Impingement syndrome
When it gets tight in the shoulder
Impingement syndrome is one of the most common causes of pain and restricted movement in the shoulder. It causes pain especially when moving the shoulder upwards, during internal rotation and overhead work or sports.
These are usually weaker at the beginning of the disease, but can increase significantly due to further overloading or injuries. A doctor should be consulted at the latest when the pain leads to severe movement restrictions. In the following text, you will learn what impingement syndrome is exactly, how it is treated, and what the chances and risks of the different therapy methods are.
Definition
What is impingement syndrome?
Impingement syndrome is one of the most common diseases of the shoulder. In this clinical picture, the narrowing of the space between the acromion and the head of the humerus results in mechanical pressure on tendons that run along this space. The supraspinatus tendon is most frequently affected.
This narrowing is usually caused by an anatomical norm variant of the bony acromion, but also by wear and tear, i.e. by long-term stress on the shoulder at a rather advanced age. Overhead work (manual work, gardening, etc.) or overhead sports (e.g. tennis, handball, volleyball) are favourable for the occurrence of the disease, which can occur regardless of age. The reason for the narrowing of the space below the acromion is often one-sided strain on the muscles.
Different causes of impingement syndrome
Due to wear and tear, bone spurs, for example, can also develop on the acromion over many years, narrowing the space. Another cause of the syndrome can be a thickened bursa. This is also caused by irritation and prolonged inflammatory reactions due to overuse and incorrect loading, but also due to the existing space problem. In addition, a worn-out acromioclavicular joint can trigger a secondary impingement or enpgass situation for the supraspinatus tendon.
Due to the resulting tightness between the acromion and humeral head, lifting the arms forward and to the side (especially between 90 - 120 degrees) pinches the tendon and bursa and triggers pain. Pain in the shoulder joint can also be triggered at rest or at night when lying on the affected shoulder.
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Therapy
What are the treatment options for impingement syndrome?
At the beginning of an impingement syndrome, a conservative (i.e. non-invasive) therapy approach is started first. If the pain has occurred acutely, it is important to protect the joint in the short term in order not to overload the tendon further and to reduce the existing inflammation. It is important that the joint is not completely immobilised, as this can worsen the symptoms.
The long-term goal of conservative therapy is to improve or alleviate the symptoms of impingement syndrome such as restricted movement and pain. This is done by utilising the natural reserve space of the shoulder joint and improving the positioning of the scapula on the bony rib cage to increase the sliding space of the tendons.
After anti-inflammation, physiotherapy can be performed as a supportive measure. However, the narrow spatial conditions themselves can only be slightly improved by conservative therapy.
Once again, the important components of conservative therapy for impingement syndrome are summarised:
- Rest (in acute condition)
- Pain and anti-inflammatory therapy with so-called NSAIDs (non-steroidal anti-inflammatory drugs, e.g. ibuprofen or diclofenac).
- Local peritendinous (applied to the tendon) hyaluronic acid injections to regenerate the mechanically irritated and roughened inflamed tendon which is combined with a cortisone preparation to treat the inflamed bursa.
- If the acromioclavicular joint is involved, cortisone injections into the joint can alleviate the symptoms. Acupuncture and pulsating magnetic field therapy should also be used to reduce inflammation and swelling and to relieve pain.
- Finally, physiotherapy can stabilise the improvement achieved.
What are the advantages and disadvantages of surgical versus conservative procedures?
With the help of so-called NSAIDs (ibuprofen or diclofenac), the pain can be relieved and the irritation of the tendon resulting from the existing constriction syndrome and the associated inflammatory reaction in the tendon can be contained.
Highly effective therapy approaches are those that try to treat the existing problem, inflammation of the tendon and bursa, directly on site. Only in this way can further measures be used in a sensible way.
The aim here is to eliminate the inflammation in the bursa and to calm and regenerate the tendon again, as it can be damaged in its structure by the permanent inflammatory stimulus and, above all, is swollen and thus intensifies the constriction syndrome. The effect is achieved by applying a protective and regenerative preparation, the so-called peritendinous hyaluronic acid, to the tendon. To avoid a ping-pong effect with the inflamed bursa and to eliminate its inflammation, a cortisone preparation is added to the injection.
In the case of a secondary impingement due to inflammation and wear in the acromioclavicular joint, a total of 3 injections, supported by ultrasound, are performed in the joint. This reduces pain and swelling. At the same time, the pulsating magnetic field therapy reduces inflammation in the joint and the acupuncture, which is intensified by the magnetic field, relieves pain.
If the symptoms do not improve despite intensive conservative therapy and if there is a bony constriction of the subacromial space (space between the bony acromion and the muscle cuff covering the head of the humerus), the cause of the constriction syndrome should definitely be eliminated. This is done with the help of an operation.
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Procedure of a subacromial decompression
The aim of the operation is to restore a sufficiently large space between the acromion and the acromion in order to provide sufficient space for the tendon and the bursa, even when moving upwards. This provides lasting relief of the symptoms. A so-called subacromial decompression (lat. decompression = pressure relief) is performed. The operation is performed minimally invasively as a so-called keyhole operation or arthroscopy.
The firststep is to examine the shoulder joint through a small incision in order to detect any additional changes that may trigger the pain and to correct them at the same time during the operation.
In a second step,the space between the bony acromion and the muscle cuff covering the humeral head is examined up to the acromioclavicular joint. The inflamed bursa is removed and the bony structures are shown in their form.
Then the tendon space is widened in a controlled manner under visual control using a wide variety of instruments. As a rule, this is achieved via 3-4 small, approx. one centimetre long skin incisions.
Arthroscopic subacromial decompression creates sufficient space in the subacromial space again. The supraspinatus tendon is then no longer pinched and the range of motion of the shoulder joint is significantly increased.
Opportunities & Risks
What can I expect from an operation? Where are the risks?
The decision for or against an operation must always be made individually together with the attending physician. The patient's own medical history, the condition of the shoulder joint and the symptoms play a role and should be included in the decision.
In general, arthroscopic subacromial decompression, as performed in this case, is associated with rather low risks. Despite all the precautions and experience of the surgeon, complications can occur during the operation (e.g. bleeding into the joint capsule or infection of the joint). However, complications during arthroscopic subacromial decompression are rather rare.
The advantage of the operation is that the space below the acromion (so-called subacromial space) can be widened by the operation, which leads to a noticeable improvement in the symptoms. It is the only way to eliminate the cause of the symptoms of impingement syndrome in the long term. However, in order to achieve optimal therapeutic success, it makes sense to integrate the operation into a comprehensive therapy concept.
Preparation & Follow-up
What do I have to consider before or after the operation? Can I prepare myself for the operation?
At an appointment in our shoulder consultation, you will first be examined again in detail. We will also ask you about the course of the disease and your current complaints. Afterwards, the current imaging examinations of the shoulder that have been carried out so far will be assessed and a recommendation for or against surgery will be made in a synopsis of all the examination results.
If an operation is necessary, you will be given our operation information folder. In it, all the necessary and subsequent steps are once again explained and described in detail and you will be accompanied by us through the period before, during and after the operation.
Your great advantage is that you are always cared for by the same doctor, who also performs the operation, and therefore no loss of information can occur and you are always in the best of hands.
Specific operation-related risks as well as the exact procedure of the operation are discussed with the surgeon in an informative preliminary talk. Another informative discussion takes place with the anaesthetist before the operation. Here you will learn everything about the possible types of anaesthesia and their side effects.
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Few after-effects thanks to outpatient treatment
Arthroscopic subacromial decompression can be performed on an outpatient basis.
In most cases you can go home again on the day of the operation. Here you should first take care of the arm and keep it still. You should also take something for the pain that occurs after an operation (e.g. ibuprofen or diclofenac) and cool the shoulder joint. It is not necessary to wear a splint or a bandage (e.g. Gilchrist bandage).
After the operation, slowly increasing physiotherapy adapted to the pain is important. This should begin directly after the operation and, if possible, be arranged before the date of the operation.
Schedule after the operation
- After about a week, normal everyday activities (cooking, shopping, etc.) can be resumed with the affected side.
- After about three weeks you can return to work (depending on your job description). How long you will be absent from work depends on your occupation and the success of the follow-up treatment.
- In order to ensure good healing of the underside of the bony acromion opened by the operation, no overhead work should be actively performed for a total of 6 weeks after the operation, as otherwise an irritation condition of the shoulder joint capsule may develop, which can lead to a significant prolongation of the recovery phase of full shoulder joint mobility.
- Sporting activities that put a strain on the shoulder joint should only be resumed when you are fully able to bear the load and are pain-free, usually from the 10th to 12th week after the operation.
You can consult your post-operative doctor about this on an individual basis.
The post-operative examinations and the removal of the stitches on the 14th day after the operation can be carried out in our practice. Appointments for this will be made with you in advance.
If you develop a fever or notice redness on the surgical wound in the first two weeks after the operation, please call our practice immediately.
