Shoulder impingement syndrome is a common injury affecting those who play ‘overhead’ sports and there are a wide range of activities that involve a repetitive movement which elevates the arm above the head, including cricket, tennis and swimming.

Known as one of the most common causes of shoulder pain, the twinge you feel when you execute your tennis serve can quickly become persistent and affect your ability to perform even the most mundane, everyday activities.

Understanding shoulder impingement syndrome

Simply put, shoulder impingement syndrome is diagnosed when a tendon of the muscle catches within the shoulder. This in turn leads to weakness in the arm and pain when the arm is lifted above the head.

It is the rotator cuff tendon that causes the condition; responsible for connecting the shoulder muscles to the very top of the arm, this long, thick tendon is situated within a narrow space, known as the sub acromial space. If it becomes trapped within the space, the tendon begins to rub against the bone, causing pain and sometimes, inflammation.

If inflammation of the tendon does occur, it is referred to as rotator cuff tendonitis. This will develop if shoulder impingement syndrome isn’t treated early enough. There’s also the chance that the tendon could start to wear away and become thinner over time.

What causes shoulder impingement syndrome?

There are actually two different types of causes of shoulder impingement syndrome referred to as primary and secondary.

Primary cause: If you are diagnosed with primary based rotator cuff impingement, it refers to the structural narrowing of the shoulder. It is possible to be born with a naturally narrow subacromial space, significantly increasing your risk of impingement. However, structural narrowing can also develop due to osteoarthritis. The condition can cause bony spurs to develop within the space, further narrowing it.

This type of shoulder impingement syndrome increases the risk of shoulder tendonitis and bursitis.

Secondary cause: This secondary cause of shoulder impingement is referred to as dynamic instability. It occurs when the muscles around the shoulder joint are weak, along with abnormal joint laxity and too much movement in the joints.

It is this type which is most commonly found in athletes, caused by repetitive activity overhead, incorrect posture or injury. The shoulder is required to work much harder if it is unstable, increasing the risk of impingement.

If it is left untreated, secondary rotator cuff impingement will worsen and re-occur.

Identifying the symptoms of shoulder impingement syndrome

There are a number of distinctive symptoms associated with shoulder impingement syndrome including:

• Weakness in the arms
• Intense pain when the arm is raised overhead
• The shoulder is painful to lie on
• Pain which extends down from the shoulder to the elbow

As the condition worsens, you could also begin to experience pain even when the shoulder is resting. Some patients experience a constant, dull ache, rather than intense pain. The condition will need to be diagnosed, typically with the aid of an ultrasound scan. This is most commonly used to identify dynamic impingement.

Shoulder impingement treatment options

The type of treatment required will depend entirely upon where the injury has occurred. Numerous structures can be affected during shoulder impingement syndrome, so identifying the problem area is key to diagnosing the correct treatment.

London Shoulder Specialists’ consultant surgeon Mr Andy Richards spoke on shoulder impingement syndrome, particularly in relation to rugby players, at last year’s Fortius International Sports Injury Conference:

“Younger rugby players – by which we mean under age of 35 – often have more functional impingement and an inability to control their humeral head with superior translation. They also have a high percentage of sub-clinical instability and standard treatments of injections and subacromial decompression will fail in this group.

“For younger patients you have to look at the pathology and identify labral or partial cuff tears and whether ACJ inflammation is also contributing to the pain they are experiencing. The MRI Arthrogram is definitely the investigation of choice. If there is no structural abnormality, then this group can be rested and rehabbed, with guided steroid injections to the bursa, but if they have a structural abnormality or fail to rehab, then surgery is the best option.”

As the new rugby season gets underway, specialists across the country brace themselves for an increase in shoulder-related injuries, including AC joint shoulder injuries.

Rugby is a notoriously tough, physical contact sport which puts the body through a significant amount of trauma. A study published last year in the Journal for Orthopaedic Sports Medicine, Arthroscopy and Knee Arthroplasty, evaluated injury risk in International Rugby Union, focusing on the Welsh National Team. The shoulder was found to have the highest injury incidence and suffered one-third of recurrent injuries. Shoulder dislocations were also found to result in the most days lost per injury.

The shoulder is a complex joint, composed of a number of different joints, bone groups, muscles, ligaments and tendons. It has the the greatest range of motion in the body and is susceptible to a number of different injuries and conditions. One of the most common injuries suffered by rugby players is injury to the acromioclavicular or AC joint.

What are AC joint shoulder injuries?

The AC joint is situated at the top of the shoulder, being the junction between the shoulder blade (acromion) and collar bone (clavicle). Due to its location, the joint is particularly susceptible to trauma during rugby, with separation and dislocation being the most common problem experienced. A direct hit to the joint can cause it to become separated, along with a fall onto an outstretched hand.

Understanding the different types of AC joint separation

Like many shoulder injuries, there are different classifications of separation that can occur in AC joint shoulder injuries. They are measured using the Rockwood scale:

Grade 1 – pain is experienced around the AC joint, but the bones remain in position.

Grade 2 – as well as pain around the joint, there is some damage to the capsule, as well as a partial tear in the superior ligament. A lump may also be visible through the skin.

Grade 3 – the coracoclarvicular and the AC ligaments are both ruptured, causing a large lump to be visible under the skin. A true separation occurs and the trapezius and deltoid will have been detached.

Grade 4 – the trapezius is ruptured due to the clavicle moving behind the joint. As with grade 3, the trapezius and deltoid are detached.

Grade 5 – similar to grade 3 injuries, though the separation is more severe. The clavicle punctures the above muscle and, as with grades 3 and 4, the trapezius and deltoid are detached.

Grade 6 – the least common injury, grade 6 sees the clavicle become hooked underneath the coracoid process after being pushed downwards. It ends up behind the coracobrachialis and biceps.

AC joint injuries: symptoms and prevention

Pain is the most notable symptom of AC joint shoulder injuries. This will be experienced towards the outer end of the collarbone. It will also likely feel tender to touch and be inflamed too. Once the injury has settled, the pain will be very localised and won’t radiate towards other parts of the body. You’ll likely notice the pain becomes worse with certain activities, such as lifting your arm above your head.

The symptoms are similar to a variety of collarbone and shoulder injuries. Therefore, a specialist diagnosis is required to ensure you receive the appropriate treatment.

If the ACJ is injured, then the lesser grade injuries can generally be treated without surgery, however, higher grade injuries may need an intervention. Recently, Mr Steve Corbett of the London Shoulder Specialists has presented both nationally and internationally on the decision making involved.

It’s very difficult to prevent AC joint shoulder injuries in rugby, as it is a contact sport with a high likelihood of knocks to the collarbone. Learning how you can stabilise the shoulder and also building up the muscles can help somewhat.

If you’re concerned that you may have an AC joint injury, book a consultation with London Shoulder Specialists at Fortius Clinic today. There are a number of treatment options available and our specialists are highly experienced in treating rugby injuries at every level of the sport.

An innovative approach to pain relief could provide hope for sufferers of rheumatoid arthritis.

In a limited trial at the University of Amsterdam, 17 rheumatoid arthritis sufferers were fitted with an electronic implant in the vagus nerve that controls many of the important functions of the body, including inhibiting inflammation which is the underlying cause of rheumatoid arthritis.

In this degenerative condition, the body’s immune system mistakenly attacks the joints causing swelling, stiffness and pain. The implant works by releasing an electric pulse that stimulates the vagus nerve, reducing the levels of immune cells that cause the damage.

All patients enrolled on the trial had previously failed to respond to medication and all reported a marked reduction in stiffness and discomfort. Rheumatoid arthritis is just one of many different types of arthritis that can affect any joint of the body, including the shoulder. The most common type of shoulder arthritis is osteoarthritis, which is often associated with ageing.

Understanding shoulder arthritis

Arthritis means inflammation of a joint in the body. As the shoulder is a very mobile joint it can develop wear and tear over a lifetime. The cartilage which lies on the bones of the shoulder joint becomes thinner and ultimately can be destroyed. As a result, one bone then rubs on the other causing pain, stiffness and loss of functional abilities. One option is to then consider a shoulder replacement. Whilst this type of surgery is not as common as hip or knee replacements, on average, approximately 4,500 shoulder replacement surgeries are carried out each year in the UK.

Unsurprisingly, the National Joint Registry found that osteoarthritis was indicated in 58% of shoulder replacements, but there are other types of arthritis or conditions that can affect the shoulder requiring replacement surgery. These include

Rheumatoid arthritis

Affecting the joint lining of the shoulder, rheumatoid arthritis is one of the more common types experienced by patients. The autoimmune condition can present itself in one or both shoulders, causing stiffness and pain. Over time, it can lead to deformity of the shoulder joints, as well as an erosion of the shoulder bones.

Post-traumatic arthritis

Shoulder injuries are common, particularly in young athletes. When an injury occurs, it can trigger post-traumatic arthritis. Patients who have experienced shoulder dislocation or fractures are particularly at risk of developing the condition. In this type of arthritis, fluid can build up within the joint, causing pain and swelling.

Rotator cuff tear arthropathy

Rotator cuff injuries are fairly common and they can lead to a type of arthritis known as rotator cuff tear arthropathy. It is most commonly caused by a longstanding tear of the rotator cuff tendons, which results in muscle weakness and loss of support for the shoulder. As a result, a painful arthritis then develops.

Avascular Necrosis

Avascular necrosis is a condition whereby the blood supply to the humeral head (ball) is disrupted. This then causes bone cells to die. The body attempts to regenerate itself but the process is flawed and the ball can become very irregular. Conditions that can cause avascular necrosis include sickle cell disease, high dose steroids, excessive alcohol consumption, previous fractures and radiotherapy.

What are the treatment options for shoulder arthritis?

As consultant shoulder surgeon Mr Andy Richards of the London Shoulder Specialists commented in a recent lecture on shoulder arthritis: “There is no cure for arthritis so all the surgeon can do is reduce the symptoms and pain. Range of movement and function may be increased through reducing pain.”

This new electric shock implant may prove beneficial for patients suffering with rheumatoid arthritis. It is worth noting, though, that the trial was very limited so although results are promising, more in-depth studies are required. Also other types of arthritis will require a different approach and these include a range of non-surgical and surgical options. At London Shoulder Specialists, we will first assess the type of shoulder arthritis prior to offering expert, impartial advice on the most appropriate treatment.

For young athletes, summer is prime time to get out there to train, compete or even just to engage in sport for fun and relaxation with friends. However, increased sporting engagement also means a rise in shoulder instability cases.

It is recognised that a trauma to the shoulder, such as a fall, can cause shoulder instability and many people know someone who has dislocated a shoulder.

However popular summer sports such as swimming, volleyball, tennis and cricket, can lead to shoulder instability, due to repetitive actions involving arm rotation. Shoulder instability can be painful and it can also put you out of action.

What is shoulder instability?

Shoulder instability presents itself in numerous ways including a full dislocation,  a partial dislocation (subluxation) and mild looseness (laxity). It occurs most dramatically when the ball (head) of the upper arm (humerus) is forced out of the socket (glenoid). In doing so, the ball can tear a ring (the labrum) that runs around the socket The problem is that once shoulder instability occurs, it is likely to recur. In repetitive sports, the injury to the labrum can be less acute and develops over a period of time.

There are a number of ways to classify shoulder instability. These include the cause of the instability – trauma, natural laxity, poor muscle patterning – the direction of the instability – anterior, posterior or multidirectional – the degree of the instabilty and the anatomic site of any injury within the shoulder.

The most common problem experienced by young athletes is anterior instability. It occurs largely in men aged between 18 and 25 and accounts for approximately 85% to 95% of shoulder instability cases. The most likely cause is trauma causing a complete dislocation, though subluxations are also common.  If there is a complete dislocation, patients can sometimes relocate the shoulder themselves, however often they need to attend hospital to have it reduced.

In the case of a subluxation, the shoulder only partially comes out and then slides back into joint by itself. This can still be painful and result in ongoing symptoms, such as pain when trying to rotate the shoulder. Very occasionally, the instability can be associated with altered sensation within the arm.

At the London Shoulder Specialists, we first assess the cause of the instability, as to whether it is the result of a trauma, natural joint looseness (hyperlaxity) or due to poor muscle control. It may be possible to utilise physiotherapy to help strengthen and coordinate your shoulder muscles and thereby reduce any instability symptoms, or the risk of a further significant event. We are often asked about the use of braces and, in certain circumstances, these can be helpful.

However, particularly in the younger population, surgery may be the best course of action to reduce the risks of further problems.

Surgery could reduce need for follow-up procedures

Research carried out by the American Orthopaedic Society for Sports Medicine, has shown first time dislocation surgery  significantly lowers the risk of re-injury and reduces the need for follow up procedures.

Within the study, 121 patients, with an average age of 19, were examined on average, 51 months after surgery. The group included 68 patients who had a first-time dislocation and 53 who had experienced several dislocations after initial non-operative treatment. Results showed that just 29% of first-time dislocation patients experienced further shoulder instability issues after arthroscopic surgery, compared to 62% in the patients who hadn’t undergone surgery.

This was a long-term, in-depth study which recorded data from 2003 to 2013. The results clearly highlight the benefits of first-time surgery for shoulder instability cases, providing hope for young athletes. It supports a number of other studies, which have shown similar findings. Indeed many of these have shown even better results for patients undergoing surgery. One area that has improved the results of surgery is better selection of patients and matching patients to the surgical options.

Most patients who suffer from first-time shoulder instability are understandably worried. This new research eases that worry and demonstrates that sometimes surgery can be the best way forward to protect their athletic career.

New painkilling techiques are being tested in the hope of reducing the amount of medication prescribed after surgery. Opioids are a common pain relief medication but there are concerns that they are being overprescribed after surgery. They reduce the intensity of pain signals before they reach the brain and affect the areas of the brain that control emotion. They range from hydrocodone, oxycodone, morphine and codeine and differ greatly in strength.

These prescription drugs can be extremely addictive. A 2015 US study published in the Mayo Clinic Proceedings, found one in four people who have been prescribed opioids go on to develop an addition. It is a worrying pandemic that’s particularly affecting young athletes. UK data is less comprehensive than that gathered in America, but a survey released by the charity Action on Addiction last year estimated that nearly one in ten UK adults believe they could be or could have been addicted to opioid painkillers, with a quarter taking opioids for more than five years.

Doctors are hoping the new painkilling techniques being tested may be used in conjunction with or instead of opioid medication to minimise patients’ reliance on this form of pain relief.

Combination of non-addictive treatments is key

Rotator cuff surgery can involve a painful recovery process, hence strong opioid prescriptions are often required in the initial post-operative period. However, the new painkilling techniques being trialled aim to deliver the same relief without the addictive nature of opioids and the dangerous side effects.

While the techniques have been used individually to relieve pain after surgery, it’s the combination of the different methods which is key according to surgeons at NYU Langone Medical Center’s Department of Orthopaedic Surgery in New York who are aiming to greatly minimise the pain experienced after elbow or shoulder surgery and, therefore, the use of opioids. Their techniques include:

• Non-addictive anaesthetic – including the use of injections around the nerves in the neck and shoulder
• Catheter implant – delivering anaesthetic over a set period of time
• Mechanical stimulation and wearable icing devices – helping to reduce swelling and pain throughout physiotherapy
• Drug regimens – helping patients to move onto non-addictive medication like Tylenol

There are of course some potential drawbacks with these techniques. Patients have to become accustomed to having weak or numb arms for a number of days. Catheter implants can sometimes be difficult to keep in place and they can seem like an ‘intimidating’ option.

Instead, single injections can be used which would effectively block pain signals for up to 24 hours. Opioid medication can still be used for a short amount of time before transitioning patients onto other medication

Many units, including Fortius London Shoulder specialists now employ regional anaesthesia, where injections are placed about the nerves in the brachial plexus to reduce post operative pain requirements. There are some risks that come with these injections such as nerve damage and the potential for the anaesthetic to leak, though these are relatively small.

Understanding rotator cuff surgery

Rotator cuff surgery is carried out in one of two ways. It can be performed via open surgery or arthroscopically. In the open surgery method, an incision is made in the skin and the procedure is performed through a large wound – the torn tendons are reaattched to the bone.

Arthroscopic surgery is performed using an arthroscope, or mini camera, so the surgeon can view the inside of the shoulder on a monitor. Small, specially designed surgical instruments are used so less extensive incisions are required. Arthroscopic surgery typically causes less trauma to the muscles surrounding the shoulder, which in turn reduces the discomfort felt after the surgery.

A study entitled ‘Effectiveness of Open and Arthroscopic Rotator Cuff Surgery’ published in the NIHR Journals Library, provided a better understanding of each method. Interestingly, the post-operative pain management required was similar with the open and arthroscopic method. Two-thirds of participants were still taking painkillers after two weeks and after eight weeks, though painkiller use was decreased from 66% to 55%.

Overall, regardless of the type of technique used, recovery from rotator cuff surgery should not be underestimated.