Shoulder Impingement: Tips & Tricks

... Shoulder Impingement: Tips  Tricks and a little bit of truth

Let’s start by briefly discussing the anatomy of the shoulder, a remarkable but complex structure with a significant range of motion available to it.
It consists of the;

• Humerus (arm bone)
• Scapula (shoulder blade)
• Clavicle (collarbone)

These structures are all connected by a series of ligaments, creating stability and connecting the bones together. The scapula has a couple of bony landmarks called the coracoid process and the acromion with a ligament (coracoacromial ligament) that attaches to them. The acromion and the clavicle bone connect to form the acromioclavicular joint (ACJ). This sits above where the head of the humerus is attached to the scapula in a shallow socket known as the glenoid fossa. The space between these structures is referred to as the subacromial space and allows a rotator cuff tendon (supraspinatus) to travel through it, has the subacromial bursa the capsule of the shoulder joint that surrounds the head of the humerus and the attachment of the long head of biceps.
The term shoulder impingement was coined a long time ago around 1972, and most people who refer to it are referring to the tissue being compressed in this space as it is quite small.
However the term is now considered a little outdated as our knowledge and treatment modalities have been researched more and more. Paavola et al (2021) suggest “the current evidence indicates that the impingement theory has become antiquated, we would also recommend to abandon the term shoulder impingement as it refers to this mechanical theory.” A significant reason for this has been because if the structures were being compressed, then the previously common “shoulder decompression surgery” would assumably be helpful in resolving a significant portion of the population's symptoms. Among a significantly growing body of evidence, a Cochrane review from 2019 concluded with a “high-certainty of evidence, that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life.” and the British Medical Journal’s 2019 clinical practice guidelines made strong recommendations against surgery and concluded that almost all informed patients would choose to avoid surgery.

Mechanisms of Injury - so what’s happening:
Impingement in this space absolutely happens and it’s considered normal, as we move our shoulder joint through ranges of motion and it’s becoming more widely accepted that this happens and is normal.
The honest answer is we’re often not sure, physiotherapists will be able to elude to what movements hurt and potentially distinguish between, bone or muscle but non-traumatic shoulder pain that isn’t related to instability, frozen shoulder, and some other diagnoses that may respond to specific medical management, happens for all sorts of multifactorial reasons.
Commonly we find that this non traumatic shoulder pain occurs when the structures that work within the shoulder complex - including the rotator cuff tendons, subacromial bursa, and long head of the biceps tendon - become overloaded for what the structures can currently tolerate, leading to pain. Overuse or repetitive overhead motions, commonly found in athletes, labourers or newbie DIYers, may lead to irritation and pain.
Structural Abnormalities and Anatomical variations, such as a hooked or curved acromion, or bony spurs, do happen and can reduce the subacromial space, contributing to impingement, and imaging will help to determine this.

Early Stage Management:
In the early stages of shoulder impingement, management primarily focuses on reducing pain, inflammation, and restoring the shoulder's function. An evidence-based approach involves a combination of strategies:
The first course of action should be to modify activities. Advising patients to modify or avoid aggravating activities or motions that irritate the shoulder is crucial in firstly making the patient more comfortable day to day, but secondly to reduce the irritability and sensitivity of the shoulder.
Numerous studies like the 2019 review by Lewis et al. in the Journal of Orthopaedic & Sports Physical Therapy emphasise the efficacy of early physiotherapy intervention in managing shoulder impingement. Patient-specific treatment plans based on the severity, causative factors, and individual needs play a pivotal role in successful outcomes. Physiotherapy exercises tailored to strengthen surrounding musculature are important. These exercises should not be significantly painful (there may be some discomfort) but ideally tolerable and should include gradual progressions as the shoulder settles and ultimately begins to improve.
Tips & Tricks:

Using Cryotherapy or Ice can be helpful for the symptomatic relief of pain, along with TENS machines, as these are proven ways to help moderate pain and can be used as much as comfortable without swallowing tablets.
Heat therapy can be helpful when there is a more tendinopathic pattern of pain. Controlling the pain and keeping it to a minimum will allow for reduced distress and allow for a greater tolerance to activities we may not be able to rest from and a greater adherence to prescribed exercises.
Finally but importantly, educating patients about their pain, discussing their options and their goals, so their understanding of their condition and pain is better will help ensure compliance with the interventions and reduce their overall distress.

In conclusion, comprehensive knowledge of the shoulder's anatomy, mechanisms of injury, and evidence-based early-stage management is indispensable for physiotherapists dealing with shoulder pain. Adopting a multifaceted approach tailored to each patient can significantly enhance the restoration of function and reduce pain, improving their overall quality of life.

References:

Lewis J, McCreesh K, Barratt E, et al. The effectiveness of physiotherapy for the management of subacromial impingement syndrome: a systematic review. J Orthop Sports Phys Ther. 2019;49(4):230-250. doi: 10.2519/jospt.2019.8871.

Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., Kavaja, L., Ardern, C. L., Agarwal, A., Vandvik, P. O., & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, 2019(11), CD005619. doi:10.1002/14651858.CD005619.pub3

Paavola, M., Kannas, J., Leppilahti, J., & Paavolainen, P. (2021). Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. British Journal of Sports Medicine, 55(2), 99-107. doi:10.1136/bjsports-2020-102216

Prather, K. K., Heiderscheit, B. C., LaPrade, R. F., & Laflamme, M. R. (2019). The impact of decreased scapulothoracic upward rotation on subacromial proximities. Journal of Orthopaedic & Sports Physical Therapy, 49(3), 180-191. doi:10.2519/jospt.2019.8590

British Medical Association. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ. 2019 Feb 6;364:l294. doi: 10.1136/bmj.l29