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The shoulder joint is a complex ball and socket joint that allows 180 degrees of movement. Shoulder impingement occurs when the rotator cuff tendons or bursa (a fluid filled sack) are repetitively compressed in the subacromial space (see image below).
This compression can cause localised inflammation and results in painful movements of the shoulder. It is one of the most common conditions we see in the clinic, especially coming into tennis and cricket season.
The impingement can be “primary” resulting from a structural narrowing of the space or “secondary” due to poor biomechanics and movement patterns of the shoulder. Some of us are born with smaller subacromial spaces or develop bony spurs over time. Secondary impingement can be a result of impaired scapula control, poor posture, or increased mobility in the shoulder joint (Holmgren et al, 2012).
Patients with subacromial impingement may experience pain when sleeping on the effected side, weakness when reaching and lifting and/or an ache referring from the shoulder down the outside of the arm.
Shoulder impingement is classified as a symptom, with many causative factors, rather than a diagnosis (Kibler et al, 2013). It is essential that your physiotherapist acknowledges the concepts of mechanical, movement-related impingement which may in hand prevent the potential for inappropriate surgical interventions (Braman et al, 2014).
The scapula is controlled by a pulley system comprised of muscles attaching to the spine, thorax and arm. Optimal shoulder posture, movement, stability and muscular control are heavily dependent on scapula performance (Kibler et al, 2013). Each muscle has a specific role in helping to tilt and rotate the shoulder blade to allow movements of the arm. The 2013 scapula summit defined altered scapula movement and position as “scapula dyskinesis”. If taping or gentle manual assistance to correct your scapula dyskinesis relieves your shoulder pain this is a fabulous indicator that you are an ideal candidate for rehabilitation and can avoid going under the knife.
As discussed, impingement is caused by a myriad of factors. Traditional treatment involved corticosteroid injections and surgical subacromial decompressions.
Recent evidence has found that exercise management for subacromial impingement is as effective as surgery at 1, 2, 4 and 5 year follow ups (Haahr et al. 2005, Haahr & Andersen (2006), Ketola et al. 2009 and Ketola et al. 2013). This is an exciting revelation in shoulder treatment, showing that a specific exercise program focusing on scapula muscle control, is effective in reducing shoulder pain and improving shoulder function (Holmgren et al, 2012). Exercise management has reduced the need for sub-acromial impingement surgery by up to 80% (Holmgren et al, 2012).
If you are experiencing shoulder pain we recommend you seek a thorough assessment to determine whether your injury will respond to a specific, personalised exercise program to avoid the need for surgical intervention.
Braman, J.P., Zhau, K.D., Lawrence, R.L., Harrison, A. K., & Ludewig, P. M. (2014). Shoulder impingement revisited: evidence of diagnostic understanding in orthopaedic surgery and physical therapy. Medical & biological engineering & computing, 52(3), 211 – 219.
Haahr, J.P., Ostergaard, S., Dalsgaard, J., Norup, K., Frost, P., Lausen, S., Holm, E.A., & Anderson, J.H. (2005). Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up. Ann Rheum Dis, 64(5), 760 – 764.
Haahr, J.P., Andersen, J.H. (2006). Exercise may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4 –8- years’ follow-up in a prospective, randomized study. Scand J Rheumato, 35(3), 224-8.
Holmgren, T., Hallgren, H.B., Oberg, B., Adolfsson, L. (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. British Journal of sports medicine, bjsports-2012.
Ketola, S., Lehtinen, J., Arnala, I., Nissinan, M., Westenius, H., … & Rousi, T. (2009). Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br, 91(10), 1326-34.
Ketola, S., Lehtinen, J., Rousi, T., Nissinen, M., Huhtala, H., Konttinen, Y. T., & Arnala, I. (2013). No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome. Bone and Joint Research, 2(7),132-139.
Kibler, W. B., Sciascia, A.D., Bak, K., Ebaugh, D., Ludewig, P., Kuhn, J., … & Cote, M. (2013). Clinical implications of scapula dyskinesis in shoulder injury: the 2013 consensus statement from the ‘scapular summit’ report of 2013. British Journal of sports medicine, bjsports-2013.
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