Dr. Gouveia discusses common causes and treatments of anterior shoulder impingement

Shoulder Impingement

Chances are if you were or are a throwing athlete, your workouts contain some overhead press, or you have a job where you repetitively put your arms overhead, such as carpentry. You likely have encountered a shoulder injury, and likely it would have been shoulder impingement. Shoulder impingement can affect other parts of our lives if we do not know how to manage it, even if we stop doing the main activity that promoted the pain.

We know about 95% of rotator cuff tears start with impingement. So what you feel in your Shoulder should be addressed early to prevent too much damage from the joint's wear and tear. This can feel like a structural issue, and people might feel like they have to look for corrective surgery or the pain is bad enough that they feel like they need an injection. These might be required, but these symptoms can often be controlled, and the root cause of the pain can be addressed through conservative care, which leads to less residual symptoms.

If you want to read more about it from an alternative source before we break down the condition with assessment, treatment, and prevention, click the link below.

https://www.medicinenet.com/impingement_syndrome/article.htm#what_are_the_symptoms_of_shoulder_impingement_syndrome

 

What classifies shoulder impingement?

Shoulder impingement is typically caused by a decrease in subacromial space between the bursa and the humerus. Repetitive strain on the supraspinatus, infraspinatus, teres minor, and/or subscapularis (SITS muscles) can cause sharp, dull, achy, sometimes throbbing pain or discomfort underneath the acromion process of the Shoulder. Four different factors can cause this:

  • AC degeneration- typically do not see normal degeneration until about the 6th decade of life.
  • Scapular dyskinesis- athletes with poor control of the joints of the Shoulder, specifically the scapulothoracic joint, through athletic movements can further drive shoulder impingement
  • Thickened coracoacromial ligament-  this is part of the upper limits for the glenohumeral or Shoulder joint, so thickening of the ligament can reduce this space
  • Upper crossed syndrome- otherwise known as bad posture of the upper quadrant of the body Scapular dyskinesis and upper crossed syndrome are the two most common causes, so that we will take a further look into these conditions.

Scapular dyskinesis

The scapula's position and movement require proper tone and movement of the 17 muscles attached to it. Suppose we have short and tight muscles paired with long and weak muscles surrounding the scapula. In that case, we often get faulty positioning or movement required to get our Shoulder in a good position for daily activities or sports. This can be secondary to various traumas, other shoulder pathology, or hyperkyphosis of the thoracic spine. As a primary or secondary condition, scapular dyskinesis can lead to decentration or improper positioning of the glenohumeral joint causing impingement.

Upper Crossed Syndrome (UCS)

UCS is a postural dysfunction described by Dr. Vladimir Janda as a combination of weak or tonic muscles and tight or phasic muscles we have a predisposition for as humans. Tight muscles include the upper trapezius, SCM, levator scapula, and pectoralis major. In contrast, the weak muscles are typically the rhomboids, middle and lower trapezius, deep neck flexors, serratus anterior, and scalenes. This is often seen with rounding of the shoulders, slumped forward position of the back, and protracted neck or chin's jutting. The problems associated with the upper crossed syndrome are headaches, disc bulges, cervical radiculopathy, and impingement or rotator cuff pathology of the Shoulder by limiting or altering the biomechanics of the Shoulder.

How we treat Shoulder Impingement

Shoulder impingement requires a complete assessment to figure out what is the primary culprit of the pain. First, we can rule out pathology by asking a series of questions in the history and performing orthopedic and neurological tests. For example, if you had a recent trauma, we may see it necessary to have imaging to rule out a fracture possibility. With a cluster of orthopedic tests, we can better understand what the pathoanatomical, or pain-causing, the structure is. This could give us information if we suspect that you have a full-thickness tear of your supraspinatus tendon. This could be out of our control as conservative health care providers, especially if you have true weakness in the musculature. We further our exam through palpation, motion assessment, and functional tests to give us a more detailed understanding of your condition specifically. These examinations will help us guide our treatment for you. The treatment can consist of chiropractic manipulation, soft tissue techniques such as Active Release Technique and Gratson, class IV laser, and corrective exercise. These will help decrease inflammation, speed up healing, and restore the joints and muscles' proper movement and biomechanics.

 

Phases of Care

We know that often fixing how someone moves, giving them postural correction, and strengthening muscles that are weak while stretching muscles that are tight can ultimately remove the pain from your life. But there are still phases to care that can help you deal with the discomfort first then attack your goals and primary reasons you came into the office. These are the three phases.

Phase 1: Pain Reduction and Postural Coaching

Phase 2: Return to Activities of Daily Living

Phase 3: Return you to your life goals

Often, the pain can sit on your Shoulder, have pain with movement, or pain while sleeping on that Shoulder. These can be helped by doing muscle work, adjusting extremities or the spine, class IV laser, or even repetitive movement of either the spine or the Shoulder to alleviate the pain. This is why it is important to find the pain generator specific to you. We also have to talk about posture, both in our day to day life and during sleep. An excellent upright position of the spine and pulling your shoulder blades down and back, often requiring stretching of short muscles or strengthening weak muscles through exercise, can help prevent a recurrence. Also, sleeping on the opposite Shoulder and having a pillow under the affected arm can help put some slack on the injured tendon and heal rather than have pressure on it for a long duration.

Phase 2 will expand on your care by adding more correctives to further correct posture or add resilience to your necessary daily activities to prevent an acute reaction to those positions or movements.  

Phase 3 is the phase of care that gets us back to what we love to do most. That's playing that overhead sport with your friends, getting back in the gym, among other activities. If you want to lift more weight overhead and not have this flare up again, we might need to address your form and give you cues and strengthening exercises to keep your good form throughout the movement. This is all about building resiliency. You might feel that after a couple of visits, you can go back to what you love, but we want to mitigate the chance of re-injury and severity of re-injury so you can do that activity longer and without setbacks.

Any sign of shoulder impingement can be a sign you need to come to see your local chiropractor. At Health Fit Chiropractic in Boca raton we are here to help. If you are dealing with any impingement pain, we encourage you to call our office and schedule a new patient exam. Our doctors will provide you with the best conservative treatment options for your condition and goals.