What is shoulder impingement?
Shoulder impingement is the feeling of pain in the shoulder with certain movements of the arm, especially overhead movements. Symptoms can range from chronic discomfort to very acute episodes of sharp pain, weakness and loss of movement in the shoulder.
The pain or discomfort is a sign of soft tissue inflammation in the subacromial space – a passage between the top of the upper arm (humeral head) and the acromion. The acromion is a bone that stands out to the front from the shoulder blade and connects to the collarbone (clavicle). The supraspinatus tendon and the subacromial bursa are the two structures primarily affected by subacromial impingement. The supraspinatus muscle is one of the four rotator cuff muscles that surround the humeral head and insert beneath it, while the supraspinatus tendon passes directly under the acromion. The subacromial bursa is a big, sack-like cavity filled with fluid. Bursas are usually found in areas subject to friction, for instance where a tendon passes over a bone or a bone glides under the skin. They help tendons glide smoothly and act as pressure absorbers.
How can it occur?
Shoulder impingent may have different causes. When the arm is raised, the subacromial space will naturally narrow. Anything that causes further narrowing may lead to an impingement of the soft tissue structures passing through it and cause inflammation.
Alterations in the positioning and the movement of the shoulder blade (scapula) are the most common cause of subacromial impingement in dancers. This condition is also known as scapula dyskinesia. The socket of the shoulder joint (glenoid) is a part of the scapula that serves as its mobile platform. Embedded in major muscle groups, the scapula moves on the thorax in 3 different planes positioning the glenoid in a wide range of locations. Full range of motion of the arm is only achieved if the movement of the scapula and the arm are perfectly coordinated. This coordination may be affected for several reasons. Most often, an involuntary reaction to pain or muscle fatigue stands at the beginning of scapula dyskinesia. If the scapula fails to return to normal function, false movement patterns can lead to muscle dysfunction of all muscle groups that have to compensate for it. Muscle dysfunction will not only raise pressure in the subacromial space but can extend down to the forearm and cause further symptoms such as “tennis arm” or wrist pain.
The shoulder is a joint that highly depends on perfectly balanced muscle function and the importance of muscle dysfunction to all kinds of shoulder problems is often underestimated.
What are the typical symptoms of shoulder impingement?
The most common symptoms are pain, weakness and restricted range of motion at the affected shoulder. Pain is often worsened by overhead arm movement and may occur at night – especially when sleeping on the affected shoulder. Other symptoms can include a grinding or popping sensation while moving the shoulder.
How can shoulder impingement be diagnosed?
Your doctor will examine your shoulder and review your symptoms as well as your current training activities. Correct diagnosis of this issue demands a thorough functional clinical examination of the shoulder girdle including specific tests to identify joint and muscle dysfunction. These tests may be provoking a sharp pain inside the shoulder, especially if there is an acute inflammation. However, it is important to relax your arm and shoulder and focus on the location of the pain during examination.
X-rays are sometimes made to find out if any bony spurs, calcifications or anatomical abnormalities are causing the problem. Your doctor may also suggest to have an ultrasound or MRI scan of the shoulder to detect inflammation of the bursa or ruptures of the supraspinatus tendon passing through the subacromial space.
This MRI scan of the shoulder shows some findings typical for a shoulder impingement syndrome. You can see a fine white line above the supraspinatus tendon. It indicates an inflammation of the subacromial and subdeltoideal bursa. The ac-joint shows degenerative changes and is inflamed as well.
What are the treatment options?
If you have severe or constant shoulder pain, you should take a break from your ballet training. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries. Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers.
In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process.
Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. Shoulder impingement syndrome demands intense rehabilitation including corrective exercises that address present muscle dysfunction and scapular dyskinesia. Working on false movement patterns of the scapula is often challenging and requires very specific exercises to be performed on a regular basis.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine. Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run. If pain is a limiting factor to an active rehabilitation approach, the use of a pain killer or a steroid injections to the shoulder may be recommended. Also, aquatic training can be a good way to start training the shoulder in these situations. Surgery is an option only for very chronic conditions. Shoulder impingement syndrome in dancers is usually a functional problem that demands an active rehabilitation approach.
Do you have shoulder pain and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Strength training: Core training – resistance band workout
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.