Impingement occurs when the rotator cuff begins to rub, pinch or impinge against the acromion process. This may occur because the rotator cuff is damaged or weak thus allowing the humeral head to migrate upwards. It more commonly occurs because the acromion process (bone) has thickened or enlarged or developed bone spurs that then dig into the rotator cuff and "impinge" or pinch against the cuff.

Long standing impingement of the bone against the rotator cuff causes pain, inflammation, stiffness, weakness and gradual loss of function. The inflammation caused by impingement is often called "bursitis" as the bursa between the bone and the rotator cuff is what becomes inflamed.

If you ignore impingement long enough, it may ultimately cause a tear to develop in the rotator cuff. The repair and subsequent recovery from a rotator cuff repair is more extensive and much prolonged compared to the treatment of simple impingement. Early, aggressive treatment of shoulder impingement can avoid a much more serious problem (torn rotator cuff).

A careful description of the onset, nature and duration of symptoms combined with specific findings on physical exam usually confirms the diagnosis. Most patients experience a gradual onset of rather vague, non-descript shoulder pain. It is often worse at night and may be made worse by doing over head activities (playing tennis, reaching, lifting above shoulder level, weight lifting - military press)

X-rays often show thickening of the acromion process or a spur on the corner or front of the acromion. The acromion is the bone above the shoulder against which the rotator cuff rubs or "impinges" causing inflammation, pain, swelling, loss of function, weakness and may lead to tearing of the rotator cuff. Long standing inflammation from impingement may also contribute to the development of calcium deposits in the tendons of the rotator cuff.

In most cases shoulder impingement comes on gradually and progresses slowly. Treatment is dictated by severity of symptoms and level of functional deficits.

1. Rest and shoulder specific exercises.
   1. Avoidance of overhead activities combined with rotator cuff strengthening exercise may be helpful in diminishing symptoms and improving function
2. Bracing:
   1. Use of an arm sling may make the shoulder feel better but will not solve the underlying impingement
3. Physical therapy
   1. Therapy modalities such as heat, ultrasound and massage may temporarily reduce symptoms. When combined with rotator cuff strengthening exercises physical therapy can help reduce symptoms and may delay the progression of shoulder impingement.
4. Anti-inflammatory medications
   1. Reduces irritation, inflammation and swelling and thus may reduce symptoms of impingement.
5. Cortisone injection
   1. Usually dramatically reduces symptoms due to the irritations and inflammation of impingement. Response to injection may last several months. When combined with rotator cuff exercises, may be associated with even more prolonged relief of symptoms.
6. Arthroscopic surgery to relieve the impingement (Decompression)
   1. This is the only treatment that actually eliminates the cause of the symptoms and protects the rotator cuff by removing the bone spurs that may be cutting in to the rotator cuff. In many cases, by the time the surgery is performed, the tendons that make up the rotator cuff are partially or completely torn. If a rotator cuff tear is identified at the time of surgery, in most cases it will be repaired through the arthroscope. Occasionally cuff tears are large and complex and are better repaired through an open incision rather than through the arthrosocope. Some cases of impingement occur because of instability within the shoulder rather than impingement from the acromion. In these cases correction of the instability through surgery combined with muscle strengthening may be necessary to correct the impingement. The actual surgical procedure is Arthroscopic Subacromial Decompression with possible Rotator Cuff Repair.

1. First you must schedule the surgery with my office. The best way to do this is to call and ask for Anne (my personal assistant) or Kerry Nye (my surgical scheduler). Kerry will help put your schedule together with mine at a location consistent with the requirements of your insurance company.
2. If you have any significant medical risk factors such as heart disease, a current infection, lung disease or a history of blood clots, such issues may need to be addressed with your internist or primary care doctor prior to proceeding with surgery.

1. Your surgery will be done at a "Same-day-Surgery" facility which means you will go home the same day, usually an hour or two after the procedure is done. I perform these procedures at the Central Utah Surgical Center, Utah Valley Regional Medical Center and Timpanogas Regional Hospital.
2. You will be called the evening before surgery by the facility where your surgery is scheduled. They will ask you some questions and tell you what time to come to the facility the next day. They will want a phone number so they can notify you if the schedule changes.
3. IT will be necessary that you have nothing to eat or drink for 8 hours prior to the planned surgery. Failure to comply with this requirement dramatically increases the risks of anesthesia and will result in delay or cancellation of your surgery.
4. When you come to the facility, initial blood and other tests may be done to verify the status of your medical condition prior to the planned surgery. If you are female, a pregnancy test is routinely performed.
5. An intravenous line will be inserted into a vein in one of your arms. This will be used to administer medication intravenously.
6. You will be placed on a bed and your shoulder will be shaved. You will be asked to mark a "YES" on the shoulder that is to receive the surgery.
7. I will come and see you shortly before the surgery, answer any additional questions that you or your family members may have, and I will also put my mark on your leg. I want to take every precaution to make sure that I do the right procedure on the correct shoulder.
8. The anesthesiologist will come and talk to you about the anticipated procedure and the roll he will play in taking care of you. He also will answer any questions you may have.
9. At the appropriate time you will be moved to the operating room where you will be given an anesthetic and the procedure will be performed.

1. The shoulder will be painted with antiseptic solution to reduce the risk of infection. You will also be administered antibiotic medication through your intravenous line for the same purpose.
2. I will make small puncture wounds on the back and side of your shoulder.
   • One is for the scope or camera which allows me to see the inside of your shoulder
   • One is for the instruments I use to relieve the impingment.
   • Other portals may be used depending on the extent of damage encountered.
3. I will carefully examine the interior of your shoulder, define the extent of damage and proceed with the appropriate repair.
4. If there are other problems such as an area of arthritis, loose debris or ligament problems I will treat those at the same time UNLESS treating those unanticipated conditions would significantly alter your course of recovery.
5. At the end of the procedure, I will remove the instruments, apply "steri-strips" to the tiny incisions, and apply gauze pads followed by an Ace bandage. At the end of the procedure but before your wake up I inject a local anesthetic into the shoulder to reduce pain or insert a Pain Pump Catheter into the surgical site to help relieve post operative pain.
6. You are then moved to the recovery room where you continue to awaken from the effects of the anesthesia. Once you have sufficiently awakened, you will get up, go to the bathroom, eat a snack and drink fluids prior to being released to go home. If you are over 65, are significantly over-weight or have pre-existing lung disease, I will require that you stay 24 hours for more careful observation. Although this may seem inconvenient, experience has taught me this careful approach.

1. Many patients feel pretty good when they get home. This is because of the nerve block or pain pump inserted at the time of surgery. Please take it easy. Put ice packs on your shoulder to help control swelling and limit your activity to light activities. Your arm will be in a sling for comfort and protection. As you start feeling better, it is OK to take your arm out of the sling and carefully move it about as allowed by pain. If it was necessary to repair your rotator cuff you must be more careful and avoid any forceful or active exercise with the affected arm except as described by me or my staff.
2. My assistant, Anne, will call you the day after your surgery to make sure you are doing O.K., to make sure your prescriptions are appropriate and to schedule a follow-up appointment in 7 - 10 days.
3. Keep the shoulder dry. On the 3rd day, remove the bandages but leave the "steri-strips" in place. On the 3rd day it is OK to get the shoulder wet in the shower but do not soak it in the bath tub. If you wish to take a bath prior to the 3rd day, keep the shoulder out of the water.
4. It is good to use the arm and shoulder and try to get back to normal but in a slow and gradual fashion. If all we had to do is relieve impingement, I expect you to be functioning without the sling within a few days to a week at the most, to have overcome pain within the first few weeks following surgery and to be "recovered" within six to 10 weeks. If there is rotator cuff involvement, the recovery will take even longer

1. It is my routine to visit briefly with you and/or your family following your surgery before you go home. I explain what I found and what I did. You will probably not remember any of this but hopefully your family will remind you of what I said.
2. Either I or my P.A. (Doug) will see you in the office about a week following your surgery. We will check your shoulder, review your surgery including providing you with copies of photos taken of the inside of your shoulder. I am not the greatest photographer but I try to at least obtain photos that demonstrate what was wrong and what I did (before and after) photos. I will also describe appropriate activities, exercises and rehabilitation efforts that should be performed.

1. Most but not all shoulder impingement surgeries require formal physical therapy during the recovery phase. Physical therapy modalities such as heat, ultrasound, and massage may offer a temporary "feel good" reaction but usually have no significant impact on your overall recovery. Exercise however is very important. By the time you decide to do surgery for shoulder impingement, chances are you have been hurting for quite some time and as such, you muscles are weak and need specific work to regain strength. Physical therapists may teach you what to do but you must do the exercises. Doug, my PA is also a certified Athletic Trainer and educated in teaching you what you can do to facilitate your own recovery. In many cases, instruction in a self-directed home exercise program may be all you need. In others, a course of formal physical therapy my be what you need to maximize your recovery. Do not hesitate to ask for any additional help you may need.