Bone spurs are the most important cause of pain in shoulder joint, they are very commonly seen in the population. These bone spurs constantly rub against the rotator cuff, causing inflamation. This is called impingement syndrome.
This leads to a painful condition of the shoulder leading to secondary stiffness , the so called frozen shoulder in layman's terminology. They also make rotator cuff more prone to tears.
Arthroscopy has now become the gold standard in the treatment of the bone spurs. We can trim the bone spurs with special instruments called burrs and shaver.
Neer describes the following 3 stages in the spectrum of rotator cuff impingement:
Stage 1, commonly affecting patients younger than 25 years, is depicted by acute inflammation, edema, and hemorrhage in the rotator cuff. This stage usually is reversible with nonoperative treatment.
Stage 2 usually affects patients aged 25-40 years, resulting as a continuum of stage 1. The rotator cuff tendon progresses to fibrosis and tendonitis, which commonly does not respond to conservative treatment and requires operative intervention.
Stage 3 commonly affects patients older than 40 years. As this condition progresses, it may lead to mechanical disruption of the rotator cuff tendon and to changes in the coracoacromial arch with osteophytosis along the anterior acromion. Surgical l anterior acromioplasty and rotator cuff repair is commonly required.
A Large Acromial spur leading to Impingement Syndrome
The supraspinatus outlet is a space formed on the upper rim, humeral head, and glenoid by the acromion, coracoacromial arch, and acromioclavicular joint. This outlet accommodates passage and excursion of the supraspinatus tendon. Abnormalities of the supraspinatus outlet have been attributed as a cause of impingement syndrome and rotator cuff disease, though other causes have been discovered. Impingement implies extrinsic compression of the rotator cuff in the supraspinatus outlet space.
Subacromial arthroscopy with a burr working to excise the acromial spur
Patients younger than 40 years - Usually glenohumeral instability, and acromioclavicular joint disease/injury
Patients older than 40 years - Consider glenohumeral impingement syndrome/rotator cuff disease and glenohumeral joint degenerative disease
Individuals at highest risk for shoulder impingement are laborers and those working in jobs that require repetitive overhead activity.
Athletes (eg, swimming, throwing sports, tennis, volleyball)
Onset of symptoms in relation to specific phases of the athletic event performed
Duration and frequency of play
Duration and frequency of practice
Level of play (eg, little league, high school, college, professional)
Actual playing time (eg, starter, backup, bench player) and position played
Lack of periodization in training - Athlete participating in same overhead sport year-round
Sudden onset of sharp pain in the shoulder with tearing sensation is suggestive of a rotator cuff tear.
Gradual increase in shoulder pain with overhead activities is suggestive of an impingement problem.
Pain usually is reported over the lateral, superior, anterior shoulder; occasionally refers to the deltoid region.
Posterior shoulder capsule pain usually is consistent with anterior instability, causing posterior tightness.
Setting during which symptoms arise (eg, pain during sleep, in various sleeping positions, at night, with activity, types of activities, while resting)
Quality of pain (eg, sharp, dull, radiating, throbbing, burning, constant, intermittent, occasional)
Quantity of pain (on a scale of 0-10, 10 being the worst)
Alleviating factors (eg, change of position, medication, rest)
Aggravating factors (eg, change of position, medication, increase in practice, increase in play, change in athletic gear/foot wear, change in position played)
Functional symptoms - Patient changed mechanics (eg, throwing motion, swim stroke) to compensate for pain
Associated manifestations (eg, possibly chest pain, dizziness, abdominal pain, shortness of breath)
Pain with humerus in forward-flexed and internally rotated position suggests rotator cuff impingement.
Pain with humerus in abducted and externally rotated position suggests anterior glenohumeral instability and laxity.
Causes of impingement
Increased subacromial loading
Acromial morphology (A hooked acromion, presence of an os acromiale or osteophyte, and/or calcific deposits in the subacromial space make patients more predisposed for primary impingement.)
Acromioclavicular arthrosis (inferior osteophytes)
Coracoacromial ligament hypertrophy
Subacromial bursal thickening and fibrosis
Prominent humeral greater tuberosity
Trauma (direct macrotrauma or repetitive microtrauma)
Overhead activity (athletic and nonathletic)
Rotator cuff overload/soft tissue imbalance
Eccentric muscle overload
Long head of the biceps tendon laxity/weakness
Glenoid labral lesions
In general, conservative measures are continued for at least 3-6 months or longer if the patient is improving, which is usually the case in 60-90% of patients. If the patient remains significantly disabled and has no improvement after 3 months of conservative treatment, the clinician must seek further diagnostic work-up, and reconsider other etiologies or refer for surgical evaluation.
Appropriate surgical referrals are patients with subacromial impingement syndrome refractory to 3-6 months of appropriate conservative treatment. Surgery may be particularly beneficial in patients with full unrestricted PROM, positive response to injection of lidocaine into the subacromial space, a type III acromion having a large subacromial spur and those in whom changes are noted in the rotator cuff tendon on MRI scanning.
Results are generally good for properly selected middle-aged patients with evidence of impingement on history and physical examination and at the time of arthroscopy.
General consensus in the literature is that arthroscopic subacromial decompression results in a good return to the previous level of function in approximately 85-90% of patients.
Patient after subacromial decompression on 2nd post Operative day