FAQ - SHOULDER IMPINGEMENT SYNDROME AND AC JOINT ARTHRITIS
Most people find going to the doctor a confusing experience and I know it's sometimes difficult to ask questions. With the help of former patients, I've come up with this list of questions and answers that I hope you'll find helpful.
How
do we treat these problems?
How
do you know if the tendon is only inflamed and not torn?
What would this surgery involve if I were to need it?
This
type of shoulder pain arises from a problem in the rotator cuff tendons. A
tendon is a thick, cord-like structure that connects muscles to bones.
In the shoulder these tendons are called the rotator cuff.
The rotator cuff tendons pass between two bones, the acromion and
the humerus (hopefully, I pointed these out to you on your x-rays).
The space is small and normally the tendons barely fit through as
the arm is raised and rotated.
If the tendon increases in size, there is not enough space, and
movement can be painful.
With repeated overuse, a single injury, or even just with the wear
and tear of age, the tendon increases in size and gets pinched or
impinges
between the bones.
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Often
the answer is obvious as the patient injured the tendon in an accident or
remembers a specific injury.
Lifting a heavy object or even a small weight in an awkward or
unusual position can also cause tendonitis.
Repeated use of the arm in the overhead position, weight lifting,
tennis, golf (grounding the club especially), or even aerobic dancing can
cause damage.
Commonly, no specific reason is found.
As we age, our ability to repair the damage that occurs during the
normal activities of daily living decreases.
What we could do in our 20's is not possible now.
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Do
I have bursitis or tendinitis or both?
"itis" is
Latin for inflammation.
When you see that on the end of any word a doctor uses it means
that this structure is inflamed.
Tendonitis then means inflammation of the tendon and bursitis means inflammation of the bursa.
A bursa is a small sac of fluid that serves to cushion the impact
of tendons as they pass over bones.
These bursae occur in many sites around the body: elbow, knee, hip,
shoulder, etc.
Like the tendon, the bursa may become inflamed and increase in
size. The
shoulder bursa lies on top of the rotator cuff tendon and it too can be
pinched between the shoulder bones.
Most commonly with impingement syndrome the tendon and the bursa
become inflamed together and most often you have both bursitis and tendonitis
together as a result of impingement.
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The
AC joint is between the acromion bone and the clavicle bone (collar bone).
There is a piece of cartilage between the bones at this joint and if it is
torn or if the ends of either bone become damaged, early arthritis can set
in. You can usually determine if this joint is causing problems by things
you might tell me ("it hurts to reach across my body" or
"it hurts right on top of my shoulder"), things I might find on
exam (pain when I push on the joint), or things we see on x-ray (narrowing
of the space between the bones).
You can have problems with the AC joint with or without impingement
problems.
Hope-fully, I have made clear to you exactly which problem or
problems you have.
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How
do we treat these problems?
Most
of the time impingement syndrome (and the consequent tendonitis and
bursitis) and AC arthritis can be treated without surgery.
Nonoperative treatment involves the following:
Rest the shoulder.
By this I mean rest the shoulder from painful motions and
activities.
When you move the shoulder and the tendon and bursa get pinched, it
is painful.
These motions continue to irritate the inflamed tendons and cause
scar tissue to form.
On the other hand, those motions and activities that are not
painful are not doing any damage.
It if hurts, don't do it.
Don't try to work through the pain.
If something you do is not painful, even if it seems strenuous, go
right ahead.
I want you to rest your shoulder, not your entire body.
Exercise.
General physical activity is helpful.
This particularly applies to aerobic sports like walking, jogging,
biking, and any other sport that raises the heart rate but doesn't
irritate your shoulder.
Physical therapy.
Specific shoulder exercises are sometimes beneficial.
If I think they will help in your case, I'll usually send you to
the therapist for 1-3 visits for instruction in exercises that can be
performed at home.
Medication level.
A trial on an anti-inflammatory medication is usually a good idea
unless your condition has been going on for an extremely long time or if
you have stomach problems.
These medicines are designs to decrease inflammation and therefore
pain.
Injections.
The purpose of this is to place a strong anti-inflammatory
medicine (cortisone) into the space around the tendons or occasionally
into the AC joint if you have a problem there.
I'll usually recommend no more than two of these.
Time.
This type of shoulder injury can take months to heal.
This can be very frustrating to both of us.
Usually within the first month or two of nonoperative treatment, we
can determine whether you will require surgery to help speed your
recovery.
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How
do you know if the tendon is only inflamed and not torn?
The
only way to know for certain is to inspect the tendon during surgery but
based on my examination of your shoulder, I do not think the rotator cuff
is completely torn.
Plain x-rays such as those taken in my office only show the bones
and not the tendons.
Special tests such as an MRI or arthrogram are needed to tell us
more about the tendons.
We usually obtain these more expensive and invasive tests if you do
not respond to nonoperative care or if I become concerned that the tendon
is torn based on things you tell me or I find on examination.
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Yes,
but we always try everything short of surgery first.
The indications for surgery are persistent pain, interfering with
your activities of daily living, work, or sports, that has not responded
to the nonoperative program described above.
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What
would this surgery involve if I were to need it?
Most
often impingement syndrome can be improved by making more space for the
rotator cuff tendons.
We can do this arthroscopically through two small poke holes by
shaving off the portion of the acromion bone that is causing pressure on
the tendons.
If AC joint surgery is indicated, this can also be done
arthroscopically through one additional poke hole by shaving off a small
portion of the clavicle from underneath.
At the same time the entire rotator cuff tendon and the joint
itself can be inspected for tears and arthritis and other problems.
If a tear in the tendon is found, this can be repaired but
frequently requires a small incision in addition to the small poke holes.
Most of the time this surgery is done on an outpatient basis but
does require general anesthesia.
The surgery itself is relatively risk free as we are well out of
the way of any nerves or vessels.
However, infection can always occur (about a 1% incidence for all
surgery) and anesthesia itself is always a risk. That's why I only
recommend surgery if absolutely necessary.
Though no surgery is 100% successful, this operation is close at
about 90%.
It is important to note that the result you achieve is to a degree
related to your cooperation and motivation.
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What
if I have more questions?
Please call the office at 713-441-3560. If we're not in, please leave a message on the voice mail and we will return your call as soon as possible.
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