Shoulder impingement syndrome decompression surgery – What are your alternatives?

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C., Brian Hutcheson, DC

Shoulder impingement syndrome – Surgeons tell patients to say no to surgery – What are your options?

You started having some shoulder pain and a limited range of motion. Maybe you had an injury at work or your shoulder has been getting worse and worse over the years. You 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 night time shoulder pain. Finally, and perhaps after months and years of chronic problems and self-management, you finally went to get some medical attention.

After an examination, your doctor/clinician may explain to you that your problem is all about inflammation or “itis.” You have a shoulder impingement, your shoulder muscles and tendons are getting squeezed between the bones of the shoulder. How did this happen? Years of activity leading to a loose and wobbly shoulder. Your shoulder is basically worn and tearing away. So you have an “itis.” This could be a rotator cuff tendinitis, shoulder bursitis, or a combination of both.

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 the subacromial bursa, the bursa that sits between your rotator cuff tendons, and the acromion process of the scapula. It may have been pointed out to you that the shoulder tendons that run over the shoulder bursae are causing too much friction. So what can you do about this? You need anti-inflammatories.

This may have been a disappointing answer for you. You are probably already on a self-medication regimen of over the counter anti-inflammatory medications. You may have even justified the need for more anti-inflammatories as “Maybe the stronger stuff will work better.” For some people, they do work better and the shoulder pain can be managed.

These are the people we do not typically see at our center. We see the people who are not really being helped by the better, stronger medications and are looking for something else.

So after a more powerful and perhaps prolonged anti-inflammatory regiment and ultimately a cortisone injection, you find yourself with maybe a little improvement

So after a more powerful and perhaps prolonged anti-inflammatory regiment and ultimately a cortisone injection, you find yourself with maybe a little improvement, but certainly not enough to get you back to work or sport.

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.

My conservative care treatments sent me to shoulder replacement

Here is a story:

After dealing with shoulder pain for a long time, I got to the point that I no longer wanted to deal with the chronic pain and for me, what was worse, the accelerated loss of range of motion. Suddenly, I could not move my arm. So I finally went to the doctor.

My regular doctor told me that my shoulder pain and limited range of motion was because I had an impingement. Fast forward some two years later now I need a shoulder replacement.

Here were my treatments: I started out with Voltaren gel which I bought online. Didn’t help. Then I was prescribed the Comfort Pac-Meloxicam for tendinitis and pain. Didn’t help. Then a cortisone injection. Helped a little, wore off. Then I was given cyclobenzaprine, the muscle relaxant. When this did not help, I was prescribed an anti-depressant because it would help with the pain, and the “extra bonus,” was that it might help with my mood.

After two years of conservative treatment, my shoulder had deteriorated to such a state that I developed fractures, and shoulder replacement was strongly recommended. In fact, it was “my only option.”

Sometimes a story will go like this:

I had an impingement injury in my right shoulder 12 years ago and it never fully healed

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:

I was injured at work, the doctors discovered an impingement

Sometimes we will be contacted by someone who had an injury at the workplace. Their story goes something like this:

I hurt my shoulder at work. It was an acute injury from years of wear and tear damage. I thought I had a full-blown rotator cuff tear. My shoulder had been a problem for years. The doctors told me I had shoulder impingement syndrome. I was prescribed anti-inflammatory medications, a dozen sessions of physical therapy, and finally a corticosteroid injection. After almost four months of this, I went back to work. First day back, no change. My shoulder hurt so bad I could not work. I am starting all over again.

Maybe you are not a physical laborer, maybe you do not play sports and workout, but carrying groceries and wearing a 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 physically, and then 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 are explained below. The news is not good.

More pain management:
Your health care provider may suggest a prolonged, up to a 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 a stronger dose until the one that works is found.

Rest:

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 of pain relief they had hoped for from cortisone and physical therapy.

Often a patient will explain to us:

I have been treated for tendonitis 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 came 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 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:

As we mentioned, people do get good results from cortisone. Even those of you who are 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.

“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.”

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:

Adding a nerve block

An April 2020 study in the Archives of Orthopaedic and Trauma Surgery (3) studied the effect of the combination of subacromial corticosteroid injection and suprascapular nerve block on shoulder impingement syndrome.

According to the study, both treatment groups showed significant relief of pain at one and three months after treatment. However, the cortisone plus nerve block group showed better pain relief.

Let’s point out here that any treatment that brings pain relief to people is a good treatment. Some people are very satisfied with symptom suppression. However others, those who need to work or have physically demanding needs, such as being a caregiver to a spouse, know that symptoms suppression is not a\treating the problem. Eventually, cortisone will wear off. If you are reading this article it is very likely that cortisone may have worn off for you.

What are we seeing in this image?

This illustration demonstrates shoulder impingements as caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement, the structures within the glenohumeral joint themselves have impinged. These conditions can be caused by excessive shoulder instability.

This illustration demonstrates shoulder impingements as caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement the structures within the glenohumeral joint themselves are impinged. These conditions can be caused by excessive shoulder instability.

This illustration demonstrates shoulder impingements as caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement, the structures within the glenohumeral joint themselves have impinged. These conditions can be caused by excessive shoulder instability.

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.

How about a laser?

Like every medical treatment, including those we offer at our center, some people will do very well, some people will do okay, and some people may not respond as well. This could be the case made about the low and high-intensity laser.

Laser therapy is considered safe, little if any pain is involved in the treatment and it may help. Red infrared laser light is placed against the shoulder. The idea is that the photons (a particle of light) will penetrate into the cells and revitalize the healing process by jump-starting the mitochondria in the cells. Mitochondria are the energy centers of the cells – the power generators. Turn them on, the theory goes, you turn on healing. How? Mostly it is about bringing blood flow and increased circulation into the area. In principle that is how all healing treatments work.

A May 2019 paper in the journal Clinical Rehabilitation (4) evaluated the effectiveness of high-intensity laser therapy on shoulder pain and function in subacromial impingement syndrome. The study included 46 patients.

The results:

What these researchers found was the laser did not help the patients any more than just the exercise alone: “The effect of high-intensity laser therapy plus exercise is not higher than exercise alone to reduce pain and improve functionality in patients with the subacromial syndrome.”

A December 2020 paper, also in the journal Clinical Rehabilitation (5) gave a more optimistic outlook. In this study, low-level laser therapy (LLLT) was combined with exercise for shoulder pain and disability in patients with subacromial impingement syndrome.

In comparison, the researchers found “Low-level laser therapy combined with exercises reduce pain intensity, improve shoulder function and reduces pain intensity and medication intake over 3 months.”

Is Shoulder impingement syndrome actually a symptom of a bigger shoulder problem? Do you even have Shoulder impingement syndrome?

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 researches 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.

In November 2019, Dr. Kuldip Singh Dhillon, published these observations in the Malaysian Orthopaedic Journal: (6)

We have to stop here to give a further explanation. There are two degenerative shoulder problems: Extrinsic and Intrinsic. These are best explained by the symptoms or diagnosis most attributed to them. Let’s bring in an explanation from the Department of Physical Therapy, Virginia Commonwealth University-Medical College of Virginia Campus published in the journal Clinical Biomechanics. (7)

Simply, Extrinsic factors deal more with the mechanical breakdown and intrinsic factors deal more with co-morbidities, other diseases that may impact the shoulder’s ability to heal.

“surgical treatment should have no role in the treatment of such patients”

Let’s return to Dr. Kuldip Singh Dhillon’s paper:

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 (8):

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 (9).

Here are the bullet points of that research:

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.

As 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.

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. (10)

“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.”(11)

A second report from doctors at Monash University in Melbourne was published in January 2019 in The Cochrane Database of Systematic Reviews. (12) Here are the findings of the researchers

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,(13) researchers from Western University in London, Ontario examined patients who had:

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 the 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.

The patient had rounded shoulder posture causing impingement

In this video, Dr. Hutcheson describes a patient case where chiropractic manipulation and exercise helps a patient with shoulder impingement

The transcript summary and explanatory notes are below

Rounded shoulder posture

The patient had a rounded shoulder posture. His head was in a forward position caused by poor posture and rounding of the upper spine and shoulders.

Dr. Hutcheson explains helping this patient: (1:40 of the video)

An overview of Prolotherapy injections for the treatment of shoulder impingement syndrome: Caring Medical research

Prolotherapy is an in-office injection treatment of simple dextrose or sugar. The science and research on Prolotherapy can be found on our Prolotherapy research page.

Is Prolotherapy like cortisone? 

Prolotherapy is a regenerative injection treatment used to treat shoulder pain by repairing damaged and weakened ligaments and tendons.

In 2009, a Caring Medical research 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 (14) 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 (15) 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 the treatment group over the same period.

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.

People get confused with PRP treatment because they think it is “just like cortisone, only safer.” PRP is NOT just like cortisone. Cortisone has an immediate pain-reducing effect for many people, not all, because it is reducing pain brought on by chronic inflammation. Nothing is being healed. PRP brings upon healing through inflammation. When tissue is repaired, the inflammation goes away.

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 any way. 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 comes 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 concentrated 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.

The research:

A December 2019 (16) study from medical university researchers in Brazil suggests that in a head to head, one-shot vs. one-shot competition, PRP would be a better treatment option for patients. Here is what they said: “The efficacy of PRP as a therapeutic modality still needs to be better clarified, but its characteristics make it a promising therapy in the treatment of rotator cuff tendinopathy. Corticosteroids, although well studied when their efficacy and side effects, remain a rising concern in its chronic use in clinical practice.”

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.(17)

In May 2017, researchers published a study “Treatment of Subacromial Impingement Syndrome: Platelet-Rich Plasma or Exercise Therapy? A Randomized Control Trial.” (18) 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 researchers suggest that they were able to achieve better results because the patients were injected twice in the same visit as opposed to once.

Summary and contact us. Can we help you?

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 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.

We hope you found this article informative and it helped answer many of the questions you may have surrounding your shoulder problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

1 Burger M, Africa C, Droomer K, Norman A, Pheiffe C, Gericke A, Samsodien A, Miszewski N. Effect of corticosteroid injections versus physiotherapy on pain, shoulder range of motion and shoulder function in patients with subacromial impingement syndrome: A systematic review and meta-analysis. South African Journal of Physiotherapy. 2016 Jan 1;72(1):1-9. [Google Scholar]
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16 Hsieh PC, Chiou HJ, Wang HK, Lai YC, Lin YH. Ultrasound‐Guided Prolotherapy for Acromial Enthesopathy and Acromioclavicular Joint Arthropathy: A Single‐Arm Prospective Study. Journal of Ultrasound in Medicine. 2019 Mar;38(3):605-12. [Google Scholar]
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This article was updated February 8, 2021

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