We are sticking with the upper extremity trend this week examining another example of pain that can be effectively treated and prevented without the need of medication or surgery. Shoulder impingement syndrome is a very common cause of shoulder and upper arm pain from younger, overhead athletes to older adults who have pain with daily life. The term impingement is a little misleading as we all have a normal amount of impingement in our shoulders when we move overhead. But it describes the cause of this injury well. Throughout this blog we will look at how impingement starts, how we can treat it, and how we can prevent it.
Causes
First, we must look at what is actually being impinged and causing the shoulder and upper arm pain. Inflammation and/or tearing in the rotator cuff is the end result of shoulder impingement syndrome. The rotator cuff is made up of four muscles that all start on different areas of the shoulder blade and attach to the same general area on the upper arm bone (aka the humerus…I’m not sure why they call it that…it isn’t very funny…like this joke). All of the tendons of the rotator cuff run under an arch made by a joint between the collar bone and shoulder blade. There is not a lot of room under that arch. There is also a bursa (protective fat pad) that creates even less space under the arch. Anything that makes that space smaller could cause impingement on the rotator cuff.
The primary job of the rotator cuff is to work as a group to help improve stability of the shoulder joint as it moves overhead as well as to move the arm in diagonal and rotational motions we use in every day life (putting on a seatbelt, reaching back to put on a coat, tucking our shirt in, etc.). The shoulder and rotator cuff have to work in sync with the shoulder blade, as well, to make this happen. When we move our arm overhead, the shoulder blade has to open up. That allows full overhead motion with as little impingement in that arch as possible.
As we already said, everyone has a certain amount of impingement at the top of the motion when raising an arm overhead. It’s normal. However; when proper mechanics between the shoulder joint and shoulder blade change, that impingement can happen sooner in the motion. As that excessive impingement happens more often over time, inflammation of the rotator cuff tendons can occur. Tearing in the rotator cuff can also occur.
This can happen in younger athletes who do a lot of overhead activity, such as swimmers and baseball pitchers, but it can also happen overtime as we age. In both instances, the relationship between the shoulder blade and shoulder joint isn’t quite right. An imbalance of general mobility, strength and stability is also present causing more rotator cuff stress and pain. In athletes or in the general population a more rounded posture (for more see previous blog on posture), tight chest and shoulder/neck musculature, stiffness in the mid back, and weakness in the rotator cuff all create a cycle of impingement. This cycle causes more pain which causes more weakness and compensation leading to more impingement and so on. We need to break that cycle.
Symptoms
The most common symptom of shoulder impingement syndrome, or rotator cuff tendinitis/tearing, is a diffuse pain on the outside of the upper arm. Sharp pain or pinpoint pain in and around the shoulder joint is also common. Typically, the pain does not radiate past the elbow nor does shoulder impingement directly cause numbness and tingling to be felt in the affected side. However; other structures, including nerves, can be irritated by structures that also contribute to rotator cuff injury, so these symptoms aren’t out of the question.
Difficulty completing daily tasks are also common, especially with chronic (over 3 months) shoulder impingement syndrome. Raising the arm at or above shoulder height, lifting weight of any amount to or above shoulder height, reaching across the body, tucking in a shirt, fastening a bra, putting on a jacket or sweatshirt, and putting on a seatbelt all can be difficult to do and/or increase pain. Hiking the upper part of the shoulder up is also a common symptom.
Treatment
So what can we do about this? Treat the inflammation? Stop doing the daily activities until it calms down? What about rotator cuff tears? Isn’t the only option for tears surgery?
I am glad you asked.
First, improving the inflammation can be helpful. Using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) as directed can help (for safe and effective use contact your physician with questions). Heat is also helpful with improving the healing process. But these are not going to treat the root cause of the pain. As we already said, we need to restore the proper mechanics around the shoulder joint and upper body to decrease the amount of impingement happening and help it happen less often. This will treat the pain and prevent it from coming back.
3 Tips to Improve Shoulder Impingement
1. Improve Postural Stability
This can be achieved by learning to activate the lower trapezius muscle who’s job is to open up the shoulder blade when we move our arms overhead. Check out this video to work on activating this muscle.
Once you have that down, apply it to every day activities that cause pain. Gently bringing the shoulder blades down and back before lifting or reach overhead can help decrease shoulder impingement. I have all of my clients work on this very frequently. It helps.
2. Improve Chest Flexibility
If the chest muscles are tight, they contribute to the shoulder blade not opening up as we move our arms overhead. Doing a simple doorway stretch is helpful. Really relax the arm against the doorway. Doing one arm at a time prevents us from holding ourselves up with the muscles we are trying to relax and stretch.
3. Improve Sleep Positions
Sleeping is the biggest complaint I hear when people suffer from shoulder impingement syndrome. The best position to decrease pain is to sleep on the unaffected side with the head, neck and torso in a straight line while hugging a pillow with both arms. Having the hips and knees slightly bent with a pillow between the knees is also helpful. If you have to sleep on the affected side, leaning towards your back about 45 degrees while following all of the other recommendations will help.
What About Tears?
As far as rotator cuff tears and surgery goes, no, surgery is not necessary to treat tears. One study showed that 65.3% of rotator cuff tears showed no symptoms at all! Of people in their 50’s with tears, 50% had no pain at all. Of people in their 60’s with tears, TWO-THIRDS had no pain at all. That means many people walk around with tears and don’t even know it. Conservative treatment for suspected or diagnosed (via imaging) tears is worth it if you want to avoid surgery!
Conservative Treatment Works
At the end of the day, we are all different. Not every case of shoulder impingement or rotator cuff tearing is alike. Physical therapists are well equipped to identify the root cause of your shoulder pain and find effective treatment that will relieve your pain while giving you the tools to prevent it from returning. Don’t let pain prevent you from putting away the dishes, picking up your kids or grandkids or enjoying a round of golf or a game of tennis. The sooner an injury like shoulder impingement syndrome is addressed, the sooner you can get back living pain free and working pain free.
Contact us today to book your appointment and get back to doing what you love pain free.
