Prof. Dr. med.
ATOS Clinic Heidelberg
Impingement syndrome is synonymous with shoulder bottleneck syndrome. Due to a bottleneck in the shoulder joint, the tendons of the rotator cuff, which are responsible for the movement in the shoulder, are trapped between the humerus head and the roof of the shoulder. In most cases, this leads to degenerative changes associated with impaired mobility.
Between the shoulder joint and the ankle joint there is a tunnel through which the tendons glide smoothly in healthy people. Since the joints are subject to wear and tear, abrasion particles can enter this space or form limescale, cause inflammation and swelling and pinch the tendons painfully (impingement syndrome). Such entrapment can also occur elsewhere on the shoulder. Due to the disturbance of the movement and sliding behaviour, the bony structures collide and the tendons becomes inflamed. This can cause small tears in the tendons, which weaken them and can lead to torn tendons.
Causes may be, for example, certain constitution-related ossifications of the shoulder roof or deposits as well as damage to the soft tissues (muscles, tendons, bursae). Damage to the soft tissues leads to so-called non-outlet impingement syndrome, which includes, for example, swelling-related narrowing by inflammation of the bursa (bursitis) or the inflammation of a tendon (tendinitis). The risk groups for an impingement syndrome include people who often move their arms at work or in sports at shoulder height and above the head. For example, the syndrome occurs frequently in athletes who throw objects, tennis players or in handball, volleyball, golf and swimming. Women and men are equally affected and hereditary dispositions occur.
Patients suffering from impingement syndrome report acute onset pain at an early stage. They usually suffer from movement-dependent shoulder pain, which usually occurs in the shoulder joint after a certain degree of arm bracing. Occasionally, the pain is reduced with the further bracing and lifting of the arm up to over the head. Due to the pain-related reduction of muscle activity, the muscles disappear very easily, and the joint loses mobility. In the case of particularly intense impingement syndromes, there is also pain in the back, while nocturnal pain is particularly pronounced.
For the secure diagnosis of the impingement syndrome of the shoulder, various tests are used in ATOS Clinics, which are supported by ultrasound examinations, X-rays and magnetic resonance imaging (MRI). During the medical history, we can often restrict diagnoses based on the duration and nature of the symptoms and previous injuries. In the clinical examination, it is then determined to what extent the affected shoulder is restricted in its mobility. In addition, imaging diagnostic procedures such as ultrasound and X-ray are used. The ultrasound examination shows existing damage to the bursae and tendons especially well. X-rays show bony changes that lead to constriction.
Treatment of the impingement syndrome is carried out by the specialists at ATOS Clinics individually and depending on the existing findings. Conservative, i.e. non-operative, treatment methods have the advantage here. In addition to anti-inflammatory, analgesic drugs and injections and physiotherapy are also used by our shoulder specialists.
In early stages this often leads to relief. Cold treatment and electrotherapy has also proved helpful here. Targeted muscle training in addition to physiotherapy to strengthen the upper arm and shoulder muscles is urgently necessary. Conservative treatment requires patience from the patient, especially as impingement syndrome develops over the years. It takes 3-4 months to be completely complaint-free.
If conservative treatment measures are not effective, the shoulder specialists at ATOS Clinics have the option of minimally invasive surgical treatment of the impingement syndrome. In this case, the large entries of the tendon space are widened by a few millimetres and bony extractions are removed. A possibly inflamed bursa is removed. At the same time, the condition of the tendon plate (rotator cuff) is checked. In addition, the actual joint space between the humeral head and the socket is inspected.
The surgery usually lasts no longer than 30-60 minutes.
Rehabilitation – Time and methods
An important part of the success of the treatment measure is the follow-up treatment of the impingement syndrome. Immediately after the operation, the physiotherapy, which is initiated in ATOS Clinics by well-trained and specialised physiotherapists, follows. In the first 2 days, a dressing must be worn for rest. Intensive physiotherapy usually begins after only 14 days. In most cases it takes 8 weeks for the full mobility of the shoulder to be restored.
Rotator cuff tear
Four contiguous muscles form the rotator cuff. These move from the scapula to the humeral head and start there with their tendons. The arm is stabilised on the upper body with the rotator cuff and can be moved upwards, sideways, outwards and inwards. The following muscles are involved: subscapularis muscle, supraspinatus muscle, infraspinatus muscle and teres minor muscle.
If a tear of one or more tendons occurs due to a traumatic event or due to wear from high stress, the function of the rotator cuff and thus of the entire shoulder is generally impaired. With age, the incidence of rotator cuff lesions increases. Rotator cuff rupture is often a consequence of an untreated impingement syndrome. It is often the result of signs of wear that occur due to age, as the consequences of an accident, genetic predisposition or a chronic constriction under the shoulder roof. The muscles and tendons, which are sometimes overburdened by inflammation, become torn, fibrillate and form ever-increasing defects. Left untreated, the defects continue to increase and irreparable damage may occur, necessitating muscle or tendon replacement surgery. With a tendon tear of the rotator cuff, the supraspinatus tendon is usually affected.
Younger people are more likely to have accident-related symptoms; older people are more likely to have degenerative symptoms, which are more common in men than women.
Patients with a rotator cuff tear usually complain of persistent pain in the shoulder or upper arm, especially painful night pain. As the stage progresses, discomfort from restriction of motion occurs up to the stiffness of the shoulder. It becomes difficult to turn the arm forward or to the side. Accidents or very large tears can lead to immediate inability to use the shoulder.
Our doctors at ATOS Clinics first ask about the circumstances that led to the complaints and then decide on possible tests for targeted examination of the affected muscles or tendons. The individual parts of the rotator cuff can be examined under motion with ultrasound examinations. X-ray images reveal the condition of the bone structures, and magnetic resonance imaging (MRI) allows all elements of the shoulder to be visualised.
The preferred diagnostic method is arthroscopy of the shoulder. Here, the shoulder is examined with an arthroscope, which is introduced under anesthesia over a minimal skin incision of a few millimetres in length. Shoulder arthroscopy optimally displays and assesses the condition of the rotator cuff tear and the surrounding muscles, tendons and bones. Ruptures located in the centre of the rotator cuff can only be reliably diagnosed with this method.
Small rotator cuff tears can be treated well by conservative treatment. Medication, autologous blood treatment (ACP), physical therapy and physiotherapy have good results while at the same time protecting the arm. Acupuncture or cold therapy combined with other conservative treatments can also help to heal and repair a mild rotator cuff tear.
With advanced severity of complaints, accidents or competitive athletes, often the fastest possible surgery is appropriate. The surgical technique used at ATOS Clinics depends on the degree of damage and the location of the tear.
The goal of surgical treatment is the elimination of pain and that the patient regains strength and flexibility. The type of rotator cuff tear operation depends on the individual diagnosis. Depending on where the tear is located, how extensive and how old it is, a suture or refixation of the tendon to the humerus in mostly arthroscopic or, increasingly rare, in open technique is carried out. An open procedure is used only if the tear cannot be sutured arthroscopically. As a rule, refractile rotator cuff tears are reconstructed well arthroscopically (reconstruction of the rotator cuff tear), and open surgical procedures can therefore usually be dispensed with.
If the torn tendon has retreated so far that it can no longer be fixed to the humeral head and the associated muscle has regressed, both can be replaced by a muscle/tendon transfer.
The surgery usually takes no longer than 60 minutes.
Rehabilitation – Time and methods
Following surgery, restraining the shoulder is required. The shoulder is restrained on special support rails to relieve the tendon in an abduction position (spread apart). So the tendons can grow together without tension.
Physiotherapeutic exercises begin after three weeks. Active movements are allowed again after 6 weeks following a rotator cuff tear – all without exertion. The full function of the shoulder is usually regained after about six months.
Shoulder dislocation / shoulder joint injury
Instability of the shoulder joint can occur in several directions. Mostly it is caused by an accident and the upper arm head has jumped out to the front. Such dislocation/bulging of the shoulder can lead to pain-related restriction of movement and loss of function. Even after the humeral head is back in the socket (repositioned) a sense of instability can remain so that the shoulder is no longer fully resilient.
The predominant cause of injuries of the shoulder joint are falls and accidents. For example, if a mountain biker crashes on their stretched arm or shoulder, the ligament structures between the collarbone and shoulder are injured as a result of dislocations, and the shoulder joint becomes unstable. In severe cases the shoulder joint disruption.
The patients have pain in the area of the affected shoulder joint and show clear movement restrictions of the shoulder. Defensive posture is typical for a shoulder joint injury, wherein the affected arm is supported by the unaffected other hand. However, pain and shoulder restriction may also be symptoms of shoulder dislocation.
After dislocation of the shoulder joint, patients suffer from severe spontaneous and movement pain. In addition, the shoulder is unstable. The area of the shoulder joint often shows skin abrasions from the fall and is swollen. The swelling later has discolouration which is mostly dark in colour to blue. With the so-called “piano key phenomenon”, the collarbone can be pressed resiliently downwards, with the outer end of the collarbone being significantly higher or shifted to the rear.
For the most part, our ATOS doctors can already conclude that the shoulder is injured from the description of the patient and a careful examination. Clarity and an assessment of the severity of the injury is provided via an X-ray and ultrasound. To make all tendon structures visible, it is also possible to create tomographic images using magnetic resonance imaging (MRI).
Once the diagnosis has been made and the severity level has been determined, it is possible to decide on the optimal treatment of a shoulder joint injury. This usually begins with pain therapy to suppress the pain in the shoulder joint with medication as early as possible during the examinations. Mild injuries can usually be treated with conservative therapies and temporary immobilisation.
Setting often helps with a dislocated shoulder. There are two methods here. In the method following Hippocrates, the patient lies on their back; and in the method following Arit the patient sits in a chair with a back cushion.
The more pronounced the ligament damage suffered, the sooner surgical treatment should be considered. More severe cases, especially complete ligament tears and severe shoulder instabilities, require surgical intervention.
At ATOS Clinics, doctors select the most favourable surgical procedure from a variety of possible surgeries. The aim is to stabilise the shoulder with special implants with an endoscopically assisted minimally invasive procedure or, in chronic cases, to strengthen it with an endogenous tendon (gracilis tendon).
For bone fractures and ligament damage shoulder surgery is necessary. As a rule, arthroscopy is usually performed, in which a specialist restores the injured structures through millimetre-sized holes using special instruments and a camera. The surgery usually takes no longer than 60 minutes.
Rehabilitation – Time and methods
After required surgery for a shoulder joint injury, healing is supported at the outset by gentle training of the arm. The shoulder is initially immobilised. Intensive physiotherapy usually begins after only 14 days. It usually takes 6-8 weeks for the full mobility of the shoulder to be restored.
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