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Shoulder Impingement and Sub Acromial Bursitis

There are many types and causes of shoulder pain. The pain can vary widely from superficial to deep, mild to severe, fleeting to a constant ache, or even catching, and causing weakness and inability to use the arm at all. Persistent shoulder pain can be very disabling; the inability to use our upper limb for our sport can be frustrating, but shoulder pain can also affect the non-sports person in everyday life – loss of the ability to manage driving, lifting, dressing, personal hygiene, and even our sleeping can be not only disabling but very distressing.

The shoulder is a complex structure.  The shoulder girdle consists of the upper arm, the collar bone and the scapula (shoulder blade) with links to the neck and upper back.  These many components can all be sources of shoulder pain. Injury to the shoulder is often persistent and fails to settle because the injury causes changes to the biomechanics or relationship of these components of the shoulder – and the problem becomes self – perpetuating. In this situation, the shoulder needs assessment and help to start working properly again.

More specifically, two common causes of shoulder pain in both the sporting and non-sporting population are an injury to the Rotator Cuff and to the Bursa. Often called Rotator Cuff tears or Tendinopathy, and Impingement (pinching) related to Sub Acromial Bursitis, these diagnoses can occur separately or frequently together. The symptoms may occur suddenly after an uncommon bout of activity or may build up over time with gradual overload to structures.

The sub acromial bursa is a fluid filled sac that reduces friction between the rotator cuff tendons and under surface of the acromion (the bony top of the shoulder). If the bursa becomes swollen there is limited space between the acromion and the upper arm, and the bursa and rotator cuff can become pinched during movement. The bursa has lots of pain receptors located within it so if inflamed or swollen and pinched it is painful, particularly when reaching overhead or back for a seatbelt, and at night time it often disturbs sleep.

Your physiotherapist or Doctor can assess for the presence of sub acromial impingement, and often confirmation of the pathology with ultrasound scanning is necessary. A common treatment for bursitis is cortisone injection. This aims to reduce inflammation and provide relief. However, if the underlying contributors and factors that pre-disposed your shoulder to be injured in the first place have not been addressed the relief may only be temporary. It is important to understand what contributed to the problem, what can be done to reduce your symptoms, and to prevent recurrence in the long term. This is the role of the physiotherapist.

The rotator cuff muscles provide dual roles; they help produce power for movements of the shoulder such as the rotation required for many sports and activities e.g. throwing, tennis, swimming, and everyday reaching and lifting. They also have a crucial stabilising role helping centre the glenohumeral head or “ball” of the upper arm into the glenoid or “socket” of the shoulder blade. This action prevents the humeral head rising into a position of impingement. Both components are essential for full, pain-free shoulder function.

Assessment of strength and control of the rotator cuff and scapula is important. The stresses on, and requirements of the rotator cuff and scapula musculature differ between sports, and rehabilitation often has to be sports or activity specific. For instance assessment of the strength ratios between the internal and external rotator components of the cuff being no greater than 1.5:1 in swimmers can be preventative of injury.

We also understand the scapula or shoulder blade position can greatly impact the efficiency of how these rotator cuff muscles work. As such significant asymmetry between sides usually needs to be addressed. Tight pectoral muscles can tilt the scapula forward; weak coupling between the components of the trapezius muscles can reduce the range and pattern of lateral rotation of the scapula essential for obtaining full reach overhead. Tight posterior shoulder muscles can reduce our internal rotation range and alter how well the “ball sits in the socket”. Several other contributing factors also need to be assessed to allow smooth coordinated pain-free action, including the posture of the thoracic and cervical spine.

All these factors require assessment and should be addressed in an individualised program. Your physio can design and guide you safely through it.

Dedication to exercise is important but will be worth the effort.

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