Shoulder Impingement – A Painful Topic

‘Shoulder impingement’ is a common term used to diagnose pain in the shoulder typically made worse by lifting the arm. Despite its often-misinterpreted label, shoulder impingement describes a normal phenomenon that occurs each time the arm is lifted and the natural movement of bones in your shoulder leads to compression of soft tissues.

For example, compression of the rotator cuff tendons (most commonly the supraspinatus tendon) or bursa. In some people, repetitive and/or excessive compression over time may contribute to significant pain, loss of function and quality of life. Metaphorically speaking, you might consider the rotator cuff tendons or bursa being stuck between a rock and a hard place.

In medical terms, such symptomatic shoulder impingement is referred to as ‘subacromial impingement syndrome’ (SAIS) or more generally ‘subacromial pain syndrome’ (SAPS) and it accounts for up to 70% of shoulder pain presentations.

How Do You Manage Shoulder Impingement?

Like many conditions that we see at Move for Better Health, it is a misconception that surgery is the best management option, especially if the problem has been there a while and there are findings on x-ray or scans showing degenerative changes.

Historically, a commonly performed surgery in patients with SAPS is subacromial decompression surgery, a surgical procedure that involves removal of excess bone and any involved soft tissues through keyhole surgery. Theoretically, removing tissues responsible for narrowing the space where impingement occurs should reduce pain and improve function. Recovery from surgery can take months and importantly involves a graded exercise programme, guided by a physiotherapist, to reduce pain, mobilise and strengthen the shoulder.

A common alternative to surgery, and usually the first recommended management option for SAPS, is Physiotherapy.

Physiotherapy starts with a thorough assessment of the factors that affect your pain and function, but also factors that may have contributed to triggering your pain initially. Treatment can include a range of techniques aimed at reducing pain and improving function in the short-term, but importantly an exercise programme that gently and gradually progresses as your strength and function improves.

A typical treatment programme for shoulder rehabilitation takes 12-16 weeks, which can be less than the time it takes to recover from surgery.

So, Do I Need Surgery?

As always, each individual case needs to be judged on its merits, however Doctors, Physiotherapists and other Health Professionals should use the most current research evidence to guide recommendations on the most appropriate treatment.

In recent years, some high-quality scientific studies have investigated the effects of subacromial decompression surgery compared to placebo-surgery (arthroscopic investigation only) or a non-surgical intervention (e.g. no treatment or exercise therapy).

The common aim was to determine the most effective method of reducing shoulder pain and improving function in people with SAPS.

Currently, results suggest that both surgical groups (real and placebo) show marked improvements in pain and function from 6 months to 2 years following surgery, with differences between groups being insignificant.

These findings demonstrate that in some people, the surgical element of ‘decompression’ isn’t a big player, with authors concluding that there is no evidence that subacromial decompression is more beneficial than placebo.

To add to this, subacromial decompression surgery appears to show no greater clinically relevant benefits than exercise therapy alone, an important consideration when discussing management approaches between patient and therapist.

Current research tells us that the surgical benefits of decompression surgery are likely due to the correct dose of rest and tissue loading (e.g. exercise therapy prescribed by a physiotherapist) following surgery.

Additionally, it tells us that exercise therapy alone is just as effective in management of pain and function in the mid-long term. Given the inherent risk of surgery and the noted wide-spread benefits of exercise therapy, a conservative approach to SAPS at first instance appears to be the best option.

At Move for Better Health, our Physiotherapists take the time to thoroughly assess and diagnose your shoulder pain.  If you have SAPS, or other shoulder related problems (e.g. rotator cuff tendinopathy or rotator cuff tear), we can help you with an individualised management plan tailored towards achieving your goals, that is based on the best current research evidence.

If you’d like to speak to our team about shoulder pain, you can do so here or by calling us on 8373 5655.

References:

Beard, DJ, Rees, JL, Cook, JA, Rombach, I, Cooper, C, Merritt, N, Shirkey, BA, Donovan, JL, Gwilym, S, Savulescu, J, Moser, J, Gray, A, Jepson, M, Tracey, I, Judge, A, Wartolowska, K & Carr, AJ 2018, ‘Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial’, The Lancet, vol. 391, no. 10118, pp. 329-338. doi:https://doi.org/10.1016/S0140-6736(17)32457-1

Lähdeoja, T, Karjalainen, T, Jokihaara, J, Salamh, P, Kavaja, L, Agarwal, A, Winters, M, Buchbinder, R, Guyatt, G, Vandvik, PO & Ardern, CL 2019, ‘Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis’, British Journal of Sports Medicine, vol. 7, no.1, pp. 1-10. bjsports-2018-100486. doi:10.1136/bjsports-2018-100486

Paavola, M, Malmivaara, A, Taimela, S, Kanto, K, Inkinen, J, Kalske, J, Sinisaari, I, Savolainen, V, Ranstam, J & Jarvinen, TLN 2018, ‘Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial’, BMJ, vol. 362, k2860. doi:10.1136/bmj.k2860

Steuri, R, Sattelmayer, M, Elsig, S, Kolly, C, Tal, A, Taeymans, J & Hilfiker, R 2017, ‘Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs’, British Journal of Sports Medicine, vol. 51, no. 18, pp. 1340-1347. doi:10.1136/bjsports-2016-096515

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