Shoulder Pain/Impingement Matthew E. Mitchell M.D.

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mattmitchellmd.com Shoulder Pain  Many conditions cause shoulder pain  Extra Articular pain “outside of the joint” –AC (acromial clavicular) joint pain –Impingement or “bursitis” –Rotator Cuff Tear  Intra articular pain “inside the joint” –Arthritis –Cartilage injury –Loose bodies

mattmitchellmd.com Extra-articular  Impingement or bursitis –Inflammation of bursa or “sac” in subacromial space  Symptoms –Crepitus which patients call “popping” “crunching” in shoulder –Pain with overhead activity –Pain localized on apex of shoulder

mattmitchellmd.com Anatomy Bursa: Location of “Bursitis” Clavicle Humerus Acromion AC joint Rotator Cuff Underneath Bursa

mattmitchellmd.com Treatment of Impingement  Physical Therapy –Regain range of motion –Start strengthening  Injections –Caution in young people –Toxic to cartilage –Limit injections to 3 or less  Surgery –Arthroscopic decompression –Shave piece of bone and remove inflamed bursa

mattmitchellmd.com Results of Treatment  Most patients get better with physical therapy and modifications to activity in 6 months  Surgery has good results when people have had a favorable response to injections

mattmitchellmd.com AC or Acromio-clavicular Pain  Pain located in the joint that connects the acromion and clavicle  Symptoms –Pain located in the mid clavicle or “collar bone” area –Sometimes occurs in weight lifters –Can also exist with impingment or “bursitis”

mattmitchellmd.com Anatomy Bursa: Location of “Bursitis” Clavicle Humerus Acromion AC joint: location of AC pain Rotator Cuff Underneath Bursa

mattmitchellmd.com AC Pain Treatment  Physical Therapy –Regain range of motion –Start strengthening  Injections –Caution in young people –Toxic to cartilage –Limit injections to 3 or less  Surgery –Arthroscopic decompression –Shave part of joint out

mattmitchellmd.com Results of Treatment  Physical therapy can be beneficial if “bursitis” or impingement is also present  Injections can give very good relief of pain  Surgery has high predictive success if injections temporarily relieve pain

mattmitchellmd.com Rotator Cuff Tear  Tear of the small muscles around the shoulder  Symptoms –Pain with overhead activity –Weakness –Pain on apex of shoulder –More common in people over 40 years old

mattmitchellmd.com Anatomy Rotator Cuff Muscle “Covers” the Shoulder Like a Cuff

mattmitchellmd.com Treatment  Treatment depends on symptoms and age of patient  Young patients with tears should probably have early repair even if symptoms are not severe  Middle age patients years old should be trialed with non- operative treatment but  enlargement of tear and arthritis is a possibility  Older patients with large tears can be treated with injections and non-operative treatment

mattmitchellmd.com Results of Treament  Very large tears are difficult to treat  In older patients pain is reliably relieved but strength may not be improved with surgery  In younger patients some improvement in strength may be possible with surgery

mattmitchellmd.com Intra-articular Pain  Cartilage Injury –Labrum (surrounds the articular cartilage) –Arthritis (articular cartilage)  Symptoms –Dislocations –Throwing pain –Loss of strength

mattmitchellmd.com Intra-articular Pain Superior Labral Tears: throwing pain Inferior Labral Tears: instability and dislocation Arthritis: articular cartilage

mattmitchellmd.com Treatment  Physical Therapy –Range of motion –Strengthening  Injections –Used to help with diagnosis  Surgery  Arthroscopic repair of labral injury  Tighten capsule if necessary

mattmitchellmd.com Results  Arthroscopic repair of labral injuries –Good results with accurate diagnosis  Arthroscopic treatment of dislocation –It has results equal to open repair but these reports are early –There may be a role for early repair in young active people

mattmitchellmd.com Summary  Shoulder pain has intra-articular and extra-articular causes  Burisitis or impingement is most common extra-articular cause  The main initial treatment is physical therapy and activity modification  Surgery has good results in most cases Back to Patient Information