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Shoulder pain can make simple chores almost impossible.  Have you ever reached for an object high on a shelf only to have pain that takes your breath away?  What causes shoulder pain when reaching across the body?  What is shoulder impingement?  What does shoulder impingement feel like?  Can a shoulder X-ray show shoulder impingement?  What are the treatment options for shoulder pain when reaching across the body?  Let’s dig in.

Why Does My Shoulder Hurt When I Reach Across My Body?

Shoulder impingement and rotator cuff injuries are among the most common causes of shoulder pain (1).  Both can cause shoulder pain when reaching across the body.

Shoulder Impingement

Shoulder impingement is a painful condition in which the bursa and muscles of the shoulder are pinched or compressed.  This occurs in any area called the subacromial space which is immediately beneath the AC joint.  This area contains the rotator cuff tendons and bursae and is identified by the red in the illustration below (2).  A bursa is a fluid-filled sac that reduces the friction on tendons and muscles as they cross boney surfaces.  A tendon is a thick collagen tissue that connects muscles to bones. The rotator cuff tendons provide important support and enable movement in the shoulder.

Rotator Cuff Injuries

There are four rotator cuff tendons:  supraspinatus, infraspinatus, subscapularis and teres minor.  Injuries can include inflammation of the tendon called tendonitis and tears in the tendon.  Tears can be partial thickness where they only involve a portion of the tendon or full-thickness when they involve the entire tendon.  If the tendon fibers pull apart from one another this is called a retraction.  Rotator cuff tears are common and the incidence increases with age.  A recent large study demonstrated a prevalence of rotator cuff abnormalities of 9.7% in patients younger than 20 which increased to 62% in patients aged 80 and older (3).  Factors that increase your risk for RC tears include advancing age, hand dominance (4), and smoking (5).

What Does Shoulder Impingement Feel Like?

Pain is the most common symptom.  It typically occurs with the elevation of the arm, forced movement overhead and when lying on the shoulder.  Impingement can also cause shoulder pain when reaching across the body.

What is the Cause of Shoulder Impingement Syndrome?

Narrowing fo the subacromial space is the most common cause of shoulder impingement syndrome (6).  The subacromial space is the area between the top of the arm bone (humerus) and the AC joint.   This narrowing compresses or pinches the rotator cuff tendons and bursa.  If left untreated the rotator cuff tendons can become inflamed, damaged and or torn.

Causes of  Subacromial Space Narrowing

  • Inflammation or injury of the AC joint
  • Instability of the AC joint
  • Increase in the rotator cuff volume due to inflammation or injury.
  • Ligament thickening
  • Muscular imbalance

Can an X-ray Show Shoulder Impingement?

No!  X-ray images bone only.  Bursa and tendons can not be seen on x-ray.  An x-ray may demonstrate arthritis and or a bone spur on the AC joint which can narrow the subacromial space which in turn can potentially compress or pinch the rotator cuff tendons.  An MRI is a much better imaging choice as it visualizes bone, ligaments, rotator cuff and bursa.  An MRI can identify shoulder impingement.

Treatment Options

Conservative Care

Conservative care is the initial treatment of choice if no major damage is present.  Options include immobilization, muscular strengthening, physical therapy, ultrasound, acupuncture, and manual therapy.

Steroid Injections

Steroid injections are often recommended as they are powerful anti-inflammatory agents.  These should be avoided as steroids are toxic to orthopedic tissue and may compromise rotator cuff tendon strength and healing. (7)

Surgery

Surgery is often recommended when conservative treatment fails.  The most common surgery for impingement is subacromial decompression where part of the AC joint and bursae are cut away.  Unfortunately, the supporting shoulder ligaments are also cut away thereby making the shoulder unstable.  New research involving 32 hospitals, 51 surgeons and more than 300 patients in the United Kingdom demonstrated that decompression surgery is no more effective than a placebo (8).  To better understand the consequences of decompression surgery please click on the video below.

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Platelet Rich Plasma and Stem Cells

PRP is useful in the treatment of shoulder impingement (9).   At the Centeno-Schultz Clinic, we have extensive experience in the treatment of shoulder impingement and rotator cuff tears. The instability of the AC joint and shoulder can be treated with ultrasound-guided injections of both PRP and stem cells.    Mesenchymal stem cells are a type of cell found in your body including bone marrow and fat.  They are an all-purpose repairman of the body and these cells have the ability to help tendon injuries heal (10).  We published the world’s first research paper on the use of bone marrow concentrate cells on patients with rotator cuff tears with and without arthritis (11).  We demonstrated excellent results characterized by a reduction in pain and increase in function after bone marrow concentrate injections.

In Conclusion

Shoulder impingement and rotator cuff injuries are among the most common causes of shoulder pain when reaching across the body.  Shoulder impingement is a painful condition in which the bursa and muscles of the shoulder are pinched or compressed. This is typically caused by the narrowing of the subacromial space in which shoulder pain when reaching across the body is common. An X-ray may suggest shoulder impingement but MRI is a better imaging choice.  Treatment includes conservative care.  Steroids should be avoided.   Subacromial decompression is a common surgery that is no better than a placebo.  PRP and bone marrow concentrate injections are effective, nonsurgical treatment options for shoulder impingement.

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1.Cohen RB, Williams GR: Impingement syndrome and rotator cuff disease as repetitive motion disordersClin Orthop 351: 95-101, 1998

2.Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther. 2011;16(1):33-9. doi: 10.1016/j.math.2010.08.004

3..Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23:1913–1921.DOI: 10.1016/j.jse.2014.08.001.

4.Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19:116–120.

5.Baumgarten KM, Gerlach D, Galatz LM, Teefey SA, Middleton WD, Ditsios K, Yamaguchi K. Cigarette smoking increases the risk for rotator cuff tears. Clin Orthop Relat Res. 2010;468:1534–1541. DOI: 10.1007/s11999-009-0781-2

6.Garving C, Jakob S, Bauer I, Nadjar R, Brunner UH. Impingement Syndrome of the Shoulder. Dtsch Arztebl Int. 2017;114(45):765–776. doi:10.3238/arztebl.2017.0765

7. Wei AS, Callaci JJ, Juknelis D, et al. The effect of corticosteroid on collagen expression in injured rotator cuff tendon. J Bone Joint Surg Am. 2006;88(6):1331–1338. doi:10.2106/JBJS.E.00806

8. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-38.DOI: 10.1016/S0140-6736(17)32457-1

9. Pasin T, Ataoğlu S, Pasin Ö, Ankarali H. Comparison of the Effectiveness of Platelet-Rich Plasma, Corticosteroid, and Physical Therapy in Subacromial Impingement Syndrome. Arch Rheumatol. 2019;34(3):308-16.DOI: 10.5606/ArchRheumatol.2019.7225

10. Costa-Almeida R, Calejo I, Gomes ME. Mesenchymal Stem Cells Empowering Tendon Regenerative Therapies. Int J Mol Sci. 2019;20(12):3002. Published 2019 Jun 19. doi:10.3390/ijms20123002

11. Centeno CJ, Al-Sayegh H, Bashir J, Goodyear S, Freeman MD. A prospective multi-site registry study of a specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis. J Pain Res. 2015;8:269–276. Published 2015 Jun 5. doi:10.2147/JPR.S80872

 

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