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

2. mattmitchellmd.com Disclaimer  Patients should discuss specific injuries with their primary care doctor or surgeon. This site is meant to give general information to patients about specific patient problems. It is impossible to individualize this discussion to specific patient issues.

3. 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

4. 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

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

6. 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

7. 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

8. 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”

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

10. 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

11. 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

12. 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

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

14. 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 40-60 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

15. 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

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

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

18. 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

19. 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

20. 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