Almost all sports and many day-to-day activities would not be possible without our shoulders. They work to support not only the entire arm, but much of the back as well. When the shoulder becomes injured it can take a toll on our way of life.
The shoulder is comprised of many moving parts which help it achieve the fluid motion we are used to. With such an intricate network of bone, muscle, and soft tissue, there are certainly things that can go wrong.
One of the most common diagnoses for shoulder pain is shoulder impingement – this implies that the tendons and nerves in the shoulder are being pinched. This can happen for a variety of reasons, but the common denominator for most of the potential causes is degeneration of tissue over time.
Degeneration is a natural process that the body goes through as it ages, but this natural process causes us to experience pain. Many doctors are well versed in shoulder pain and can help direct a patient toward a treatment plan, but the conventional course of treatment is not the only one. Regenerative therapies offer an alternative, and often less complicated, treatment.
The shoulder contains an intricate network of bones, muscle, and soft tissue which work together harmoniously to allow for motion. There are many tissues at play in the shoulder and each has a specific and important role in overall shoulder health and functionality.
As far as bones, there are three which make up the majority of shoulder:
- Humerus: one of the longest bones in the body, the humerus aids in all motion concerning arm movement. It is located in the upper arm.
- Scapula: the shoulder blade provides support to the arm and upper back and connects the humerus and clavicle. It is located on the back side of the body.
- Clavicle: the collar bone provides support to the arm during movement as well as structural support for the arm and ribcage. It is located at the top of the rib cage and the bottom of the neck.
A fourth bone, the acromion, is equally as important though not necessarily a part of the shoulder itself and helps determine the likelihood an individual will develop shoulder impingement. It is located above the scapula and helps to protect the ligaments and muscles that make up the shoulder joint.
The acromion can grow in three different formations: flat, curved, and hooked. Shoulder impingement is more likely in the curved or hooked types, as their more curved structure is likely to pinch the tendons below them.
Under the acromion you will find the bursa and rotator cuff tendons. Bursae are a fleshy sac that exist in joints all over the body. Bursae act as a cushion between bones and the surrounding soft tissue in joints. The soft tissue which bursae aim to protect include muscles, ligaments, and tendons. In the shoulder joint, the bursa is located under the acromion and is meant to act as a buffer between the rotator cuff tendons and acromion. The rotator cuff tendons are used in most functions of the arm and connect at the top of the humerus.
The configuration of these bones can cause symptoms of impingement because the area called the subacromial space (between the acromion and the ball-and-socket joint) can pinch the tendons lying inside. Over time with degradation the subacromial space can become smaller which may lead to pinching as well.
Causes of Shoulder Impingement
The interconnectedness and complexity of the shoulder system means that pain is often caused by several things simultaneously. These are some of the most common causes of shoulder impingement:
- Overuse: activities that involve frequent overhead motions such as swimming, tennis and baseball can contribute to a more rapid degeneration of the shoulder muscles and tendons. It is not only athletes who can be affected by shoulder impingement; anyone whose lifestyle involves frequent overhead motion can be susceptible.
- Previous injury: people who have sustained shoulder injury in the past could be at risk of developing shoulder impingement.
- Osteoarthritis: arthritis is characterized by the degeneration of tissue surrounding or inside of joints. As these tissues degrade, the shape of the subacromial space changes and can lead to impingement.
- Bone structure: patients with acromion that are hooked or curved typically have smaller subacromial space. The reduction in size can lead to symptoms of shoulder impingement.
- Poor posture: slouching frequently can pinch the subacromial space over time.
- Age: people become more prone to shoulder impingement as they age due to the natural degeneration of cells in the joint that support function.
It is important to note that while each of these causes contribute to shoulder impingement, they manifest into one of two varieties of impingement – secondary or primary. Primary impingement refers to structural issues in the joint.This would include a naturally small subacromial space or a curved or hooked acromion. Secondary impingement is categorized by the injury being due to activity. People who make frequent overhead motions are susceptible to secondary impingement.
Just as there are many potential causes and ways to classify impingement, the signs and symptoms can also be different for every patient.
Shoulder pain can intrude on a person’s way of life and in the case of shoulder impingement it can surface in several forms. Pain during activity, especially if it involves overhead movement, can be one of the first warning signs of shoulder impingement. It is also important to watch out for these signs:
- Pain source: pain in the upper arm and shoulder area can indicate impingement. Pain can come on during activity or inactivity and have a wide range of severity.
- Limited range of motion: impingement can sometimes lead to a lack of ability to move the arm in certain ways.
- Weakness or soreness: the muscle in the affected area may feel weak or sore.
- Swelling: sometimes the injury’s location can become inflamed and tender.
If the pain is affecting an individual’s way of life it may be time to consult a doctor. As shoulder impingement is a fairly common injury, many doctors are capable of diagnosing it.
With shoulder pain, it is common for doctors to initially try some tests involving range of motion so that they can pinpoint the location of the pain to better diagnose it. This usually means sitting with them and attempting to move the arm; based on when the pain starts and how it is described, doctors can begin to pinpoint the source of pain. Depending on the results of these motion tests, a doctor might recommend further testing. These further diagnostic measure include:
- MRI imaging: allows for doctors to have a visual aid of the potentially damaged tissue.
- X-Rays: used to determine non-tissue-related issues with the area. These include arthritis and structural issues. An X-Ray would be able to determine the shape of the acromion which could be leading to the pain as well.
- Arthrography: involves a tiny camera called an arthroscope. They allow doctors to check aspects of the tissue that may have been missed with other diagnostic techniques.
- Ultrasound: another way of observing tissue for abnormalities.
Treatment of Shoulder Impingement
Doctors will start off most patients with a recommendation to take anti-inflammatory drugs (such as Ibuprofen or Naproxen) and rest well. A lot of shoulder impingement injuries simply heal on their own over time.
If the pain persists, some types of physical therapy are recommended. Physical therapy can have varying degrees of intensity depending on the injury and patient’s abilities.
If problems with pain become more severe, doctors sometimes recommend cortisone injections. Cortisone is an anti-inflammatory drug. Though pain relief is typical with cortisone shots, they do little to actually heal the injury and can contribute to worse nerve damage over time.
If the non-invasive conventional methods of treating impingement do not seem to be working, many doctors will suggest surgery. There are several types of surgery that one might undergo. One of the common aspects doctors consider when recommending shoulder surgery is the likelihood of more than one thing happening at once. If this is the case, it means that surgeons can attempt to resolve several issues while a patient is under.
Shoulder surgery can be either closed or open surgery. Closed surgery involves making a small incision and sometimes using an arthroscope to guide the surgical tools. If there are several issues happening at the same time, doctors often opt for open surgery so that they can attempt to treat all underlying conditions in one surgery. It is common for doctors to remove some of the acromion and the bursa in an attempt to increase the size of the subacromial space and reduce the compression pains this way. This can take place in both open and closed surgeries.
In surgery that is being done to treat symptoms of shoulder impingement, surgeons will often elect to remove a part of the acromion in a process called acromioplasty. While performing surgery, it is possible that certain other injuries such as tears on the tendon, arthritis, or inflammation can be treated at the same time.
Once the surgery has taken place it is highly recommended that the patient gets as much rest as possible. Doctors will also often come up with a plan for starting regular physical therapy after surgery to maintain the strength of the muscle and continue to grow the arm’s range of motion. Sometimes doctors will recommend prescription painkillers after surgery. These must be taken as prescribed because they can be highly addictive. The recovery process can take anywhere from two weeks to a year.
Regenerative Therapies and Shoulder Impingement
In recent years, regenerative therapy has gained a lot of traction in the scientific community. The two most common regenerative therapy types are:
- Stem Cell Therapy: this form of therapy works by first extracting a patient’s own stem cells, usually harvested from bone marrow, blood, or fat cells. These tissues are processed in such a way that doctors end up with a substance known as mesenchymal stem cells. The stem cells are then injected into the injury or pain site. Doctors use ultrasound technology on the affected area to locate the exact spot to inject the stem cells.
- PRP Therapy: also often using the patient’s own cells, PRP starts with a blood sample. The sample is then placed in a centrifuge which seeks to separate the platelets in the blood cells from the rest of its contents. Once the platelets are separated, they are injected at the pain site. Doctors also use ultrasound technology to locate the injection site in PRP therapy.
Both stem cell and PRP therapy work by being able to signal to healing cells in the body. They can call these cells to the injury site so that the healing process can begin, and with the extra growth factors, proteins, and cells, the healing process takes less time than conventional treatments alone.
These regenerative therapies work well in soft tissues, particularly tendons, muscle and cartilage. In shoulder impingement, because one of the main causes of pain is pinched tendons in the subacromial space, regenerative therapies offer a potential solution. They are able to help repair a damaged tendon. They also have the potential to help repair a damaged bursa and shoulder joint.
The recovery time for stem cell and PRP therapies is only a matter of weeks. Patients will sometimes experience some pain or soreness within the first few weeks after the procedure, but this often goes away shortly. In that time, patients can expect to notice a reduction in pain. A patient’s range of motion can also be affected, increasing after treatment. A physical therapy plan can also help the patient regain strength and motion after the regenerative therapy has been applied.
Surgery is often seen as a last resort in treatment options, but it is worth considering that regenerative therapy could help. In many cases it is less expensive than surgery, it is generally much less invasive, and the recovery time is significantly shorter.
Shoulder impingement can be a serious injury with several causes. The many portions of the shoulder can be affected differently, and impingement can express itself in a variety of ways, but the good news is that there are treatment options available.
We know that there is often more than one underlying cause to pain in the shoulder area and have several methods of treating it. From rest to surgery to regenerative therapies, there are plenty of options to help with pain. If surgery seems daunting or even unnecessary, consider alternative therapies to help with a speedier recovery.