MRI of the shoulder joint

MRI of the glenohumeral joint has proven particularly useful for assessing any accompanying injuries to the tendons of the rotator cuff or the extent of bursitis of the shoulder. However, MRI of the shoulder is not a diagnostic tool that is always used in the early stages of impingement.

Therapy

In the treatment of impingement syndrome, a distinction is made between conservative and non-conservative therapy. As a rule, one starts with a conservative treatment attempt, which mainly consists of one: In the acute treatment phase, the arm should first be spared and as little stress as possible. Strong lifting and carrying movements should initially be avoided.

Parallel to the protection, a consistent physiotherapeutic treatment should be started. The aim of this treatment is to specifically train muscle groups in the shoulder area that are rarely used in order to relieve the shoulder joint as much as possible.The training is initially successful with so-called isometric exercises. These are muscle exercises that should be performed statically with as little weight as possible and without any self-loading.

Mostly these muscle exercises are performed passively. In the further course of time active muscle exercises can be added. The conservative treatment of impingement syndrome also includes drug treatment.

In this case, pain treatment is especially important, as well as the anti-inflammatory effect of the medication. For this reason, drugs from the group of non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen or diclofenac, are usually used for drug treatment. The aim is to use the pain-inhibiting effect to get the patient out of the constant relieving posture caused by the pain.

Only then can further damage, which can be triggered by an impingement syndrome, be avoided. Furthermore, conservative approaches include cooling and thus physically anti-inflammatory measures. If the conservative therapy for impingement does not bring any improvement, it must be considered whether it makes sense to start a non-conservative or surgical therapy.

Physical form of treatment and a
Drug treatment.

The aim of the exercises is to enlarge the subacromial space. To do this, it is important to train the muscles of the shoulder that pull the head of humerus downwards (caudally). Furthermore, the muscles of the rotator cuff and also the muscles of the shoulder blade must be trained.

One exercise to increase the subacromial space is to place the affected arm backwards on the back (hand is above the buttocks) and then use the other hand to carefully pull this arm towards the buttocks. This pull is then maintained for 20-30 seconds. Another exercise is the oblique push-ups.

Here you push yourself off with almost stretched elbows shoulder-wide in an inclined position on the edge of a table or chest of drawers. From this position, the arms are now slowly bent at the elbows to almost 90°. Then the arms are carefully stretched out again.

This exercise is done in 2 to 3 passes with 15-20 repetitions each. A further exercise is the raising of the torso. You are sitting in a bent (slight hump) position.

Then straighten up by pulling the shoulder blades backwards and lifting the head so that you look straight ahead. One adopts a tight military posture. This is an exercise that can also be done in a standing position and is a great way to work on the computer in between.

Two other exercises for home use require a Theraband. You can get these for under 20 Euros in sports stores or orthopedic stores. The first exercise trains the external rotation in the shoulder.

The arms rest against the body and are bent at 90° at the elbow. With both hands a Theraband is now held in place. This is best done by wrapping the Theraband around your hand like a loop.

One elbow remains close to the body. With the other arm you pull the Theraband slowly and steadily outwards. It is important that the elbows remain in contact and that the movement is only a rotation of the upper arm – the palm of the hand turns backwards.

This movement is done in 3 passes with about 20 repetitions. And this for each arm. The other exercise requires a theraband and a kind of fixation point on the ceiling (e.g. a stable hook or ring).

Over this fixation point you put the Theraband, that you now have two parts of equal length. These you take into your hands. You stand straight and stable.

The elbows are bent at 90° and the upper arms are bent forward at about 20°. Now both arms are moved backwards into extension at the same time and evenly. This movement is performed in 3 passes with about 20 repetitions.

As a rule, all exercises should not provoke pain. In case of pain or ambiguity during the exercises a doctor should be consulted. Surgical therapies can be performed on the open shoulder joint or minimally invasively by means of arthroscopy.

In the second surgical procedure, a camera is advanced into the shoulder joint through a small incision. This camera provides real images of the inside of the joint and shows the actual anatomical conditions. With open therapy, this is not necessary, as the surgeon himself can take a look inside the joint.The aim of the surgical therapy is to remove inflamed tissue from the joint space on the one hand and to remove disturbing bony protrusions from the joint space on the other hand.

If the raven beak process contributes to the narrowing of the shoulder joint, it is notched during open surgery as well as during minimally invasive arthroscopic surgery, so that it no longer gets in the way of the muscles running nearby. Particularly in older patients, impingement syndrome is only secondary to anatomical narrowing. In most cases, an arthrotic change in the shoulder joint is also responsible for impingement.

For this reason, once severe osteoarthritis has been seen in the shoulder joint, an attempt is made to remove parts of the clavicle. This is intended to achieve two different effects. On the one hand, it was intended to create space in the already very narrow joint space, and on the other hand to prevent the muscles involved in shoulder movement from rubbing increasingly against the bone, thus causing pain.

If parts of the clavicle are removed, this inevitably leads to a free space in the area of the clavicle and to instability. However, this instability is generally not of great duration, as scar tissue soon takes up the space between the collarbone and the acromioclavicular joint. Especially after surgical, non-conservative therapy approaches, a consistent follow-up treatment with physiotherapeutic measures is indispensable.

Irregularly performed exercises can lead to a massive deterioration of the prognosis and to a chronic impingement syndrome. However, no relevant improvement can be achieved in about one third of those affected by surgery. In most patients, however, where there is no major damage in the subacromial space, conservative therapy is effective in the first few months.

Therefore, in most cases it is worth trying conservative treatment first. In about 80% of all patients a relevant reduction of pain and complaints can be achieved by conservative therapy alone. It is important that the patient really cooperates, spares himself and refrains from heavy work and movements that further promote impingement.

If extreme defects of the tendons of the supraspinatus muscle or distinct bony growths are already visible on X-rays at the initial presentation, then this can be a reason to resort directly to a surgical measure. If these measures are no longer effective, the next step is to start using medication. Painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) can be used, such as ibuprofen, which counteract both the pain and the inflammation.

Drugs that can be injected directly into the affected joint have a greater effect. Cortisone is often used for this purpose. Cortisone is a very effective anti-inflammatory drug, but it has a rather strong effect and is associated with many side effects, so it should not be used lightly and, if at all, then only temporarily.

In addition, physiotherapy and physical therapy are very useful in case of an impingement syndrome. However, this should always be carried out under the supervision of a doctor or a trained physiotherapist in order to avoid causing even greater damage to the joint. Techniques that are helpful here are mainly special stretching exercises and muscle building.

The strength in the shoulder should thereby be restored and movement restrictions are ideally minimized. In addition, certain mobilizations of the joint can also have a direct anti-inflammatory effect, as they stimulate the blood circulation of the affected tissue and thus also regeneration processes. However, it should be noted that these exercises can only have a positive effect if they are performed consistently, correctly and above all regularly over a longer period of time.

If conservative therapy does not lead to pain relief, surgical treatment may be considered. Various options are available. First of all, one always tries to treat impingement syndrome conservatively, i.e. without surgery.

If all the available options of this form of therapy do not produce the desired effect of freedom from pain or at least considerable relief, surgery must ultimately be resorted to.There are several alternatives here, which must be weighed up depending on the severity of the disease and the individual condition of the patient. The least invasive and costly is the arthroscopic procedure. Only very small incisions are necessary, through which the surgeon inserts a camera into the joint, with the help of which he can directly identify bony structures that lead to constrictions and remove them with a small device if necessary.

With this variant, the operation can normally be performed on an outpatient basis, i.e. the patient can leave the hospital on the day of the operation. In the case of more pronounced clinical pictures, an open therapy is usually preferable. In this case, larger bone spurs can be removed and at the same time any existing adhesions can be removed.

If necessary, the surgeon can also remove parts of the joint and/or smooth joint surfaces. With this method, however, a larger incision of about 4 cm in length must be made, which means a longer stay in hospital. The most drastic variant is the so-called subacromial decompression.

The purpose of this operation is to widen the joint space in order to treat the existing impingement syndrome and prevent a relapse. Depending on which structures of the joint were responsible for the symptoms, bone parts, tendons or parts of bursae can be removed during this procedure. After each type of surgery, extensive physiotherapy is prescribed, whereby it is important to find a good balance between overloading the joint too early and immobilising it for too long, both of which can have a long-term negative effect on the healing process.

The more extensive the intervention, the slower mobilisation of the joint should be started and the longer it usually takes to regain completely normal mobility and freedom from pain in the affected shoulder. After the operation, not all movements should be performed immediately with full force. Since subacromial decompression not only removes bone fragments and the bursae, but often also sutures or reconstructions are performed on the supraspinatus tendon, it must not be fully loaded.

For the first 2 days after the operation, the arm must be worn in a so-called gill-christ bandage. No active movement of the arm should take place in the first week after the operation. This means that the arm may only be moved by a physiotherapist.

In addition, the surrounding musculature (neck, back, shoulder blade) should be trained, because these are now increasingly needed to keep the upper arm in the ideal position. Over the next few weeks, a plan is worked out together with the physiotherapist until the patient can almost fully load his shoulder again after about 4-5 weeks. However, it is also important to avoid sports that cause heavy impacts or strong forces to act on the shoulder.

The exercises that are done postoperatively with the physiotherapist correspond in principle to the exercises listed under Exercises for at home. It should be noted that some movements and exercises may not be performed for each patient individually. The surgeon will include this in the post-operative treatment plan and depends on the course of the operation and whether other muscles or tendons were affected.

Tapering the shoulder in case of impingement syndrome is a frequently practiced technique. The aim is to relieve the muscles and improve the position of the humeral head. There are various methods that are used.

Depending on the method used, several strips of tape of different lengths are needed for taping. In the first method, a tape about 20 cm long (depending on the size and muscle dimensions of the patient) is stuck diagonally from the acromion (shoulder height) over the shoulder blade to the spine. This is done under tension.

A second tape is then stuck from the deltoid muscle along the shoulder blade. Another possibility is to stick a tape horizontally below the head of the humerus from the base of the pectoral muscle at the sternum over the adjacent upper arm to the shoulder blade. A second tape is applied diagonally from the chest over the shoulder to the lateral part of the shoulder blade.

The tapes are placed in such a way that there is an area between them in which the head of the humerus lies. A third possibility uses a split tape.This is glued to the base of the deltoid muscle (lateral upper arm) with the upper arm in contact. Then, one part of the tape is glued around the deltoid muscle at the front and the other part around the back, so that the head of humerus lies in between.

Both parts then join together in a glue dot behind the acromion. Another tape is then applied from the lateral upper chest over this adhesive point to the shoulder blade. And a third tape is then stuck lengthwise over the deltoid muscle from the upper arm to the lateral neck. The exact application of these methods should be done by an experienced person. Incorrect application will not achieve the desired effect and in the worst case may even worsen the problem.