Shoulder impingement / Rotator cuff tendinopathy
Tendinopathy is a common and troublesome pathology that is very prevalent in musculoskeletal medicine consultations. The rotator cuff tendons are one of the most common areas to be affected.
The general consensus of what tendinopathy actually is is still widely debated, but recent evidence supports more of a degeneration change within the tendon itself with disorganisation of the collagen fibres and an increase in the microvasculature and sensory nerve innervation. This is in contrast to the previous belief that it was solely an ‘inflammatory’ process that was taking place. Tendinopathy – PubMed.
These pathophysiological changes cause the tendon to thicken, narrowing the clearance space between the top of the humeral head and the undersurface of the acromion. As a result, when the patient lifts their arm overhead, the tendon can be ‘squeezed’ between the two bony surfaces, resulting in a condition referred to as ‘subacromial impingement’. Despite this, it remains a poorly understood entity with ongoing debate about its actual presence. Subacromial Impingement Syndrome of the Shoulder: A Musculoskeletal Disorder or a Medical Myth? – PMC
What are the signs and symptoms?
Patients typically complain of pain over the anterolateral aspect of the shoulder. It is usually worse with overhead tasks and any lifting activities where the arm moves out to the side of the body. Weakness can be present but is usually not as obvious as seen in rotator cuff tears and is due to pain inhibition rather than true weakness. Sleep is commonly affected, especially when rolling onto the affected shoulder in the night.
The shoulder will still have a full range of movement, but pain through the range is typically present, and ‘impingement positions’ that reduce the natural size of the subacromial space where the tendons sit are often provocative.
How is it diagnosed?
Rotator cuff tendinopathy is typically a clinical diagnosis, but imaging is often used to help exclude other potential causes that may have a similar set of symptoms.
An x-ray may be requested; this is to interrogate the subacromial space to see if there are any structural causes that may be adding to your symptoms, such as bony spurs or large pieces of calcification that are irritating the tendons. An ultrasound or MRI is helpful to confirm the rotator cuff tendons are intact; it will also confirm the tendinopathic changes and any inflammatory changes within the subacromial bursa (bursitis).
How is it treated?
- Activity modification +/- analgesia/short course of NSAIDs. Sometimes in mild cases all that is required to relieve symptoms is a short period of relative rest, avoidance of the aggravating factors (where possible) and analgesia.
- If symptoms persist, the first-line management is physiotherapy. This is essential for this condition; it follows the basic principles of any tendinopathic tendon. This is a structured and progressive rehab programme to improve the tolerance and capacity of the rotator cuff tendons and surrounding stabilising muscles of the shoulder girdle. For the vast majority of patients this will settle symptoms within a 3-month period.
- In persisting cases an ultrasound-guided steroid and local anaesthetic injection into the subacromial bursa can provide excellent relief. It can also be helpful from a diagnostic perspective. Further compliance with physiotherapy is important after to allow the best prognosis. If this was helpful initially but there is a relapse in symptoms, this can be repeated; however, if symptoms persist still, then further management options will be discussed.
Arthroscopic subacromial decompression. In rare cases, for persisting symptoms despite extensive conservative care as listed above, surgical management can be discussed. Simply put, the surgery involves ‘shaving’ any bony spurs or thickened ligaments within the subacromial space to make more room for the tendon, allowing it to glide more freely. It can also allow for better interrogation of the rotator cuff and surrounding structures to make sure there is no occult pathology or tears that may have been missed on initial imaging that can be addressed at the time. The Outcomes of Arthroscopic Surgery for Patients with Shoulder Impingement Syndrome: A Systematic Review – PubMed
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