“Impingement” of the rotator cuff is one of the most common causes of pain in the adult shoulder. It results from pressure on the rotator cuff from the acromion and coracoacromial (CA) ligament as the arm is lifted overhead. The acromion may have a curved shape—which causes bony impingment. It sits over and in front of the humeral head. As the arm is lifted, the acromion and CA ligament rub on the rotator cuff, and this can eventually cause either partial or full thickness tears of the supraspinatus or infraspinatus tendons, and a rupture of the long head of the biceps tendon.
Physical therapy and a subacromial cortisone shot are successful in up to 80-85% of patients. If, however, pain and limited use continue beyond 3 months, arthroscopic surgery is an option. This outpatient procedure takes 30 minutes and can be performed under a regional anesthesia. During the procedure, inflammed bursa is removed, the cuff is inspected and debrided, if partial tears are present, and the biceps tendon and AC joint are evaluated. If these structures are felt to be contributing to the pain, biceps tenotomy/tenodesis, and distal clavicle resection may be recommended. Release of the CA ligament is a critical component of the procedure so long as the rotator cuff is in tact.
A sling is worn for 3-5 days. PT is helpful for the first 4-6 weeks, and usually recovery is complete or near complete by 2 months. Although this intervention is more agressive than "conservative" treatment, it restores normal function in the vast majority when shoulder pain fails to improve with therapy. In the absence of a full thickness tear---any decision to proceed with arthroscopic evaluation and treatment will rest on my patient's expectatons for recovery, desire to abandon conservative treatment, and my judgement that success with surgical intervention is likely to be successful. When a full thickness tear is the cause of symtoms, I will generally advise repair to afford the best possible functional return.
