Impingement is a way of describing the catching or rubbing of the rotator cuff tendons and the fluid filled sac (bursa) on the bones and ligaments in the top of the shoulder. This can lead to inflammation and pain in the top part of the shoulder (bursitis).
Why does it happen?It occurs for a variety of reasons which we think of as either
Intrinsic - this is due to a muscle imbalance, fatigue or wear and tear of the tendons. In these situations, the muscles are not working as well to hold the humeral head (ball) in the centre of the glenoid (socket). This can be a result of overuse from heavy work or due to poor posture in a more desk/driving based job. Muscle imbalances can occur even in sporting individuals despite taking part in regular exercise. This is usually caused by the stronger more well developed muscles at the front of the shoulder overpowering the weaker less well used muscles at the back. Finally, age related wear and tear of the muscles from years of use can lead to impingement syndrome.
Extrinsic - this is where bony spurs and thickened ligaments in the top of the shoulder rub and wear the tendons of the rotator cuff and the bursa. These bony overgrowths tend to develop with age and are more likely to cause pain when the arm is in certain positions such as reaching forwards, twisting the arm and performing overhead tasks and sports. It is not clear why these spurs and thickened ligaments develop but it is likely that they are related to wear and tear and prolonged use of the shoulder.
What are the symptoms and signs?Most people experience pain at the side of the shoulder and upper arm. It is usually worse with movements such as reaching out to the side, reaching around your back or performing overhead tasks. Sleep is often affected by the discomfort. Some people also describe weakness in the shoulder. This is commonly due to pain and as such it is common to avoid certain activities. Painful clicking and catching is also a common complaint. Painless clicking however also occurs in many normal shoulders and is not always a sign of a shoulder problem.
Shoulder impingement acromion before bone removal
Shoulder impingement acromion after bone removal
What tests are required?In mild cases, no further tests are needed. If your symptoms fail to settle then an x-ray may be requested. This is performed to look for bony spurs or other possible causes for your pain. In some situations it is difficult to determine if there is any underlying damage to the rotator cuff and as such an Ultrasound scan or MRI scan can provide further information.
What treatments are available?Pain control - initially treatment is centred around improving the painful symptoms. This involves the rest, avoiding painful activities and the use of pain killers such as paracetamol and anti-inflammatory medications. Your doctor or pharmacist should be able to advise which ones are safe for you to take. Sometimes stronger pain killers are necessary but these require a doctors prescription.
Physiotherapy - this is absolutely essential in the successful management of impingement syndrome. Many people can be cured with a structured program of stretches and exercises to improve posture, build up core strength and help position the shoulder blade better. Resistance exercises are used to build up the strength in the rotator cuff muscles, particularly the ones at the back of the shoulder. Injections - these can provide excellent pain improvement by reducing inflammation and swelling in the bursa (fluid sac above the rotator cuff tendons). Reducing the swelling can also provide more room for the tendons to move. The local anaesthetic effects are fairly short lived and steroids can take anything from a few minutes to a couple of weeks to take effect. Usually the pain relieving effects of the steroids can persist many months. Side effects of steroids are uncommon but can included the injection not having any pain relieving benefit, damage to the rotator cuff tendons (especially if too many are administered), infection and post injection flare of symptoms (lasting 2-3 days - 5%).
What happens if these treatments don't work?Where the previous treatments have failed to improve your symptoms sufficiently, then keyhole surgery is considered. It is important to have tried at least 6 months of good structured physiotherapy and to consider injections prior embarking on this stage of treatment.
How does the operation work?The surgery is known as a Subacromial decompression. It can be performed under general anaesthesia (asleep) or with you awake after having an injection to make the arm and shoulder go numb (brachial plexus block).
The surgery requires two small incisions, both around 8mm in size which are placed at the back and the side of the shoulder. A small camera (arthroscope) is inserted into the joint and a full inspection of all structures is carried out. The camera is then placed into the top part of the shoulder (subacromial space) and any inflammation, bone spurs and thickened ligaments can be shaved away and removed. This allows the tendons to glide more freely. The procedure takes approximately 30 mins.
The success rates for the surgery are approximately 80-85% over the course of 3 to 12 months. Some patients feel a great benefit from the operation in the first few weeks however it is also normal to feel quite sore in this period. We would expect you to be noticing some improvement by 3 months post surgery and continue to improve in the subsequent 9 months. Complications are uncommon but persistent pain or stiffness (frozen shoulder) are occasionally seen. Rare complications include infection, nerve injuries, blood clots in the legs or lungs, nerve injuries, and strokes.
What happens after the surgery?The surgery is surgery performed as a day case, meaning that you usually leave hospital the same day. A sling is provided however we encourage you to get the arm and shoulder moving as quickly as pain allows (after the nerve block has worn off).
It is normal to be sore in the first couple of weeks after the procedure and your normal painkillers can be taken. The stitches require removal after 10 days and we will give you a letter so this can be performed by your local practice nurse. Physiotherapy will be organised after the surgery and this forms an essential component of your recovery and outcome.
A big thank you to Simon and his team for their care, patience and perseverence looking after me through all stages of both shoulder and elbow surgery.
Since the shoulder stabilisation I have continued my sailing and fitness training without the worry that my shoulder might dislocate; and I don’t have to think twice whether my ulnar nerve will hinder any progression in my sports.
With their amazing help, I’ve been able to get back to sailing competatively and am now a double National champion.
After multiple shoulder dislocations Charlie helped me set a route for recovery, which has been nothing but smooth sailing. Surgery went successfully and I am well on my way to playing the sports I was previously. Would highly recommend.
Simon successfully operated on my frozen left shoulder in 2012 with fantastic results. This year he has overseen and advised treatment for my frozen right shoulder (via hydrodilation injection). His unrivalled experience in orthopaedic shoulder treatments, coupled with his reassuring bedside manner and excellent results, gave me huge confidence throughout. I’m hugely grateful to have my quality of life back and wouldn’t hesitate to recommend his services. Thank you Simon.
I had suffered with a painful shoulder and pins and needles for three years following a right shoulder fracture and failed half joint replacement prior to meeting Mr Pennington. He explained the situation in a way I could relate to and I’m delighted to say my revision shoulder replacement has gone well and for the first time in years I can use my arm and am pain free. I was even able to walk my daughter down the aisle 3 months after surgery! Many thanks.
I would like to thank Charlie Talbot and his team for the operations performed on both my shoulders and also the aftercare put in place after my operations. I have played golf since I was 12 years of age and thought at one point that I would never get back to playing again. Charlie was always very positive and told me that he would get me playing golf again. Well, I have now been playing golf for nearly 2 years. Before surgery I had a handicap of 12 and I am now down to 9, not bad at the age of 68. So many many thanks.
I had PRP injections into my right elbow last year and within 3 months I was pain free, a year on it is more or less 100% better. Fabulous I would recommend it to anyone with Tennis Elbow, in fact I have gone back again this year to get my left elbow done. Thanks Simon.
Mr Pennington I really wanted you to know how very thankful I am for the excellent care & treatment you and your staff gave me. It really meant a lot that you were so clear, friendly & professional and listened to me – so thank you again.
After more than four decades of shoulder problems with a total of three surgeries the full shoulder replacement surgery by Mr. Talbot has changed my life beyond expectations. I am now able bodied for the first time in years and pain free.
Thank you to Mr Boyle and team for the excellent care and attention both before and after Replacement Shoulder surgery, using the Tornier Simpliciti procedure. After very many months of severe pain and lack of movement I was pain free from day one. Now, after nine weeks, the shoulder and arm movement continues to improve, beyond expectation, with physiotherapy and exercise. I am extremely grateful for all the continuing care.
Following two years of recurrent problems with my left shoulder I was recommendedto Consult Mr Neil Pennington. I had the opportunity to have my surgery quickly and at my convenience, this fitted well around my professional and home commitments. The surgery was carried out as a day case procedure and Mr Pennington visited me following the surgery to explain everything. My operation was a minimally invasive procedure so my recovery was straightforward with only a few restrictions; in fact I was encouraged to keep my shoulder moving. I was driving and back to work after 2 weeks – after 2 years of pain and sleep disturbance I found this operation to be life changing! I found Mr Pennington to be a very professional and compassionate surgeon and he is surrounded by a whole team of professionals that gave me the utmost confidence in the care and treatment I received.
I would like to thank Mr. Talbot and the amazing team of nurses, physiotherapists and support staff for their care and support during my recent visit to the Duchy Hospital, Harrogate, for a replacement shoulder. The care and attention I received was unparalleled. The pain free movement I now have has changed my life.