of impingement.

Q :		What about my AC joint?
A :		The AC joint is between the acromion bone and the clavicle bone (collar bone). There is a piece of cartilage between the bones at this joint and if it is torn or if the ends of either bone become damaged, early arthritis can set in. You can usually determine if this joint is causing problems by things you might tell me ("it hurts to reach across my body" or "it hurts right on top of my shoulder"), things I might find on exam (pain when I push on the joint), or things we see on x-ray (narrowing of the space between the bones). You can have problems with the AC joint with or without impingement problems. Hope-fully, I have made clear to you exactly which problem or problems you have.

Q :		How do we treat these problems?
A :		Most of the time impingement syndrome (and the consequent tendonitis and bursitis) and AC arthritis can be treated without surgery. Nonoperative treatment involves the following: Rest the shoulder. By this I mean rest the shoulder from painful motions and activities. When you move the shoulder and the tendon and bursa get pinched, it is painful. These motions continue to irritate the inflamed tendons and cause scar tissue to form. On the other hand, those motions and activities that are not painful are not doing any damage. It if hurts, don't do it. Don't try to work through the pain. If something you do is not painful, even if it seems strenuous, go right ahead. I want you to rest your shoulder, not your entire body. Exercise. General physical activity is helpful. This particularly applies to aerobic sports like walking, jogging, biking, and any other sport that raises the heart rate but doesn't irritate your shoulder. Physical therapy. Specific shoulder exercises are sometimes beneficial. If I think they will help in your case, I'll usually send you to the therapist for 1-3 visits for instruction in exercises that can be performed at home. Medication level. A trial on an anti-inflammatory medication is usually a good idea unless your condition has been going on for an extremely long time or if you have stomach problems. These medicines are designs to decrease inflammation and therefore pain. Injections. The purpose of this is to place a strong anti-inflammatory medicine (cortisone) into the space around the tendons or occasionally into the AC joint if you have a problem there. I'll usually recommend no more than two of these. Time. This type of shoulder injury can take months to heal. This can be very frustrating to both of us. Usually within the first month or two of nonoperative treatment, we can determine whether you will require surgery to help speed your recovery.

Q :		How do you know if the tendon is only inflamed and not torn?
A :		The only way to know for certain is to inspect the tendon during surgery but based on my examination of your shoulder, I do not think the rotator cuff is completely torn. Plain x-rays such as those taken in my office only show the bones and not the tendons. Special tests such as an MRI or arthrogram are needed to tell us more about the tendons. We usually obtain these more expensive and invasive tests if you do not respond to nonoperative care or if I become concerned that the tendon is torn based on things you tell me or I find on examination.

Q :		Is surgery ever needed?
A :		Yes, but we always try everything short of surgery first. The indications for surgery are persistent pain, interfering with your activities of daily living, work, or sports, that has not responded to the nonoperative program described above.

Q :		What would this surgery involve if I were to need it?
A :		Most often impingement syndrome can be improved by making more space for the rotator cuff tendons. We can do this arthroscopically through two small poke holes by shaving off the portion of the acromion bone that is causing pressure on the tendons. If AC joint surgery is indicated, this can also be done arthroscopically through one additional poke hole by shaving off a small portion of the clavicle from underneath. At the same time the entire rotator cuff tendon and the joint itself can be inspected for tears and arthritis and other problems. If a tear in the tendon is found, this can be repaired but frequently requires a small incision in addition to the small poke holes. Most of the time this surgery is done on an outpatient basis but does require general anesthesia. The surgery itself is relatively risk free as we are well out of the way of any nerves or vessels. However, infection can always occur (about a 1% incidence for all surgery) and anesthesia itself is always a risk. That's why I only recommend surgery if absolutely necessary. Though no surgery is 100% successful, this operation is close at about 90%. It is important to note that the result you achieve is to a degree related to your cooperation and motivation