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Subacromial impigment syndrome Print E-mail

This syndrome involves a musculotendinos structure around the shoulder joint, a group of four muscles and tendons that cover the upper part of the humerus and control the movement and lifting of the arm. These muscles and their tendons cooperate with the deltoid muscle to provide motion and strength to the shoulder for all movements at waist or shoulder level or above.


The subacromial tendinitis is an inflammation of a group of muscles in the shoulder along with an inflammation of the lubricating mechanism called bursa. In fact arthrobursitis should not be considered as a diagnosis but rather as a symptom of subacromial tendinitis.

This situation is usually caused by or associated with repetitive activities above shoulder level, like throws, the picking of the harvest, car or windows washing, and many other repetitive movements. It may also be the result of an injury. The subacromial injuries are the most common causes of shoulder pain and limitation in sports activities for all ages. The subacromial tendinitis is the most painless form of subacromial injury.

The shoulder has a unique arrangement of muscle and bone. The rotator group of muscles (group of 4 muscles forming the rotator cuff) is located between two bones, just like a sock is located between the heel and the shoe. So, as by walking the sock wears out in such a way the muscles wear out from the constant rubbing onto the bone. As the muscle begins to wear out, it reacts to injury by inflaming and aching. After continuous wear, like a rope, it can finally be broken.


What are the symptoms?

The classic symptoms include a pain that resembles a toothache, coming from the outside of the arm up to a few inches below the top of the shoulder. However, pain can also appear on the front and on top of the shoulder. It may disturb the patient during sleeping. It may also awaken the patient from a deep sleep with a very annoying pain in the upper arm.

Symptoms usually get worse when we lift the arms or during activities that require the rotation of the body, like getting something from the backseat of the car. Moreover, to reach back to buckle up or move a seatbelt forward may worsen the pain to the arm and shoulder.

You may also hear a clicking in the shoulder when you raise your hand high above your head.

What are my choices regarding my treatment?

A detailed history examination and a physical examination almost always lead to the correct diagnosis. The x-rays will show the changes on the bone where the acromial muscles join, but a MRI will give us an accurate diagnosis. The review illustrates the muscles and whether the muscle becomes inflamed, injured or ruptured.


Conservative approach

The following steps should be followed as a conservative approach to treatment of subacromial tendinitis:

• Stop or significantly reduce any activity requiring the use of the shoulder at shoulder level or above.
• Put ice in the region.
• Begin treatment with anti-inflammatory drugs to reduce pain in hand and shoulder.
• Begin an exercise program to maintain elasticity.
• Avoid carrying heavy objects with the hand that hurts or hang bags with the strap on the side that hurts.

Initially, anti-inflammatory medication can help us considerably. However, for the inflammation to give in, it is important to limit any repetitive activity, and also to try to keep the elbow below the shoulder when we use our arm.

Daily stretches during a hot bath is also very beneficial. Should the pain become stronger an empowering drug therapy could help or an injection of cortisone.

Injections of cortisone can be very effective in treating pain. When used, they should be combined with a home exercise program for flexibility and strengthening, changing daily lifestyle and ice application. Some other pain treatment options are heat, ice, ultrasound and therapeutic massage.

For a young patient under the age of thirty and when talking about tendonitis that happens for the first time and that is treated directly according to the above, the recovery period varies from two to four weeks. For patients with recurrent tendinitis episodes and some risk factor, subacromial tendinitis can take months until recovery, and in rare cases may require surgery.


If symptoms do not subside, a procedure for the surgical removal of the projecting pieces of bone on the acromion can increase the space for the tendon that becomes inflamed and can prevent further deterioration or complete rupture. If the magnetic resonance imaging demonstrates full muscle injury, that may require surgical correction.

Surgery for recurrent subacromial tendonitis (arthrobursitis) can be performed at the following situations:

• To remove an overhang or a projecting piece of bone subacromialy.
• To remove chronically inflaming, weakened and fibrotic bursa tissue.

• To investigate the condition of the tendons, arrange and sometimes restore any damage to the tendons.


The previous processes often occur in combination. This can be done by open or arthroscopic approach while starting a simpler recovery program one or two days after surgery and proceeding after that to a more demanding program of approximately two to five weeks after surgery. The beginning and progress of such an exercise program depends on the findings of the patient during surgery, the surgical procedure and the degree of healing.



What are the possible risks of surgery?

The operation is performed in a clinic and there are no significant complications. Potential risks include infection, bleeding, nerve injury and problems with wound healing. Very rarely, shoulder stiffness can be observed.


How to prepare for surgery?

• Complete the pre-operative or lab tests that your doctor prescribed you.
• Arrange for someone to drive you from hospital to home.
• Do not take aspirin or any other non-steroidal anti-inflammatory drugs for one week before surgery.
• Contact the center where your surgery will take place to confirm the time of your appointment.
• Do not eat or drink anything after midnight the night before surgery.

What should I do on the day of surgery?

• If you are taking any medication at this time, you can get it the day of surgery with a single sip of water.
• Do not wear jewelry, earrings, makeup, nail polish, hair clips or contact lenses.
• Leave valuables and money at home.
• Wear loose, comfortable clothing.

What happens after surgery?

You should not worry about the pain because you will receive adequate medication for pain. Sometimes interscalene block is applied to control the postoperative pain in the arm and shoulder. This is done before surgery and numbs the hand until the morning after surgery.
The treating doctor will inform you about the necessary postoperative treatment before leaving the clinic. The wound will be checked regularly and you will receive medication including painkillers.

How long for the recovery period?

The time for full recovery differs and can vary from two to four weeks in a first time, properly treated, light incident, until several weeks or months in chronic or recurrent situations or in people with more severe and extensive surgery.

In most cases you can start an exercise program four to six weeks after surgery and return to usual daily activities six to twelve weeks after surgery. However, every case is unique, so the treating doctor should instruct you accordingly.




What is the rehabilitation process after surgery?

Although no specific rehabilitation process after the subacromial tendinitis exists, the patient should follow some basic principles:

1. Initially, you have to recover all passive movements

2. Subacromial strengthening should start by placing the hand to the side.

3. Then, strengthening exercises of the deltoid muscle and the shoulder will be added when the shoulder will not hurt so much.

4. We must ensure strengthening of the scapular muscles so that the patient can regain normal shoulder motion and power even when the hand gets completely over his head. The degree of strengthening depends on the individual patient's needs, the demands on the forces he wants to submit his shoulder, as well as the progress made concerning the original program.

5. Before the athlete returns to sports, a rehabilitation exercise program that relates to the specific sport should be added, neither demanding nor at a competitive level, though. During this sub-program the athlete will use a 25-50% of his capability (concerning duration, frequency and intensity).

If the athlete functions well at this level without feeling pain for the next days, he can gradually increase his activity in intensity, frequency and duration.

How will I manage at home during recovery from surgery?

Most patients can look after themselves within a few days for surgery. However, it is very helpful if a family member is present to help the patient, especially with the stretching exercises.

How often should I arrange the post-operative appointments with my treating doctor?

The physician will advise you on your postoperative appointments.