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Impingement Syndrome

Rotator Cuff Tendonits/Partial Tear/Bursitis

What is Impingement Syndrome?

Impingement Syndrome represents a spectrum of problems involving the shoulder including Bursitus, Rotator Cuff Tendonitis, and eventually Rotator Cuff Tears.  Early stages of Impingement Syndrome includes Bursitus which is inflammation of the bursa (a lubricant layer that sits just above the Rotator Cuff muscles).  Progression of the disorder can lead to inflammation of the Rotator Cuff Tendons (Rotator Cuff Tendonitis),  If it continues to progress, it can eventually lead to partial and even full thickness Rotator Cuff tears.  

 

What is the rotator cuff?

The rotator cuff is a group of four muscles (Supraspinatus, Infraspinatus, Subscapularis, and Teres Minor) that have a very important role in all movements of your shoulder.  More specifically, they are involved in rotational movement (internal and external rotation) and elevation of the arm, as well as to help stabilize the glenohumeral joint (i.e. the shoulder ball-and-socket joint).  All four of the Rotator cuff tendons sits below a shelf of bone called the Acromion.  

 

Why does Impingement Syndrome occur?

The cause of Impingement Syndrome is multi-factorial, and usually due to a number of coexisting factors.  The basic pathology is the pinching or impinging of the soft tissues (Bursa/Rotator Cuff Tendons) between the Acromion bone and the Humerus bone.  Part of this may be from overuse of the shoulder from sports or frequent activities above the shoulder level.  Part of it may be from bone spurs that can frequently occur from the Acromion bone causing pinching of the Bursa/Rotator cuff muscles, especially with overhead activities.  Some patients whose ligaments are "stretchier" than normal allows the Humerus bone to not only ride higher causing more pinching, but also makes the Rotator cuff muscles work overtime in trying the keep the joint stable, producing tendonitis. Sometimes, it just happens.  

 

Symptoms:

Patients usually present with pain especially with activities above the shoulder level, or any activity activating the Rotator cuff muscles.  This pain often radiates down from the shoulder almost down to the elbow.  Side sleeping on the affected shoulder often causes pain waking patients from sleep.  Patients who have more significant or full thickness tears may also experience a weakness that makes it difficult to raise their arm.  

 

Imaging:

X-rays are usually ordered first and may reveal bone spurs or calcium deposits within the rotator cuff tendon. Other radiologic studies such as an Ultrasound may be used to help characterize the tear, or in those patients who cannot have an MRI due to medical reasons.  In those patients suspected to have full thickness tears or have enough pain that might warrant an injection or surgery, an MRI is often ordered to confirm the diagnosis and determine its severity. MRI can show whether there is just inflammation, or whether it has progressed to a Rotator cuff tear.

Treatment Considerations:

Treatment of impingement syndrome depends on what part of the spectrum the patient is in.  Nonoperative treatment is the preferred first line treatment, and usually consists of activity modification (specifically avoiding overhead activities and heavy lifting) and Physical Therapy.  The goal of Physical therapy is aimed at decreasing inflammation, and strengthening the rotator cuff and scapular stabilizing muscles.  Typically, Dr. Lee will recommend a physical therapy protocol for at least 6 weeks.  

 

If either this nonoperative treatment does not provide satisfactory improvement, or if the patient has an unusual amount of pain, injections may be warranted.  Based on the MRI, if the patient has significant inflammation without evidence of a partial tear, a steroid injection such as Cortisone may provide pain relief.  However, if there is a partial tear, Dr. Lee feels a steroid injection may cause the rotator cuff to tear further due to the fact that steroids can weaken collagen/tendons.  In these cases, treatment with biologics such as Platelet Rich Plasma may be warranted.

 

Surgical Treatment:

If nonoperative treatment does not provide adequate improvement after a trial of at least 6-12 weeks, surgery may be warranted.  The decision on whether to progress with surgery is purely driven by the patient depending on the amount of pain and functional limitations the patient might have.  

 

Dr. Steven Lee performs this procedure entirely Arthroscopically, which  minimally invasive that entails making very small incisions over the shoulder.  A small camera is then inserted through an incision into the shoulder joint, which displays a picture onto a television screen that Dr. Lee can view.  Dr. Lee will remove any inflamed tissue, and shave down any Acromial bone spurs (called a Subacromial Decompression) that may be impinging upon Rotator Cuff tendons.  Any tears of the Rotator cuff  tendons can be be addressed at this time with repair or debridement.  The decision to do the above procedures is case-specific and depends on what Dr. Lee is seeing within the shoulder joint when he first inserts the camera. Learn more about scheduling surgery. 

Dr. Steven Lee has performed thousands of arthroscopies and is fellowship trained in Sports Medicine.  He is part of the teaching faculty for the Lenox Hill Sports Medicine Fellowship (which is the oldest sports medicine fellowship in the country), and is currently the Associate Director at NISMAT, which is the first institute in the country dedicated to sports medicine research.  He has also authored a paper dedicated to Rotator Cuff Repair technique, which was honored as William A. Grana Award for Best Research.

 

Post-Operative Care:

Patients will be placed into a soft dressing and sling following shoulder surgery. Patients will continue to wear this sling until their first post-operative appointment 7-10 days following surgery. The dressing from the operating room can be removed 48 hours after surgery and the small incision sites covered with bandaids.

 

Patient will have their sutures removed at their first post-operative appointment.  At this point, Physical Therapy can usually be started, which can go on for 6 or more weeks.  Basic home exercise instructions will furthermore be prescribed and discussed at this appointment. 

It is important to note that return to normal activity normally can take at least 6 weeks. It is furthermore common for patient to experience continued strength and functional improvement for up to 6-12 months after surgery.

 

Learn more about post-operative care.

 

Post-Operative Instructions

Download here.

 

*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables.  It is provided as an educational service and is not intended to serve as medical advice.  Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.

 

*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.