Shoulder Impingement

Shoulder Series

PART 4

Shoulder Impingement

 What is Shoulder Impingement and how does it occur?

Shoulder Impingement refers to a reduction in the subacromial space (the space below the acromion process and the AC joint) caused by protraction of the scapula and/or bony development of the acromion process.

The rotator cuff tendons that lie within the subacromial space are loosely protected from the acromion process by the subacromial bursa, a small sac of fluid that helps to reduce the friction generated between bone and soft tissue.

In the normal glenohumeral joint with adequate subacromial space the humeral head can be taken through its range of motion without being impeded. If the bony acromion process has developed into a spur (as with age or years of repetitive above head activites) OR the individual’s posture is excessively kyphotic causing protraction of the scapula, then movement of the humerus into forward flexion or abduction can be blocked as the soft tissue gets pinched, causing pain.

Recurrent impingement can lead to an inflamed bursa and/or rotator cuff tendons. So the client’s diagnosis could be subacromial bursitis, rotator cuff tendonitis, shoulder impingement or any combination of the three! In chronic cases however, the symptoms maybe coming from the inflammatory pathology but the CAUSE is most likely the orientation of the scapula and its ‘impinging’ effect. This would arguably dictate the course of treatment.

 What are the symptoms of Shoulder Impingement?

PAIN ! As with most movement dysfunctions, clients will report pain and discomfort during movement first. It will predominantly be located over the anterior aspect of the glenohumeral joint but can also refer to the upper arm and even up into the neck.

Because of the mechanics of shoulder impingement, it is not uncommon for client’s to be symptom free whilst the arm is resting by their side, only becoming aware of it when they try to lift their arm above the height of their shoulder. Activities such as brushing hair, putting a coat on, reaching high and sleeping can increase the client’s pain. As with any injury, the longer the client has the problem, the weaker they become in that area.

What causes Shoulder Impingement?

Shoulder Impingement is more common in middle-aged people, the result of degenerative change to their acromion process. More recently, with the increased use of computers and prolonged seated postures at work, people are suffering shoulder impingement earlier in life. Testament itself to the fact that the condition is posture led.

Most cases are chronic where the pain has increased over time and the specific cause is unknown. However, some clients can develop shoulder impingement following an acute injury that has suddenly reduced the subacromial space:

·       Reaching behind the car seat to lift something

·       Falling directly onto the shoulder

·       Painting a ceiling

·       Swimming, tennis, squash, etc

How to treat Shoulder Impingement

The majority of shoulder impingement cases can be managed with conservative treatment including manual therapy, posture correction exercises (PILATES!) and possibly electrotherapy.

Depending on the chronicity of the client’s symptoms and the underlying extent of inflammation within the subacromial space, sometimes a subacromial cortisone injection is administered to reduce the pain. This treatment can often reduce pain enough to allow the client to tolerate conservative treatment.

If the client has not responded to a thorough conservative treatment plan then they may undergo surgery to reduce the impingement. Typically, the surgery is performed arthroscopically (keyhole incisions guided by camera) and the surgeon will aim to ‘shave’ the bony spur of the acromion process and possibly remove the inflamed bursa, thereby opening up the subacromial space again.

Following surgical intervention it is crucial that the client undergo the same rehabilitation in order to correct the cause.

Shoulder Impingement and Pilates

As outlined in previous articles, it is not often a Pilates teacher will be referred a client with Shoulder Impingement but more likely an existing client experiences it or has had a history of it. It is a pity really, as due to the nature of its onset and the fact that impingement is largely brought about by poor scapula orientation and movement Pilates is perfect for sufferers of impingement!

Pilates exercises that focus on correcting thoracic kyphosis, releasing tension of the anterior scapula protracting muscles, improving good scapula-humeral rhythm, rotator cuff strength and postural alignment will undoubtedly help with Impingement. In particular, Reformer and Cadillac work using varying degrees of resistance is excellent for long-term management and post-operative treatment alike.