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Impingement – syndrome of the shoulder

Subacromial syndrome

If lifting the arms or various movements and loads on the shoulder are accompanied by pain, the cause may be shoulder impingement syndrome. Incorrect loads, monotonous movement sequences or incorrect postures can also cause striking pain to spread to the shoulder. Impingement syndrome of the shoulder is by far the most common complaint of the shoulder.

Impingement syndrome is not a disease in the classical sense, but a symptom that can have a variety of causes. The problem lies in the entrapment of tissue in the joint space of the shoulder, which limits mobility and is accompanied by pain. Athletes involved in overhead and throwing sports have a higher risk of developing impingement syndrome, as do some occupational groups, such as painters and varnishers or hairdressers.

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Table of Contents:

What is impingement syndrome?
Causes of impingement of the shoulder
Symptoms of impingement syndrome

What is impingement syndrome?

Anatomically, the space under the acromion is very limited. The so-called subacromial space is located between the acromion and the humeral head. Between four cuff-like muscles surrounding the shoulder joint (rotator cuff), the associated tendons connect the individual muscles to the bone. The tendons moving here are protected by the bursa (subacromial bursa), which prevents friction on the acromion. If the naturally already small space in the subacromial space is additionally narrowed due to swelling, injury, tissue changes or deposits, a bottleneck occurs in which the tendons can no longer glide.

This results in constant squeezing and rubbing of the bursa or underlying tendons. This usually long-lasting overstimulation of the tissue leads to inflammation, which can have serious consequences without comprehensive treatment. This circumstance is called impingement, impingement syndrome, or impingement shoulder syndrome. If the impingement remains untreated, the symptoms intensify with pain and, in the worst case, can become chronic, causing permanent damage to the shoulder situation and the rotator cuff in particular.

Causes of impingement of the shoulder

A distinction is made between the primary “outlet impingement syndrome” and the secondary “non-outlet impingement syndrome”. While the first variant causes the narrowing due to bony changes, the second is based on non-bony aspects, such as inflammation of the bursa, tendon and muscle damage. Inflammation is usually accompanied by swelling in the tissues, which further increases the constriction in the shoulder space. Severe pain and restricted movement are typical.

In advanced stages, damage to the rotator cuff may occur. These are problems with the four tendons that guide the shoulder joint and, roughly speaking, hold the humeral head in the socket. If a tendon rupture occurs, the system becomes even more unbalanced. Self-reinforcing worsening of the impingement occurs. Muscular imbalances can also cause impingement, for example when the muscles and tendons are too weak to guide the joint head in the socket.

Symptoms of impingement syndrome

The classic symptomatology begins insidiously without accident. The pain initially manifests when the arm is raised and is projected onto the upper arm. Patients are then usually unable to sleep on the corresponding shoulder. Especially twisting movements such as slipping into a jacket or activities with an outstretched arm, such as inserting the parking ticket at the gate when leaving the parking garage, are extremely painful.

In more advanced stages, impingement manifests with an increase in pain during extraordinary loads, especially during activities performed above the head. Although the onset of symptoms is gradual, patients can often identify a trigger event with an extraordinary stressful situation.

The clinical sign of impingement is restricted movement when lifting the arms. If the arms initially hang loosely on the body and are then stretched and lifted sideways, pain begins at an angle of about 60°, and further lifting is usually not possible. This aspect is called the “painful arc”.

The fact that affected patients usually adopt a protective posture and avoid painful movements is problematic and exacerbates the symptoms. This can lead to an intensification of the syndrome and at the same time promote muscle loss at the shoulders. This further weakens the stability of the shoulder joint.

Fig. 1 : A bony prominence under the acromion can be seen. This bony entrapment (impingement) can be removed arthroscopically (keyhole technique).

Figure 2: After the operation, a sufficiently wide space between the humeral head and the acromion can be seen.

Figure 3 and 4: The arthroscopic procedure is performed with the aid of a precision burr. The bony spur (left arrow) under the acromion can be seen. In picture 4, the spur was successfully removed.

What diagnostics and therapies are used for impingement?

The diagnostic process begins with a detailed medical history, which of course includes a comprehensive physical examination. In addition, there are imaging procedures such as an ultrasound, sonography and X-ray, as well as magnetic resonance imaging. This gives a clear picture of the situation at hand, the extent of the damage, and the cause that needs to be addressed.

Regardless of the cause, the therapy is divided into two pillars: In the first step, the inflammation must be treated and the pain situation alleviated. This is done by administering painkilling and anti-inflammatory drugs and sparing the affected shoulder. Once the inflammation has subsided, causal therapy can begin. Thus, in the second step, depending on the wear of the tendons or other causes, therapy can be carried out with hyaluron, autologous blood and shock wave therapy.

In parallel with the therapy already mentioned, once the inflammation has subsided appropriately, the muscles and tendons must be centered in order to optimize the rhythm of movement again. The physiotherapist plays a central role in this process. The therapist should be specialized in treatment for impingement of the shoulder. The goal is a targeted muscle building program, which can be supplemented, but not replaced, by massage or trigger point therapy. Only if the complaints are not improved by the versatile therapy approaches, an impingement surgery can be considered.

Treatment for Impingement Syndrome at the Orthopaedic Center Munich East (OZMO)

Do you have shoulder pain where your arms can no longer be lifted unrestricted at the sides or can you no longer lie on your side at night? In addition, if there is acute or prolonged shoulder strain from arm movements that pass over the head, you may be affected by impingement syndrome and should be investigated and treated. At the Orthopaedic Center Munich East (OZMO), we are happy to assist you with experienced orthopaedic surgeons so that you can successfully begin your road to recovery as soon as possible.

From diagnostics with modern medical technology to adept treatment, for example with sophisticated adapted shock wave therapy, we offer medical services for impingement syndrome as well as many other diseases of the joints and musculoskeletal system. If your impingement symptoms cannot be resolved despite comprehensive treatment, our accomplished team with many years of surgical experience will be happy to assist you.

Impingement syndrome – What therapy helps?

Prof. Dr. Diehl: Impingement – Rotator Cuff Rupture

Mo – Th:	08:00 – 18:00
Fr:	08:00 – 12:00