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Shoulder Impingement
Overview
“Impingement” in the shoulder usually refers to a condition specifically known as subacromial impingement. This condition occurs when the rotator cuff tendons become pinched underneath the acromion process, a bony prominence at the top of the shoulder extending up from the scapula. There are two main types of subacromial impingement: primary impingement and secondary impingement.
Primary impingement usually occurs in patients 30 years or older and is often associated with spur formation on the undersurface of the acromion process in the front of the shoulder, where it can protrude downward into the rotator cuff tendons. This can cause painful inflammation in the subacromial bursa, a fluid-filled sac that cushions between the acromion and rotator cuff. In severe cases, an acromial spur can eventually tear the rotator cuff tendons as the tendon fibers rupture due to repetitive abrasion with shoulder motion.
Secondary impingement occurs not due to structural abnormalities but to underlying biomechanical imbalances that lead to compression of the rotator cuff underneath the acromion. Scapular dyskinesis and scapular winging are often present, positional problems of the scapula. Another potential cause is shoulder microinstability, where the humeral head rides up from the socket. If a patient presents with subacromial impingement and is under 30 years of age, they most likely have secondary impingement.
Distinguishing diagnostically between primary and secondary subacromial impingement is essential because the proper treatment for each is very different. For secondary impingement, appropriate treatment almost always consists of a rehabilitation program to correct the underlying scapular imbalance or shoulder instability. It is infrequent that an individual under the age of 30 years would require surgery for subacromial impingement. For primary impingement, on the other hand, arthroscopic surgery can be curative for this condition. Initial treatment for patients with primary impingement should be with a period of relative rest and oral anti-inflammatory medications. Subacromial injections and physical therapy can be helpful in some cases. Subacromial decompression surgery can be highly effective for patients who do not respond adequately to an initial trial of conservative treatment and who have an identifiable structural abnormality causing the impingement on X-ray or MRI. Dr. Meier performs this surgery arthroscopically, consisting of an acromioplasty that involves re-shaping the acromion’s undersurface to flatten out any spur or prominence, increasing the available space for the rotator cuff to move, eliminating the impingement. This procedure is often performed along with a rotator cuff repair when there is a tear. Sometimes subacromial decompression is performed on its own if a patient presents before there is significant damage to the rotator cuff.
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