Shoulder Impingement Information
Impingement Syndrome (AKA Shoulder subacromial bursitis)
The rotator cuff is made up of four muscles which blend together and attach to the ball of the shoulder, the humeral head. The rotator cuff helps to hold the ball down in the socket and to facilitate movement and arm positioning.
The cuff is between the top of the shoulder (the acromion bone) and the ball (head of the humeral bone). Here the rotator cuff lives between the proverbial "rock and the hard place". Frequent irritation results in "bursitis4 an inflammation of the bursa in this area. This tissue is forced to perform strenuous tasks in this unforgiving environment. As we age, the tendons of the cuff may wear and weaken, allowing the ball to apply more pressure to the cuff. This is what we refer to when we say "Impingement Syndrome".
Initial symptoms may include shoulder pain or catching with certain activities like overhead sports or work. If the symptoms do not go away and pain increases in duration and frequency (like aching which keeps you awake at night), an exercise program may be helpful. The treatment program may include activity modification, specific stretching and strengthening exercises, rest, anti-inflammatory medications, an occasional cortisone injection, or other physical therapy modalities. Surgery for "impingement syndrome" is only considered after an adequate trial (generally at least 3 months) of dedicated non-operative treatment.
The Surgical Procedure: "Acromioplasty"
If non-operative treatment fails, we consider surgical treatment. The objective of this type of treatment is to take away the pressure on the rotator cuff and restore normal unrestricted motion. This is usually accomplished by removing bone from the roof (acromion) of the shoulder which often has a bone spur and removing the excess bursa. We also release a ligament which attaches to the roof in the same location where the spur forms. This takes the pressure off the rotator cuff and allows you to perform the exercises that are necessary to rehabilitate the shoulder. Sometimes there is associated arthritis at the acromioclavicular joint with must also be treated by removing the end of the clavicle.
Removal of the inflamed lining over the rotator cuff (the bursa), along with bone spur removal and ligament release may be accomplished with either arthroscopic or open surgery. Each procedure has specific advantages and disadvantages. For instance, the open procedure allows for greater exposure, release of adhesions or repair of a rotator cuff tear. However, it requires an incision through the skin and muscle. On the other hand, arthroscopy allows us to look inside the joint and actually see the inner surface of the rotator cuff, the joint surfaces and ligaments. No muscle incision is required. Both surgical procedures involve admission to the hospital on the same day as the operation. Either procedure may be done using a nerve block or general anesthesia.
The risks of the operation are those of any major surgical procedure. There is the risk of infection, either superficial (like skin) or deep (as in the joint). There is risk of injury to vital structures such as blood vessels or nerves, which may lead to bleeding, numbness, weakness, or paralysis. Mechanical or electrical instrument failure may potentially rarely occur, terminating the procedure or necessitating open removal of broken equipment. Occasionally, surgery is not helpful, resulting in recurrence or persistence of symptoms. As with any surgery there are potential risks to other organ-systems such as the heart, kidney, or lungs. Other risks of anesthesia (such as allergic reactions), are possible but are all extremely rare.
After the Operation:
We like to begin early motion to prevent scar tissue from forming. Surgery is generally done as an outpatient, unless associated medical problems make admission necessary.
After arthroscopic acromioplasty, we have a therapist instruct you how to do the exercises. You may assist the operated limb with the exercise motions, but it is all right to use the arm on its own. You may begin the strengthening exercises as soon as you can do them comfortably.
If the open method has been used for acromioplasty, your rehabilitation may be delayed somewhat for weeks while the muscle incision is healing. This means that you should not push, pull, or lift the operated limb without assisting with the other arm. Motion may be achieved lying down or with a pulley. During this time, activities may be done with your arm at your side.
Unless you make specific arrangements, it is important for us to check your progress at one and two weeks and again at six weeks after the operation. Often we suggest the assistance of a professional physical therapist in your post-operative recovery.
We gratefully acknowledge the generosity of the late Dr. Douglas Harryman of the University of Washington in permitting us to adapt this information for our patients' benefit.