Shoulder impingement syndrome | Surgeons tell patients say no to surgery in new research

Danielle R. Steilen-Matias, MMS, PA-C

You have shoulder pain and your health care provider gave you a diagnosis of shoulder impingement syndrome. Shoulder impingement syndrome means that your rotator cuff tendons or your shoulder bursa, (you may have heard the word “bursitis,” inflammation of the bursa) are being squeezed between the shoulder bones.

If you are reading this article you have probably reviewed many articles which line up the symptoms and treatment of Shoulder impingement syndrome for its readers. Most of the articles will repeat the same primary symptoms treatment course.

  • You have a problem with shoulder rotation and the ability to lift your arms and you should use rest and medication to get you well.

Rotator Cuff Impingement SyndromeWhat if you have already rested and tried to alleviate your problem with anti-inflammatories and painkillers and you still have a problem? Now what?

If you are like our patients:

  • You are likely concerned that your shoulder problem that is already making doing your physically demanding job difficult at best, will eventually progress to making it impossible to do your job. Shoulder impingement syndrome can lead to rotator cuff tears and surgery.
  • You are an athlete, a swimmer, an athlete that throws a ball, any one who plays a sport with your hands over your head you maybe wondering how much more time are you going to lose?

Your initial treatment options for shoulder impingement syndrome. Do they work?

You may have just returned from your first or follow up visit to your health care provider. You may be frustrated. He/she wants to start or continue you on a “conservative care,” approach to dealing with your impingement. They would like to try the non-surgical route as long as possible. The reasons for not going to surgery is explained below. The news is not good.

As Shoulder Impingement Syndrome is sometimes called “Swimmer’s Shoulder,” I would like to invite you to read our article Swimmer’s shoulder treatment | subacromial shoulder pain. In this article we discuss the research that has shed light on several specific shoulder injuries that often are incurred by the competitive swimmer that may be bundled under the single diagnosis subacromial impingement syndrome.

Pain management:
Your health care provider may suggest a prolonged, up to two month program of anti-inflammatories and painkillers. If you are not getting results somewhat immediately from these medications, your medications will be changed until the one that works is found.

  • The anti-inflammatory or NSAIDs  (Non-Steroidal Anti-Inflammatory Drugs,) are thought to be a first line treatment as your impingement problem is causing swelling and painful inflammation. This is a treatment that we do not recommend. In our article When NSAIDs make pain worse, we show the research that:
    • NSAIDs’ temporary reduction of pain, stiffness and swelling comes at great long-term expense, the destruction of cartilage and shoulder stability.
  • Stronger Pain medications.  This particular recommendation has very little long term appeal as it can make your situation worse. Please see our article, when Painkillers make pain worse.
  • Corticosteroids / cortisone or steroid injection. (This is also a treatment we do not recommend. Please see our article Alternative to cortisone shots, in which we examine new research that is providing more warnings that cortisone does not heal and, in fact, accelerates deterioration of already damaged joints.

Rest:

  • Your health care provider may prescribe rest or avoidance of shoulder motion that is causing the pain.
  • Many of your reading this article have probably already done that. That is why you are reading this article, you need so more answers.

The answer to your problem may be to treat the shoulder, not the impingement.

This is not a play on words.

For one thing, when you have shoulder pain that has a somewhat nondescript cause (your whole shoulder is problematic), shoulder impingement is often used as a diagnostic term to validate treatment. Impingement means something is trapped and being squeezed. In this case, it is your rotator cuff tendons or it is your shoulder bursa. You may have developed a bursitis, an inflammation of the bursa. The bursa is a small protective fluid filled sac that act as spacers so the bones do not bang against each other abnormally.

I know, based on what we see in the office that some of your eyes just got wide. “Bones banging against each other abnormally,” that is what my shoulder sounds like!

They are being trapped under and being squeezed by the acromion, a bony “wing” of the shoulder blade. In the illustration below this is shown in the example of the EXTERNAL IMPINGEMENT.

So if you tell your health provider you have pain trying to reach for something at shoulder level or above your head, shoulder impingement will likely be discussed along with possible treatments.

 

Is shoulder impingement a diagnosis or a symptom of a bigger shoulder problem?

In our clinics, we do not like to describe shoulder impingement as a diagnosis. We like to describe it as a symptom of shoulder instability. What this means is that if you try to repair shoulder impingement alone without addressing the problems of the shoulder which can cause the tendons to be trapped or the problems of the extra pressure of bursitis or swelling causing irritation, pain and constant wearing and weakening of the rotator cuff tendons, you will likely not be successful.

In research, doctors in Germany wanted to make clear that shoulder impingement is indeed, a whole shoulder issue and treatment should include

The German team from the Technical University of Munich writing in the German language journal Der Orthopäde (Orthopedics) reported these findings:

  • Isolated impingement syndrome of the shoulder is the most common diagnosis in shoulder disorders and is of high relevance in orthopedic sports medicine.
  • In fact, impingement of the shoulder is not the diagnosis but rather a symptom of a functional or even a structural shoulder damage. (We call this shoulder instability, the excessive motion of the shoulder due to weakened and damaged ligaments, allows the soft tissue of the rotator cuff to be pinched, caught, or impinged upon by the bones of the shoulder).
  • Detailed knowledge about the different types of impingement and the underlying causes is essential to provide adequate treatment.
    • Primarily, impingement of the shoulder should be treated nonoperatively.(1)

Which brings us to the latest research on surgery for shoulder impingement.

New research: No surgery for shoulder impingement syndrome. It’s “useless.”

This is from a press release issued by the University of Helsinki upon the publication of a new study from the University’s researchers in the July 19, 2018 edition of the British Medical Journal.(2)

“In a landmark study published this week in the British Medical Journal, (our) researchers show that one of the most common surgical procedures in the Western world is probably unnecessary.”

“Keyhole (arthroscopic) surgeries of the shoulder are useless for patients with “shoulder impingement”, the most common diagnosis in patients with shoulder pain.”

“These results show that this type of surgery is not an effective form of treatment for this most common shoulder complaint. With results as crystal clear as this, we expect that this will lead to major changes in contemporary treatment practices,” said the study’s principal investigators chief surgeon Mika Paavola and professor Teppo Järvinen from the Helsinki University Hospital and University of Helsinki.”(3)

Surgery useless? Then what type of treatments can I get? A different surgery? Non-surgical Prolotherapy?


Doctors in the Czech Republic thought that PRP injections could help people with Shoulder Impingement Syndrome. They thought that it would take three injections, given one week apart, to acheive  they desired results. They also wanted to see how these three PRP injections did against a single injection of cortisone.

After the treatment was complete they would look at the patients at

6 weeks, 3 months and 6 months after the administration of the injection.

Group I (PRP with the mean age of 48.7 years (15 men and 10 women),

Group II (Cortisone) with the mean age of 50.1 years (16 men and 9 women),

Based on the results of our study, the hypothesis can be accepted that the concentrate of platelet-rich plasma administered through a series of 3 injections applied in the subacromial space in patients with shoulder impingement syndrome has positive effects on the daily activities of patients as well as on the objective evaluation via the selected scoring systems.

https://www.ncbi.nlm.nih.gov/pubmed/30257756


Arthroscopic shoulder impingement surgery shaves down the bone of the acromion to give the rotator tendons more room to move about pain-free. We now see that this is a useless surgery in the long-run. Rotator cuff tendon surgery then may be recommended for lack of anything better than conservative treatments including pain medication, anti-inflammatory medication, physical therapy and exercise did not offer a positive response.

We feel that someone suffering from impingement syndrome should seek a consultation with a Prolotherapist for a non-surgical regenerative medicine consultation before jumping into rotator cuff surgery.

In our office, we stimulate the soft tissue of the shoulder to repair with Prolotherapy injections to the ligaments and tendinous insertions of the rotator cuff and deltoidProlotherapy, in combination with gradual re-strengthening of the rotator cuff muscles, gives an excellent chance for a full recovery.

Prolotherapy gets rid of the impingement by stabilizing the acromioclavicular (smaller shoulder joint) or the glenohumeral joint (larger shoulder joint). The excessive motion that was pinching the tendon no longer occurs, because the joint is stabilized. The excessive motion is gone, the pinching and symptoms are gone, and over time the bone spur will be reabsorbed by the body.

Prolotherapy Specialists

Get Help & Information on your shoulder pain

Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD

1 Beirer M, Imhoff AB, Braun S. Impingement syndromes of the shoulder. Orthopade. 2017 Apr;46(4):373-386. [Google Scholar]

2 Paavola M, Malmivaara A, Taimela S, Kanto K, Inkinen J, Kalske J, Sinisaari I, Savolainen V, Ranstam J, Järvinen TL. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. bmj. 2018 Jul 19;362:k2860. [Google Scholar]

3. University of Helsinki press release – Finnish study shows that most common shoulder operation is no more beneficial than placebo surgery

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