Shoulder impingement syndrome – Surgeons tell patients say no to surgery – What are your options?
Ross Hauser, MD. Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David Woznica, MD. Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C . Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Shoulder impingement syndrome – Surgeons tell patients say no to surgery – What are your options?
You started having some shoulder pain and a limited range of motion. You also started to find it increasingly more difficult to reach above your head for something. You took some over the counter pain relief pills, maybe tried a rotation of heat and ice and started to sleep in different ways because of your shoulder pain while sleeping. Finally, and perhaps after years of chronic problems and self-management, you finally went to get some medical attention.
Usually pain in the shoulder like yours will send out a signal to your clinician that you may have rotator cuff tendinitis or you have bursitis, inflammation of the shoulder bursa. Your clinician may have explained that the bursae (plural because you have more than one bursa in the shoulder), is a fluid-filled sac that helps to reduce frictional wear and tear in your shoulder. The clinician may have even mentioned subacromial bursa, the bursa that sits between your rotator cuff tendons and the acromion process of the scapula.
Your clinician may also explain to you that your problem is all about inflammation or “itis.” The squeeze of the impingement on your shoulder’s soft tissue is causing wear and tear friction and inflammation on your shoulder tendons This can lead to a diagnosis of rotator cuff tendinitis and the bursitis they suspect.
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 and the same primary treatment course, rest and anti-inflammatory medication. If you are here reading this article it is very likely that the conservative care primary treatment course is not working for you.
What 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 or playing your sport, will eventually progress to making it impossible to do your job or continue in your sport. 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?
Carry groceries and wearing my handbag is a problem
Maybe you are not a physical laborer, maybe you do not play sports and workout. Many women describe that part of their regular daily routine of activities is simply going food shopping two to three times a week. It’s good exercise, walking the aisles for an hour or more. You have been going to physical therapy, you may be proceeding well, but you still cannot lift the groceries you buy. So you have the bag person put fewer items in each bag, and you carry your handbag on the other shoulder. For some people, these adjustments will be helpful but they will also be a daily reminder that they have a shoulder problem. For some people these adjustments and physical therapy will be all they need. For some people these adjustments and physical therapy will be all they need, for others these adjustments and physical therapy will go on for a long-time, not produce the results of where the patient wishes to be at physically, and then a surgery will be called for.
You may have just returned from your first or follow up visit to your health care provider. Now what? More pain management? More rest?
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,” we 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.
More 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 and given in stronger dose 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.
- 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 some more answers.
Cortisone and Physical Therapy?
Many people benefit from cortisone and physical therapy. These are not the people we see in our clinics, we see the patients who did not get the benefit or pain relief they had hoped for from cortisone and physical therapy.
Often a patient will explain to us: I have been treated for tendinitis and impingement for over a year now. I had a cortisone injection and I thought I was cured. After 2 weeks ,the pain came back. Don’t get me wrong, I was happy to have the two weeks being pain-free but the pain cam back, worse than before. I started physical therapy after that. I found the whole experience to be very painful and I did not see any benefit. I have been told to keep trying the physical therapy because the surgery may not help me either in the long run.
Researchers at Stellenbosch University in South Africa published a comprehensive evaluation of conservative care treatment options for shoulder impingement syndrome in The South African journal of physiotherapy (1). In addressing a direct comparison of cortisone injection to physical therapy the researchers noted these results in patients:
- Besides a significant improvement in shoulder function in favor of cortisone injection at 6–7 weeks’ follow-up, no evidence was found for the superiority of cortisone injection compared with physiotherapy for pain and Range of Motion (ROM) in the short term.
- The medium- and long-term outcomes for pain, ROM and shoulder function do not favor the use of cortisone injection over physiotherapy.
As we mentioned, people do get good result from cortisone. Even you reading this article may have benefited from cortisone injections initially. But there is a limit to cortisone’s effectiveness and when you reach that limit cortisone becomes detrimental to your healing.
Our opinion meets with that of numerous research studies. At the Department of Trauma, Shoulder and Hand Surgery at Agatharied Hospital Hausham Germany, (2) doctors published their findings in conservative care management of their patients with shoulder impingement syndrome. What they found was:
- The initial treatment of conservative care with non-steroidal anti-inflammatory drugs, cortisone, and patient exercises yielded satisfactory results within 2 years in 60% of cases.
- Corticosteroid injections to lessen acute pain and improve shoulder mobility in the first eight weeks are a standard form of treatment
- Cortisone must be injected in the vicinity of the tendons, not into the tendons themselves. (Cortisone damages tendons).
- The injections should be repeated no earlier than 3–4 weeks after than the initial injection, and no more than 2 or 3 times.
At our clinics we frequently work with physical therapists who are treating shoulder impingement patients. For physical therapy to achieve maximum benefit, the shoulder capsule itself has to be capable of providing muscle resistance. If the tendons of the rotator cuff and the ligaments that hold the bone structure of the shoulder are compromised, as seen by excessive shoulder instability and hypermobility, including partial dislocation, the shoulder may not be able to provide the resistance needed for maximum gain.
Shoulder impingement syndrome can be a symptom that you have 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 a bigger shoulder problem, that of shoulder instability. What this means is that if you try to repair shoulder impingement alone without addressing the problems of the unstable shoulder, it is likely you will not have as much success in treatment as you may have hoped for.
If you are like many of our patients or someone who researchers the internet a lot, this already has made a lot of sense to you. Shoulder impingement syndrome is part of a larger more complex shoulder problem that requires a more detailed understanding and a more aggressive treatment protocol than medication and rest.
Let’s bring in some more opinions.
Here is what doctors at one of Germany’s leading sports university hospitals, Technical University of Munich writing in the German language journal Der Orthopäde (Orthopedics) reported (3):
- 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, that allow 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.
Which brings us to the latest research on surgery for shoulder impingement.
More research: Impingement of the shoulder cannot be treated in isolation. You need to treat the whole shoulder.
The controversy over managing Shoulder Impingement Syndrome as an isolated problem or a part of systematic shoulder failure was also the subject of doctors in the United Kingdom who published their research in the Indian journal of orthopaedics (4).
Here are the bullet points of that research:
- Subacromial impingement syndrome is a syndrome that encompasses a spectrum of subacromial pathologies ranging from bursitis, rotator cuff tendinosis, and partial tears leading up to full-thickness tear of the rotator cuff. (Comment – in black and white, Subacromial impingement syndrome IS part of a bigger generative shoulder problem).
- Research suggests that the impingement process can be broken down into three distinct stages.
- Stage I of the process is defined as edema and hemorrhage of the subacromial bursa, often in patients under the age of 25 years.
- Stage II impingement is when irreversible changes have developed and are represented by tendinitis and fibrosis of the rotator cuff tendon, seen in patients between the age of 25 and 40 years.
- Stage III impingement is said to have occurred when there are chronic changes such as rotator cuff tears, common in patients over the age of 40 years.
- There is ongoing debate on how impingement begins and how it creates rotator cuff tears, but is likely to be multifactorial.
Treating Shoulder impingement syndrome as part of a problem of degenerative shoulder disease
One of our main treatment philosophies is that you cannot treat spinal; or joint problems in isolation. This includes the problems of the shoulder. To treat shoulder impingement syndrome, you need to treat the whole shoulder.
Above we discussed above, NSAIDs, painkillers, and cortisone are limited in their ability to help long-term and in fact can be seen as detrimental to the patient. What else then is available? Typically physical therapy and surgery.
New research: Surgery for shoulder impingement syndrome is “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.(5)
“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.”(6)
A second report from doctors at Monash University in Melbourne was published in January 2019 in The Cochrane database of systematic reviews.(7) Here are the findings of the researchers
- “The data in (our) review do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life. “
Surgery and Physical Therapy or Physical Therapy alone? Which Benefits patients most? Surgeons say they can’t tell
In May 2019, in the medical journal Public Library of Science one,(8) researchers from Western University in London, Ontario examined patients who had:
- a shoulder impingement syndrome surgery and physical therapy and
- a “placebo” or fake shoulder impingement syndrome surgery and physical therapy,
to see if the “real” surgery plus physical therapy was more beneficial to patients than physical therapy alone.
This is what the researchers wrote:
“We synthesized very-low to moderate-quality evidence and continue to suggest that physiotherapy intervention programs (with exercise component) be used as the main and first treatment approach for treatment of patients with shoulder impingement. Ultimately, the surgical option may be considered, however, it is important to note (despite the very-low to moderate quality evidence), the lack of clinically important benefits of surgery over physiotherapy (mainly exercise). In addition, patient goals, values and shared decision-making need to be incorporated when discussing treatment options for patients with subacromial pain syndrome.”
“The effects of surgery plus physiotherapy compared to physiotherapy alone on improving pain and function are too small to be clinically important at 3 months, 6-months, 1 year, 2 years, 5 years and more than 10-years follow up.
Similarly, surgery plus physiotherapy vs placebo (surgery) plus physiotherapy comparison demonstrated no clinically important differences in terms of improving pain or function at 3 months, 6-months, 1 year, 2 years follow up.”
Surgery useless? No better than physical therapy alone? Then what type of treatments can I get?
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 this section of our article we will look at research that supports the use of regenerative medicine to rebuild the soft internal structures of the shoulder. Here we will look at Prolotherapy, the injections of simple dextrose or sugar into the shoulder as well as explore the use of your blood platelets in Platelet Rich Plasma therapy.
These techniques have been shown valuable in the treatment of many types of shoulder problems. In our clinics we use these treatments to rebuild, repair, strengthen and stabilize the shoulder by repairing damaged shoulder ligaments and tendons.
An overview of Prolotherapy injections for the treatment of Shoulder impingement syndrome
In 2009, a Caring Medical Regenerative Medicine Clinics researcher team lead by Ross Hauser, MD studied 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy. The results of this study, published in the Journal of Prolotherapy (9) showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation) with Prolotherapy, including the 39% of patients who were told by their medical doctors that there were no other treatment options for their pain and the twenty-one percent who were told that surgery was their only option.
- Over 82% of all patients experienced improvements in sleep, exercise ability, anxiety, depression, and overall disability with Prolotherapy. Ninety-seven percent of patients received pain relief with Prolotherapy.
As mentioned above, in our clinics we treat the problems of shoulder impingement as a problem of the whole shoulder. This study marked its results in improvements in overall shoulder health.
Other researchers specifically targeted Prolotherapy’s effectiveness in treating shoulder impingement
In 2013, a presentation (10) at the American College of Rheumatology’s annual meeting by Turkish researchers offered these results:
- In this single-center, randomized placebo controlled, single blind, prospective study, 80 patients with chronic shoulder impingement syndrome received two dextrose injections in the affected shoulder at two weeks intervals.
- The patients were randomly assigned into two therapy groups, either dextrose or other control (lidocaine) groups. The injections were repeated two times with two weeks between injections.
- Clinical assessments included measurement of range of motion (ROM), pain assessment, shoulder functions and daily living activities. Magnetic resonance imaging (MRI) evaluation was conducted before the first injection and compared with MRI’s taken again on the third month following the second injection.
- There were no adverse events reported. The study demonstrated significant improvements in pain and function scores in both injection groups, Prolotherapy and lidocaine.
- Shoulder flexion, abduction, internal and external rotations showed significant improvements in both groups in the first 3 months. However, while the range of shoulder flexion did not improve in the control group during the last three months, this range of motion continued to improve significantly in treatment group over the same period.
In other words in longer-lasting results, the Prolotherapy group showed significant improvement in range of motion.
Further, a March 2019 study in the Journal of ultrasound in medicine (11) recorded these results:
- Thirty-one patients with chronic moderate-to-severe shoulder pain were recruited from September 2015 to September 2017.
- Ultrasound-guided Prolotherapy was performed by injecting 10 mL of a 15% dextrose solution into the acromial enthesis of the deltoid or acromioclavicular joint capsule.
- Prolotherapy was given in 2 sessions separated by a 1-month interval.
- Twenty of the 31 patients reported substantial pain reduction without adverse effects after the intervention. Ultrasound-guided prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint arthropathy.
Our note here is that we would have injected the entire shoulder capsule as opposed to single introductions at one or two points.
Ross Hauser, MD explains and demonstrates a Prolotherapy treatment to the shoulder.
A main point of this article is to bring attention that Shoulder impingement syndrome can be caused by shoulder instability and that shoulder instability can be treated with simple Prolotherapy injections. The video below is a demonstration of the treatment.
- This particular person is not sedated. The treatment is well tolerated. The treatment begins at 1:36.
- The first injection was intra-articular, directly into the shoulder joint. Next the acromioclavicular joint. The whole shoulder is being treated to help address issues of rotator cuff weakness and shoulder instability.
- Next are the posterior shoulder structures including the posterior joint capsule as well as the various ligament attachments in the back of the shoulder.
- Next the interior structures in the front of the shoulder are done including the ligaments as well as the various rotator cuff tendon attachments including the Supraspinatus tendon.
- Prolotherapy is effective for rotator cuff tears, labral tears and biceps tendonitis, various tendonitis as well as shoulder instability.
- Finally treating the acromioclavicular joint, or AC joint as the biceps tendon attachments.
Platelet Rich Plasma Therapy (PRP) and shoulder impingement
In this video a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder treatment I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in anyway. Most patients tolerate the injections very well. The treatment goes quickly. However we do make all patients comfortable including sedation if needed.
- This patient in particular come to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
- With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrate cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments in this case it was in his anterior shoulder attachments to address the chronic dislocations.
Before we get to the research, it is important to realize that we offer a very comprehensive PRP treatment, not a single one-time injection. In much of the research on PRP, there is a one or two time treatment and that is the measurement of success. In our patients we rarely find that one or two treatments can reverse years of degenerative damage such as is found in shoulder impingement. The video above shows our comprehensive program of PRP and Prolotherapy together. We do not offer PRP without Prolotherapy. The two work together to bring about stability and repair. Prolotherapy is the consistent missing component of PRP research.
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 achieve they desired results. They also wanted to see how these three PRP injections did against a single injection of cortisone. Their findings were reported to the Czech society for orthopedics of traumatology.(12)
- After treatment patients were followed at 6 weeks, 3 months and 6 months. Based on follow up, the researchers concluded that 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 superior to cortisone.
In May 2017, researchers published a study “Treatment of Subacromial Impingement Syndrome: Platelet-Rich Plasma or Exercise Therapy? A Randomized Control Trial.” (13) In this study published in the journal Orthopaedic journal of sports medicine, doctors looked at patients who would receive exercise therapy or PRP injections for their Subacromial Impingement Syndrome.
In this study the patients who received PRP had two treatments, two injections at each treatment. The first treatment at the onset of their research participation and the second injection, one month later.
Here are some of the learning points of this research:
- “The main finding of the present research was that the shoulder pain emanating from Subacromial Impingement Syndrome can be reduced through either PRP injection or exercise therapy. At final follow-up, there was no significant difference between the 2 groups in our primary outcome measure (pain), but the exercise therapy group had significantly higher Western Ontario Rotator Cuff (Rotator Cuff motion) scores and abduction ROM (the ability to move your arm away from your body).”
- Despite other studies showing limited or no benefit of PRP, “In the current study, 2 PRP injections were given 30 days apart. The injections were made both into areas of tendinopathy and into the bursa. The continued clinical improvement seen in our patients could be related to the difference in PRP technique.”
The researchers suggest that they were able to achieve better results because the patients was injected twice in the same visit as opposed to once.
- According to the researchers: “This study showed that both PRP injection and exercise therapy can significantly reduce pain and improve shoulder ROM and functionality in patients with Subacromial Impingement Syndrome, with these beneficial effects lasting for 6 months. In spite of our hypothesis, exercise therapy was found to be more effective than the other treatment option until 3 months after initiation. Moreover, neither treatment choice significantly improved shoulder muscle force. What is more, even though the treatments resulted in clinical improvement, MRI findings did not change.”
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 deltoid. Prolotherapy, in combination with Platelet Rich Plasma injections gradual re-strengthening of the rotator cuff muscles, gives an excellent chance for a full recovery.
Our treatments can get 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.
If you have questions about Shoulder impingement syndrome and treatment options, get help and information from Caring Medical
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