Shoulder Impingement

What is the shoulder?

The shoulder is a complex ball-and-socket joint that allows full movement of the arm.

It offers a wide range of motion, but also makes ist vulnerable to injury.

At the shoulder, three major bones meet and create a 90-degree angle. These bones are the

  • Collarbone (clavicle)
  • The shoulder blade (scapula)
  • Humerus, the largest bone of the arm.

Three joints are formed from the junctions of these three bones and the sternum. These joints are the

  • Glenohumeral joint,
  • Acromioclavicular (AC) joint and
  • Sternoclavicular joint.

Each joint in the shoulder is surrounded by cartilage for padding, ligaments to connect the bones, muscles and tendons to attach the muscles to the bones.

What is Shoulder Impingement?

Shoulder Impingement occurs when there is an impingement of tendons or bursa in the shoulder from bones of the shoulder.

Over time, Shoulder Impingement can lead to inflammation of the rotator cuff tendons and bursa.

Causes of Shoulder Impingement

  • Using arms overhead
  • Repetitive lifting
  • Result of a minor injury

Shoulder Impingement symptoms

Shoulder Impingement may cause pain and sufferers have the following symptoms:

  • Minor pain, present with activity and rest
  • Pain radiating from the front of the shoulder to the side of the arm
  • Pain with lifting and reaching movements
  • Pain at night
  • Loss of strength and motion

Diagnosis of Shoulder Impingement

Dr Biggs will need to diagnose the specific nature of Shoulder Instability

Often, Shoulder Impingement can be identified during a physical exam by a medical professional. By examining the joint the cause of symptoms can be pinpointed.

Diagnostic methods include:

Consultation - During this consultation Dr Biggs will:

  • Take a medical history
  • Perform a physical examination
  • Assess the joint’s range of motion

Arthroscopy

Imaging tests - In order to clearly understand the nature of any loss of the joint space or bone spur formation imaging scans are required:

  • X-rays – Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur. A special x-ray view, called an "outlet view," sometimes will show a small bone spur on the front edge of the acromion.
  • MRI - can create detailed images of both hard and soft tissues. An MRI can produce cross-sectional images of internal structures required if the diagnosis is unclear.
  • Ultrasound - can allow the doctor to examine the inside of your affected area in motion.

While not all of these approaches or tests are required to confirm the diagnosis, this diagnostic process will also allow Dr Biggs to review any possible risks or existing conditions that could interfere with the surgery or its outcome.

Treatment for Shoulder Impingement

When deciding on the appropriate treatment for Shoulder Impingement Dr Biggs will consider you age, activity level and general health.

Nonsurgical Treatment:

  • Rest
  • Non-steroidal anti-inflammatory medication
  • Physiotherapy

Shoulder Impingement Surgery

Shoulder Impingement surgery may improve function and reduce pain to the shoulder joint and prevent future pain.

Shoulder Impingement surgery has traditionally been performed as open surgery, with large incisions and a long recovery process.

Minimally Invasive Shoulder Surgery

Shoulder Impingement surgery can now be performed arthroscopically, depending on the patient’s particular situation, with much smaller incisions. Occasionally, however, arthroscopic surgery may need to be converted to open surgery to properly repair the damage to internal structures.

Two or three small incisions(portals) are made. Each incision is called a portal.

In one portal, the arthroscope is inserted to view the shoulder joint. Along with the arthroscope, a sterile solution is pumped to the joint which expands the shoulder joint, giving the surgeon a clear view and room to work.

With the images from the arthroscope as a guide, the surgeon can look for any pathology or anomaly. The large image on the television screen allows the surgeon to see the joint directly and to determine the extent of the injuries, and then perform the particular surgical procedure, if necessary.

This may involve repairing a tear in the labrum as well as tightening the capsule and ligaments.

After stabilising the shoulder, the portals (incisions) are closed by suturing or by tape.

Untreated Shoulder Impingement

Shoulder Impingement is not life threatening but can severely impact a patient’s quality of life and function.

It can affect anyone: elite athletes and the active individual, manual labourers and office workers.

Shoulder Impingement can lead to

  • Short Term Impact – inflammation of the rotator cuff tendons and bursa.
  • Long Term Impact – rotator cuff tendons may start to thin and tear.

Impingement Surgery Risks

As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

It is important that the patient is informed of these risks before the surgery takes place.

Complications can be medical (general) or specific to surgery.

Medical complications include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reactions to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attacks, strokes, kidney failure, pneumonia, bladder infections.
  • Complications from nerve blocks such as infection or nerve damage.

Serious medical problems can lead to ongoing health concerns, prolonged hospitalisation or rarely death.

Specific complications for surgery are rare but may include:

Infection - Infections can occur superficially at the incision or in the joint space of the shoulder, a more serious infection. Infection rates vary; if it occurs it can be treated with antibiotics but may require further surgery.

Shoulder Stiffness - Shoulder stiffness with loss of range of motion is a common complication that can be greatly minimized with strict adherence to your occupational therapy program prescribed by your surgeon.

Dislocations - Dislocations and/or subluxations with activity can occur before healing has taken place. It is very important that you follow your surgeon’s guidelines for activity restrictions.

Damage to nerves of Blood Vessels - Also rare but can lead to weakness or loss of sensation in part of the arm. Damage to blood vessels may require further surgery if bleeding is ongoing.

Damage to the joint - Joint damage to the cartilage or other structures can occur during surgery and may require another operation to repair.

Blood Clots (Deep Venous Thrombosis) - Blood Clots can form in the arm muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If the patient suffers arm pain, redness or swelling, or have shortness of breath at any stage, contact Dr Biggs

Hemarthrosis - A condition caused by excess bleeding into the joint after the surgery is completed. This may require additional surgery to irrigate the joint.

Preparation for Impingement Surgery

Once Dr Biggs decides that surgery is required, preparation is necessary to achieve the best results and a quick, problem free recovery.

Preparing mentally and physically for surgery is an important step toward a successful result.

  • Dr Biggs will create a treatment plan and
  • Patients will also need to understand the process and their role in it

Participating and completing a tailored exercise program before (ie. pre-hab) with a trained physiotherapist will achieve the best result after surgery.

Dr Biggs will also need to:

  • Discuss any medications being taken with your doctor or physician to see which ones should be stopped before surgery
  • Do not eat or drink anything, including water, for 6 hours before surgery
  • Stop taking aspirin, warfarin, anti-inflammatory medications or drugs that increase the risk of bleeding one week before surgery to minimise bleeding
  • Review blood replacement options (including banking blood) with your doctor
  • Stop or cut down smoking to reduce your surgery risks and improve your recovery

Post Surgery

The patient will wake up in the recovery room and then be transferred back to their hospital room.

  • Pain medication will be provided to keep the patient comfortable.
  • A bandage will be around the operated shoulder and the arm will be in a sling or brace.
  • The sling will be worn for about 4-6 weeks to facilitate healing.

Dr Biggs will see the patient prior to discharge and explain the findings of the operation and what was done during Surgery.

  • The bandage will usually be removed 48 hours post surgery and place dressings provided by your surgeon over the area.
  • It is normal for the shoulder to swell after the surgery.Placing Ice-Packs on the shoulder will help to reduce swelling. Ice packs should be applied to the area for 20 min 3-4 times a day until swelling has reduced.

The patient should keep a pillow under their elbow while lying in bed.

  • The patient will not be allowed to lift anything over your head or anything greater than 1 kilo for the first 6 weeks.
  • 7-10 days after surgery Dr Biggs will see the patient to monitor their progress and remove the sutures.

It is recommended that the patient not drive during the first 6 weeks while wearing a sling due to safety reasons and the risk of injury to the surgical site.

The patient will be given specific instructions regarding activity and a rehabilitation program of exercise and strengthening.

Eating a healthy diet and not smoking will promote healing.

  • Australian Orthopaedic Association
  • Royal Australasian College of Surgeons
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