Shoulder Impingement Part 2 Let s talk about what goes wrong with the shoulder. The first problem is things that occur underneath the acromion. This is the subacromial space, which is one of those apparent joints. The key to the subacromial space is actually two important structures. The first is the muscle called the supraspinatus. The supraspinatus, runs from above the spine of the scapula and through this little gap, which is a dangerous place to be. It then runs underneath here and attaches to that large bump. Over that is a sac, which is called a bursa. So these are the two key structures, the tendon of the supraspinatus running through that tiny little gap and the sac itself. This is a kind of a design fault because this is one of a few areas in the body, which tend to always break down. The key to this is something called coupled movement. There are two muscles which are going to make this joint work, but they have to work in the correct order, otherwise problems occur. The first is the supraspinatus tendon, and the second is a big muscle, which sits over the top, which gives the bulk to most people s shoulders and that s called the deltoid. The deltoid which attaches to the edge of the acromion, hooks around and attaches to the humerus with big insertion there. Now what should happen is that if you want to lift your arm up like that, the supraspinatus should fire first. Page 1 of 10
It s part of the rotator cuff. It fires first and it pulls the humerus head inwards and down. So it holds it like that. Now once it s being held like that when the deltoid contracts, it will pull up your arm and you ll have all the space in the world. No problem. But if the supraspinatus becomes damaged - remembering it is running through that little canal - if you do a movement or you do something that injures it, it will not fire properly. Page 2 of 10
Then if you want to lift your arm up, the supraspinatus is asleep, the deltoid contracts, and when it contracts it pulls the arm up. It then rotates and it digs in. Where it digs in is into the sac, the bursa, so the sac becomes inflamed and the supraspinatus tendon can become damaged. When you look at rotator cuff problems, you end up with the supraspinatus tendon in the vast majority is the first tendon that becomes damaged and once it becomes damaged, it doesn t function properly. As you move like this you get what s called impingement, the humerus digs into the joint. When you get impingement you don t actually feel it where the damage is occurring. You feel the pain down over the deltoid and lower down and you feel it over the front and over the back. People will say, As I lift my arm up, I get a oh! I get a horrible pain, it s about there. Page 3 of 10
So if you lift your arm up that s where it hurts, it impinges, and the place you feel your pain is running down your arm, sometimes all the way to your elbow. That is the commonest shoulder problem. It s a rotator cuff problem, which arises from usually a tear in the supraspinatus tendon and inflammation of the sac, the bursa, subacromial bursa. It s a difficult problem and common. Now, when I talk about treatment I just want to take a step back, which is, there is a question that I ask people, doctors in particular, and that is what function does the shoulder have without which you would die. I can t remember anybody who s actually thought of it. I mean it s a weird question, isn t it? The answer is that the shoulder is there to put food in your mouth. That s what it does. So that s a certain movement in the shoulder. If you take something in your hand and imagine yourself putting it in your mouth there s a certain flow of movement in the shoulder. What you can see when I do that kind of movement is that there s a huge amount of space here, the humerus head is miles away from anywhere, you just have this nice sweet glide down this plane. This is the movement which you lose last. It is the most basic movement and is like your hip where you have a particular plane in which the hip joint works and that movement is the movement that you lose last. Page 4 of 10
Even if you get terrible osteoarthritis in that hip you ll find that you can still do that gliding movement but when you try and move outside that you find that you can t; you get terrible pain in rotation. The shoulder is the same. This movement is the movement that you re able to do even when your shoulder is badly damaged. The movement that is furthest away from this plane is lifing up your arm. Lifting your arm up is in fact the movement, which the shoulder is least designed to do and this is why impingement is such a major problem. The shoulder is poorly designed to make that movement. So in treatment the first thing is to explain to people who have impingement why it happens and to say, Look, there are so many ways that you can do things, which do not require you to lift your arm up. So that you stop banging your head against the wall, so you stop causing impingement because what tends to happen is this. People will say, I washed the car and my shoulder killed me afterwards or I was washing the window, and what they re doing when they do that movement is that they re grinding the head of the humerus into the joint. What you could do is utilize that lovely movement of feeding yourself and you could wash like this and if you want to get up the window, you take a squeezy mop and you do that. So, all the time you re doing things for instance when people drive a car, a lot of people lift their arms up and then they say Ah kills me when I drive. But you don t have to, you can just drop your elbows down and drive like this. So recognizing which movement the shoulder is happy doing and doing more of that and doing less of the movement that hurts you is a first and obvious way to help people with impingement. So that s very important and then you ve got to get out of bad habits, that s number one. Number two, you can re-learn how to do this movement, and this is a beautiful bit of mind body awareness. The thing that allows this to dance together in a beautiful way that it does, is your brain. So all I need to say, if I am going to teach somebody how to make this movement in a way that doesn t hurt, is that I will show this picture. Page 5 of 10
I will say, you see how much space you have, you can have at the moment you re digging in. Now, how can you learn to create that and the way you can do this is you put your hand on the top of your shoulder, which is the acromion on your good side and you lift your good side up. As you do that, if your shoulder is working nicely, you need to do something in your mind, which is that you create a feeling of things dropping. So where your hand is as you lift your arm that humerus head should never lift up, but it should actually drop down, and as it drops down what you re really doing is you re creating the space to do the movement. So you get the feeling of doing that in your good shoulder, which is what you naturally do anyway. Then you change yourself to your sore shoulder and what s happened is that because it hurts when you impinge, most people as they start lifting will lift everything to try and stay away from the actual impingement. What you need to do is you need to let go so there is a dropping feeling. As you feel the dropping, what s actually happening is the supraspinatus is contracting, pulling the head in, and down. Then you create space, and you can actually learn very carefully and nicely to make that movement in a way that s painless. The only way you can really do that is by exploring it yourself, but this is what you can teach. So the first thing is stay away from the movement as much as you can, but if you do make the movement, make it in a way that s pain free. The third thing is that all the rotator cuff muscles, which occur in this area - the supraspinatus, the infraspinatu, the subscapularis and the teres - once you ve got an impingement syndrome, they will get triggers in them. So for people who are good with massage you can find or you can treat the triggers and the doing this is very effective in reducing the pain once you ve got more natural movements and you understand not to impinge. Under these circumstances the majority of people will start to get better. Sometimes, people just don t. It s usually because the whole area is so inflamed, the bursa is so thickened and inflamed that none of them can make that movement. When they lie down to sleep, the pain keeps them awake at night. Under those circumstances, the next and most effective thing is to actually inject a little bit of cortisone into the space. Page 6 of 10
It s not a complicated injection, you feel for the edge of the acromion, there s the space you want to go into, and you can just run a needle in underneath the space. When you go into the space here, it s usually relatively painless. So as you go in it may have a tweak, but once it is in there, there s quite a big space and you put in a long-acting cortisone with local anesthetic. You can do this under ultrasound guidance and so using an ultrasound, you can see the bursa itself and put the needle into the bursa. The results with ultrasound guidance are slightly better than those without as it s lacking accuracy, however you have to use more equipment. The cortisone is going to work for about twelve weeks and at the end of twelve weeks it s gone. So the real secret is the cortisone is there to reduce the pain, but if you carry on doing what you were doing before you got the cortisone you end up back to where you were. It s not the cure. The cure is changing how you use your shoulder and that s really the whole key. Switching off the triggers around here and the triggers in the power muscles as well as in the trapezius will also make a huge difference to getting smooth function of your shoulder back again. The last thing is to work on the stabilizers of the scapula because if the scapula is weak and wobbly as you go to lift the whole thing will drop down and you will impinge again. So there re certain exercises that you can do, which are scapula stabilizing group of exercises. Just very simply, there s a lovely yoga movement, which is a cat movement, so you are on hands and knees and you pull shoulders back and push shoulders forward and pull shoulders backward. Like that, that s actually working the muscles, the stabilizers of the scapula. Let s talk about tears for a minute. Tears in the rotator cuff, are a very common diagnosis that s made. Here s a fascinating statistic. These are figures from studies which are quite accurate. 60% of people over 60 will have a tear in the supraspinatus tendon. Not on one side but on both sides. Isn t that fascinating? What happens is that people had routine x-rays of the shoulder and the x-rays didn t show very much at all. They then discovered the ultrasound, and the ultrasound shows soft tissues and the shoulder is all about soft tissues. What doctors did was they started off and they said, Well, we don t know too much about this. It is a learning curve. What we ll do is always when we scan your one shoulder we ll scan the other one as a comparison. Page 7 of 10
So this is done throughout much of the western world. This is standard. You have both shoulders scanned and the interesting thing that was found is that in people who had a tear on the side that was killing them a very high proportion had a tear on the other side, which was completely not sore at all. Now this was a huge puzzle, and the key is that the two ways to get a tear in the tendons of the rotator cuff. The first way is if I fall, or do something traumatic so there is a traumatic tear that occurs. When you get a rapid tear, it s painful. The second and much more common way for getting a tear is that over time as you move and as you do things, you have attrition. So it s a bit like if I took my shirt and I just did little movements like this and I keep doing that, not a lot of stress but just enough then I do it thousands and thousands of times. Gradually, the fibers will star to form a tear as I keep moving. The difference between my shirt and a tendon is that tendons have an ability to heal. So there is a dynamic balance between damage from normal movements and healing, and what happens is gradually, over time you can get quite large tears occurring in a tendon, which can be partial or sometimes even all the way through. But because it s occurred over a long period of time you have done this marvelous adaptation. You ve adapted your movements so that you can still function very well and are pain free. So the fact there s a tear there doesn t mean, Oh my God! I m in real trouble. I ve got to go and see a surgeon and have it sutured or repaired. Tears don t have to cause pain. As long as you use your shoulder in the most effective and functional way and turn off the triggers around there and reduce inflammation if you need to, the tear actually fades into the background just like the other side. That is in a really large proportion of cases. Sometimes the tear is massive and it tears right through the tendon or tears with some of the other tendons, and then you ve got a shoulder that is just wobbly and moves around and digs in, and it s just not going to heal. Under those circumstances, it is, you ve just got to go and have a surgical repair. Surgical repair of tears of the rotator cuff? That s difficult. That s a difficult operation because the trouble is that you dealing with tissue that s thin. Page 8 of 10
A friend of mine who is a very fine surgeon and says shoulder operations are like trying to sow up blotting paper. So what s happened is that if there is a large tear of your rotator cuff, a surgeon will go back until they find decent tissue. They ll pull it forward and they ll put screws into it. They ll put titanium screws down into the muscle and then after the surgery when the patient wakes up, he will be in a sling and told not to move at all because it s got to heal. You re dealing with tissue that s not in good nick. It s a very sore operation. After six weeks, you ll start with very gentle movements and in about three, four, and five months, you ll be actually moving your shoulder normally. So it s a big deal operation and it s usually much more intrusive than having a whole hip taken out and replaced. So with rotator cuff tear operations, repairs are difficult and fraught with pain and if they re not in good hands, they may fail. Let s talk about imaging for a shoulder. X-ray shows tags in the bone, which is a very minor part of shoulder problems. Ultrasound is really valuable, because it shows ligaments and tendons, and it has one other thing which is fabulous and that is, it is dynamic, which is what the shoulder is all about. So, somebody doing the ultrasound of the shoulder will actually ask you to move your arm. They ll find the structures that they are interested in, for example the supraspinatus tendon, and then they ll ask you to move your arm, and as you move your arm, they ll see what happens to the tendon, they ll see what happens to the bursa. Does it bunch up and do things get stuck, or is there actually space available? Then look at the tears and see what happens to them as you move around. So that s a huge benefit of ultrasound. The negative side of ultrasound is that it is hugely operator dependent. So when you re looking, the pictures that you get later when you look at and when they come up on the screen do not tell the picture. The picture occurs when the operator is doing the dynamic movements. So you re very dependent on the operator. The next investigation is an MRI, and MRIs show everything beautifully. They show the bones, they show the cartilage, they show the tendons and ligaments in great detail. They show a really important structure, which is the labrum, which I didn t mention, so this is around the edge of the glenoid fossa. There is rim of strong fiber cartilage, which is called the labrum and that can also become torn and damaged. We don t see this on ultrasound but you can see this on an MRI. So MRI is really Page 9 of 10
valuable. It shows all the structures but you can t move, so it doesn t show the dynamic components of the shoulder. There are the strengths and weaknesses of each modality or way of imaging. Page 10 of 10