Impingement syndrome of the shoulder
Shoulder pain is a common complaint among patients visiting an orthopedist. A common cause of chronic pain is impingement syndrome of the shoulder.
The doctors at the K+31 multidisciplinary clinic diagnose, treat, and surgically treat this condition. Depending on the severity of symptoms and the stage, we select therapy and provide rehabilitation recommendations.
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Causes and mechanisms of development
The key cause is an imbalance between the bony portion of the scapula (the acromion) and the head of the humerus. Over time, the space between the two segments narrows.
When moving the arms, the two segments collide. The tendons rub against the bony process, causing constant trauma. Here are some predisposing factors for impingement syndrome:
- Congenital anatomical features of the acromion
- Osteophytes in the acromioclavicular region
- Thickening of the muscle tissue along the anterior part of the acromion
- Post-traumatic deformities in bone tissue
- Arthrosis
- Chronic bursitis
- Rotator cuff inflammation in the shoulder
- Unstable shoulder joint position
Risks increase with increased physical activity and previous injuries.
Classification and types of impingement syndrome
Depending on the severity of the disease's progression, it is divided into three stages. In the first stage, hemorrhages appear and soft tissues swell. The condition and integrity of the tendons remain unchanged, and the patient experiences no discomfort.
In the second stage, signs of chronic inflammation and tissue fibrosis can be detected. Tears appear on the tendon surface.
The third stage is characterized by the formation of osteophytes. Degenerative processes begin in the soft tissues. Even with minimal stress and rotational movements, the tendon may rupture.
By nature of occurrence, the syndrome can be primary—caused by congenital anomalies and hereditary factors—or secondary—caused by trauma and excessive stress.
Let's consider the classification of the disease by location.
Subacromial impingement syndrome
It occurs due to pressure on the supraspinatus tendon. Immediately after this pressure, the tissue swells, and small hemorrhages appear. Due to pain, the patient can barely raise their arm.
Furthermore, fibrous changes begin, and the connective tissue grows. The pain becomes aching, and its intensity decreases at rest.
After about 3 months, degenerative, dystrophic changes begin. The tendons become damaged, even to the point of rupture, and bone volume increases. There is no pain at rest, but range of motion is severely limited. Due to the lack of mobility, muscle volume decreases.
Subcoracoid impingement syndrome
In this case, the subscapularis tendon is compressed. Gradually, the muscle becomes less functional. As the inflammation progresses, the pain intensifies, and spasms occur. Over time, degenerative processes begin in the tendon area.
The pain is predominantly felt in the upper anterior portion of the limb, and becomes more intense when turning or bending the arm.
Anterosuperior and posterosuperior impingement syndrome
In the anterior-superior type, the tendon surface is injured by the anterior portion of the glenoid cavity of the scapula; in the posterosuperior form, it is injured by the posterior portion. This form is never congenital, but rather secondary, and is most often observed in injuries to professional athletes.
Pain occurs in the front or back, when swinging the arm. Range of motion is limited when rotating the limb.
Symptoms and stages of the disease
The exact symptoms depend on the form and stage of the pathology. Here are the characteristic signs.
Signs of impingement syndrome
In the early stages, patients report pain in the shoulder after intense physical activity, especially lifting heavy objects. After relaxation, the discomfort disappears at rest.
Later, pain occurs with circular movements of the shoulders and pulling the joint back. Athletes experience discomfort with certain actions, such as throwing a ball into a basket or lifting dumbbells.
As the syndrome progresses, the pain becomes more frequent. The patient can no longer raise their arm above their head, and arm mobility subsequently decreases significantly. This impacts their overall health, ability to work, and self-care.
A crunching sound is heard when moving the arm. The joint may swell. In later stages, pain occurs primarily at night.
Stages of Syndrome Development
Here are the stages of disease development:
- This stage lasts up to two weeks. The pain is severe, both at rest and with movement, and intensifies at night. Because of this, patients do not sleep on the affected side. Shoulder movement is limited due to discomfort.
- The second stage lasts 2-3 months. The pain becomes nagging rather than sharp, occurring primarily with physical activity.
- The third and final stage lasts from 3 months. Range of motion in the affected area is significantly limited. Pain at rest is virtually absent, but may occur at night. Work capacity is significantly reduced due to the immobility of the arm.
Thus, the main symptom is pain of varying intensity in the shoulder area with a gradual decrease in mobility.
Diagnosis of impingement syndrome
During the examination, the orthopedist reviews the patient's complaints, conducts an examination, and performs tests. Diagnostic tests are included in the protocol. Let's look at each method in more detail.
Diagnostic Methods
After palpating the affected area, tests are performed. Here are a few examples.
Impingement Test
The Neer test is common. The specialist fixes the scapula in a certain position, then extends the patient's arm forward and vertically until discomfort occurs.
Another test is flexion. The patient is asked to bend their arm and rotate it inward, toward the body. If there is a problem, pain occurs at 120 degrees of rotation.
The doctor checks for internal rotation issues. For this, the patient lies down, their arm is abducted at a right angle, and gently rotated. Limited range of motion indicates pathology.
The next test is shoulder abduction. If pain occurs at 70-120 degrees, this indicates a damaged supraspinatus tendon. Pain at 120-180 degrees indicates damage to the acromioclavicular joint.
Hardware diagnostics
Among the instrumental diagnostic methods, dynamic ultrasound examination is particularly noteworthy. The specialist places an ultrasound probe on the affected joint and asks the patient to perform specific hand movements. This method allows for the precise location of the inflammatory process.
The gold standard for diagnostics is MRI. With this scan, the doctor can see areas that cannot be seen on ultrasound images—the deep layers of the ligaments. The images visualize inflammation, tears, and ruptures.
Arthroscopy is prescribed if indicated. The diagnostic device is inserted into the joint cavity through a puncture, and the doctor collects synovial fluid for further laboratory testing, such as cytology and bacterial culture.
Treatment of shoulder impingement syndrome
According to clinical guidelines, treatment depends on the stage of the disease and the severity of symptoms. At the stage of mild swelling and hemorrhage, treatment is conservative, with the doctor prescribing medications. In cases of fibrous changes, surgery is indicated. Osteophytes on joints and tendon ruptures are direct indications for surgical treatment.
Conservative treatment
In the early stages, conservative therapy is possible, including the following:
- Reducing stress on the arm. If pain is present, physical activity should be avoided. The patient is advised to avoid movements such as rotation and shoulder abduction.
- NSAIDs. Nonsteroidal anti-inflammatory drugs are taken in courses. The doctor may prescribe injections, tablets, and later topical ointments and creams. Important: Long-term use of NSAIDs is not recommended, as it increases the risk of gastrointestinal bleeding.
- Glucocorticosteroid injections. Injections or blocks are administered into the subacromial area. They relieve severe pain and have a prolonged effect. Another method is the administration of platelet-rich plasma, which slows degenerative processes.
- Physical therapy. After the acute phase has subsided, exercises are prescribed. Specialized, measured exercises strengthen muscles and maintain joint mobility. Exercises are conducted with a gradual increase in range of motion and load.
- Physiotherapy methods. Electrophoresis, which delivers medications to tendons and joints using electrical impulses, is common. An orthopedist or rehabilitation specialist may prescribe laser irradiation and shock wave therapy. Physiotherapy relieves discomfort and inflammation and slows degenerative changes.
Conservative treatment is effective only in the early stages of the disease. If the tendons are already injured or osteophytes have developed, the patient should be hospitalized in a surgical department.
Surgical treatment
In stages 2 and 3 of the pathology, surgery is prescribed. The main method is decompression using an arthroscope. The surgeon creates a free space for the tendons and muscle tissue of the cuff. This prevents soft tissue damage from bone.
In case of a cuff tear, reverse arthroplasty is performed. The specialist swaps the humeral head and the acetabulum. Any muscle tears detected during surgery are sutured.
During arthroscopy, procedures are performed through small punctures up to 1 cm in size, under video camera guidance. This speeds recovery and makes manipulations more precise.
General information
Rehabilitation after treatment
After shoulder surgery, the patient remains in the hospital for 1-2 days for observation. In some cases, a cast is applied for immobilization.
After a week, the sutures are removed, and the recovery phase begins. The patient undergoes a course of exercise therapy to strengthen muscles and joints. Physiotherapy, which accelerates tissue regeneration, is part of the rehabilitation course.
Intense physical activity should be avoided for 2-3 months. In some cases, the doctor imposes lifelong restrictions on strength training, professional sports, and heavy physical labor.
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General information about impingement syndrome
In this syndrome, soft tissues are compressed by denser joint structures, causing pain and limited movement. The term first appeared in 1972. Scientists described the condition using the glenohumeral joint as an example. The condition involves mechanical compression of the glenohumeral cuff and tendons.
The result is an inflammatory process that gradually increases in intensity. Constant trauma triggers degenerative processes and joint deformation.
Clinical signs most often appear in male patients over 40 years of age who engage in physical labor. Among the younger population, the problem is more common among professional athletes.
Due to the absence of symptoms in the early stages, many seek medical attention only when degenerative changes have already occurred, complicating treatment.