Shoulder Impingement Syndrome
This may not sound like something familiar to you. However, it is perhaps one of the most common musculo-skeletal complaints that I see in my office, especially in people middle-aged and older. I am sure that you will recognize this. Let me weave the scenario for you….The victim is commonly a middle-aged person, whose connective tissue is just not what it used to be thanks to the ‘all-to-unpopular-process’ called aging. (This can be found in younger patients for other reasons, but I am not going to deal with this today.) Usually it begins with activity, often activity that involves lifting or overhead-type motions. Good examples of these include putting the holiday ornament boxes back up on the shelf from whence they came. How ’bout painting ceilings? Putting up crown molding fits the bill. Sometimes it starts with something innocuous like reaching over the front car seat to pull something out of the back. Sports which involve any type of overhead activities, like throwing a baseball or a football, serving or spiking a volleyball, or serving in tennis are great risk factors. Many people swim more during the winter because it is often too miserable outside to exercise. Swimming, especially the crawl stroke, is a notorious bad player in this arena. Wintertime activities like shoveling snow can start this off. Sometimes there may be no recalled injury at all. Once the pain starts, however, it has a very typical pattern. The pain is in the front or on the side of the shoulder. It often radiates down the outside of the affected shoulder all the way to the middle part of the upper arm. It is throbbing and aching in character. As the symptoms worsen, it markedly affects the patient’s ability to sleep. Lying on the affected side is very uncomfortable. Putting on a coat or a shirt becomes a chore. Hooking a bra in the back is also very difficult. Probably the worse movement of all involves lifting the affected arm up and above or behind the head. Now I bet this might start sounding familiar to some of you baby boomers, eh? What is it all about?
There is a space in the shoulder located under the acromion and above the humeral head. It is called the subacromial space (sounds pretty logical, doesn’t it). Actually, the roof of the subacromial space involves two other very important structures. The coracoacromial ligament, the only ligament in the body to attach a bone to a bone, forms the anterior part of it. Just inside the acromion is a joint which is not labeled above. It is called the acromioclavicular joint. This joint is very prone to arthritic spur formation as we age, which actually helps fuel the entire problem. The subacromial space contains a bursa and the top of the rotator cuff, the supraspinatus tendon. (The supraspinatus is one of the four rotator cuff muscles which are the main reason why the shoulder works as well as is does. The other three muscles are the infraspinatus, teres minor and the subscapularis. The biceps tendon, though technically NOT a rotator cuff muscle, goes right through the middle of the cuff, so it is intimately related to its misery. A bursa is like the slippery shell remnant of a grape once the fruit has been squeezed out. It simply allows different structures to slide more easily past each other. There, I think that covers all the important terms). This space is VERY small, but normally it is large enough to accommodate all of its inhabitants. When any of the involved players are injured, they swell and the space becomes much smaller. The smaller it becomes, the more the structures within it are pinched or impinged which causes more swelling, decreasing the space even further. Range of motion decreases as pain increases. Now the vicious cycle has been established. If you keep pushing through the pain, you could eventually tear or rupture your rotator cuff. This is when you will go and see your ‘friendly-neighborhood’ orthopedic surgeon.
In order to TREAT this syndrome effectively, YOU MUST INTERRUPT THE CYCLE!!!! Here is the treatment regime that I actuate with all my patients suffering from this dilemma.
1. Avoid all provocative activities. In other words, if it hurts, don’t do it. This is not rocket science. Everysingle time you feel that painful pinch in your shoulder, it is propagating your problem. Stop activities in what I call the ‘no-fly’ zone. Stop lifting your arm above shoulder level. Put your coat or shirt on, bad-arm first. Do not sleep on the affected arm or shoulder. Wearing a pair of PJ’s with pockets and sticking the affected arm in a pocket is a nice way to keep your arm at your side. Avoid overheads and serves in tennis, sticking primarily to ground strokes. On the links, chip-and-putt only. No full arc hitting. Swimming presents a particular challenge. All of the swimming stokes are problematic with shoulder impingement, with perhaps the exception of a side-stroke with the bad arm up. Since this is a not a great stroke for aerobic conditioning, might I make some suggestions to all you aquaphiles out there? Consider water aerobics or vest running. Remember to keep your arms down. In pilates and yoga, be cognizant of your arm positions. This may mean eliminating some positions or exercises. Finally avoid any unnecessary home-related overhead activities. Do you REALLY need to paint, construct or clean right now? Will the world stop turning if the boxes stay on the floor? If the answer is really ‘yes,’ then get someone else to do it.
2. Keep your shoulder moving! Here I go again, speaking out of both sides of my mouth! First I say ‘don’t move it,’ and now I say ‘keep it moving.’ Besides tearing your cuff, the other big problem associated with shoulder impingement syndrome is called adhesive capsulitits, or as I like to call it, ‘frozen shoulder.’ The shoulder capsule is the thin membrane that lies inside the rotator cuff and surrounds the entire joint. If this contracts and gets tight, the loss of motion and pain are unbelievable. The main reason that this develops is that a person with a sore shoulder, no matter what the cause, stops moving it to avoid the pain. Therefore, we must keep it moving within a painless range. The best way to do this is by Codman exercises, otherwise known as pendulum swings.
To do these, first grab a can of juice or a light weight in your affected hand. Next, lean over resting your good hand on a table or chair so that the bad arm with the juice can hangs straight down. Now, gently swing your shoulder back and forth, to and fro, and even in circles. This should be painless. Do them several times a day.
3. ‘Better Living Through Chemistry.’ With this problem, there is usually a component of inflammation. Taking an anti-inflammatory is often very helpful. An over-the-counter choice might be naproxen or ibuprofen. “Taking these medications might not be right for everyone. If your suffer from hypertension or kidney disease, if you have or have had stomach ulcers, are taking blood thinners, or have any known allergies to these medicines, please check with your doctor first.” I never thought I would say this, but the only thing I hate more than the attorneys’ ads on televisions are the pharmaceutical ones. I just love it when my 12-year-old daughter asks me what a priapism is while watching a ‘Cialis’ commercial.
4. Ice is Nice. If something hurts, it is almost a no-brainer to try some ice. For this, thawing frozen vegetables out on your shoulder that you will later use for a meal is a good trick. The small vegetables conform very nicely to the contour of the shoulder. Crushed ice in a zip-lock bag is also a good choice. A good time to do this is after your Codman exercises.
5. Sometimes you need help. If you have tried the above suggestions and your misery persists, then it might be time to check with your health care provider. Getting a professional opinion will help clarify the diagnosis so that more specific therapy can be ordered. Problems like arthritis of the acromioclavicular or the shoulder joint itself, or biceps tendonitis could be the real problem and the treatment could be different. Even the best diagnosticians sometimes have problems deciding if the shoulder is the primary problem, or if it could be related to problems in the neck. MRI scanning is sometimes necessary to help better define the problem. I will often inject xylocaine and cortisone into the affected area. This does several things. Firstly, the numbing medication usually provides IMMEDIATE relief. Secondly, if relief occurs, then I know we have defined the problem correctly. I can then feel assured that the cortisone, the real worker here, is in the correct area. It will usually start to work in several days. How long it works is very variable. The longer it works, generally speaking, the less complicated the problem turns out to be. You might say, why not inject right away, and forget all the other stuff? To this I reply that the injection is simply a ‘band-aid to a boo-boo,’ one that came about from poor mechanics. If you don’t correct the mechanics, the problem may come back. For this reason, I prescribe several home exercises to be done on a regular basis after my evaluation, as well as reiterating all of the above. Sometimes, I may refer you to a physical therapist for more aggressive hands-on therapy.
I hope this has helped you recognize, and therefore better deal with, a very common problem that you are bound to see at some point in your life. And remember……… aging isn’t for sissies.
