Overview

This is the most common cause of pain in the 30 - 50 year old age group, but can occur outside this range. Yes, something can be done to help relieve the pain and to slow down or minimize the progression to further damage of the cuff.

Impingement occurs when the ball of the head of humerus pinches or wears the soft tissue between it and the arch above. This may occur because

1. the head has ridden up due to loss of muscle tone/strength holding it down (dynamic impingement)
2. the soft tissue between is larger than the space. e.g.

	the bursa is swollen with fluid or walls are thickened. (inflammation)
	the rotator cuff muscle is swollen or torn with a flap which folds on itself
	there is a lump of hard calcium in the tendon

3. the arch has thickened narrowing the space beneath

	a spur has grown under the acromion
	spurs have grown around an arthritic A/C joint (between collar bone and shoulder blade)
	the ligament is thickened and rigid as it attaches under the bone. (occurs with age)

Conservative Treatment

Most patients may have tried one or more of the treatment modalities below but the rational is to combine them to get the best result.

• exercises to balance and strengthen the rotator cuff muscles about the shoulder. This holds the ball down against the center of the cup keeping it away from the bone above (acromion) opening the (subacromial) space and minimizing pinching of the bursa and wearing of the cuff. Often a physiotherapist may supervise these exercises.
• anti-inflammatory tablets if they can be tolerated. This reduces the swelling of the bursa and reduces pain so that the exercises above can be done. Pain inhibits muscles!
• injection of cortisone (steroids). This has the above effect but is more local and lasts for up to 6 weeks. The day of injection is quite good because local analgesia is injected at the same time but some patients may notice the next day some ache which is eased by 2 paracetamol tablets with each meal. They should then improve over the next 3 - 4 days

Arthroscopic Laser Subacromial Decompression

Surgically removing the thickened bursal tissue, coracoacromial ligament and bone spurs can be accomplished by 2 methods, through the arthroscope or by open cut surgery.

1. Open cut surgery was the standard method before 1986 before the arthroscopic method became possible and subsequently more popular. An incision is made over the point of the shoulder, the deltoid muscle is split or detached and the front edge and under surface of the acromion resected. The shoulder is usually rested in a sling till healing occurs, before full movement can be regained, rehabilitation is usually much slower.
2. The conventional arthroscopic method is to use mechanical debriders and burrs in conjunction with high pressure fluid distention to compress the vessels and electro diathermy to seal the larger bleeding blood vessels. Unfortunately this often causes marked distention of all the tissues about the shoulder which causes pain after the surgery.
3. The arthroscopic Laser can cut and sculpture the tissues while sealing the vessels at the same time, and with minimal bleeding into the space, good visualisation is easily maintained. The need to keep changing instruments and distend the tissues with high volumes of fluid are therefore avoided and this may be the reason that pain experienced by patients treated with the Laser is reportedly less.

After Arthroscopic Laser Surgery

Since no major structures are damaged during this procedure immediate movement and rehabilitation is encouraged.

• Hourly range of movement is begun in the recovery room and aided throughout the first 24 hours. Since there are no drainage tubes necessary and minimal swelling this does not cause a lot of pain and minimises adhesion formation.
• Ice is applied each hour after the exercises.
• As pain is less when performed with the LASER, some patients may do this at home with the help of their partner, most elect to stay overnight in hospital and are helped by the nurses. No sling is required.
• Normal daily activities such as feeding, toileting, dressing and maintaining independence are not difficult.
• Sleeping may be uncomfortable for some time and most find the more upright they are the better i.e. sleeping in a reclining chair or with a "U" pillow and multiple other pillows to prevent rolling onto the operated shoulder.
• Most patients are able to return to light duties by 3 weeks, some after a few days depending on what is available. Driving is quite comfortable by 3 weeks.
• No heavy lifting or overhead work until 3 months after the operation.
• Most sports can be resumed at 3 months.

Complications

Complications such as anaesthetic, medical and surgical can occur after any surgery but fortunately are uncommon. The anaesthetist will discuss risks of anaesthetic with you prior to the operation and advise on the safest form (you may contact him/her before the day of surgery if you wish or your doctor is concerned).

Possible complications with shoulder surgery include:

• infection, we take all steps to minimise this, including covering the operation with an antibiotic
• bleeding, swelling, stiffness and possible nerve injury
• frozen shoulder and/or adhesions often self limiting, more common in Diabetics and minimised by starting movement early. Muscle tension and spasm tend to make patients more prone to this so must be controlled.
• scar formation is usually minimal because of the arthroscopic technique

Study by Andreas Imhoff - comparing Laser treated patients to conventional surgery

Arthroscopy, Vol. 11, No 5 (October), 1995: pg. 549-556

"Because of the low level of postoperative pain, the absence of adhesions and the almost complete lack of swelling, the patients in group L (laser), were able to regain full range of shoulder motion sooner than those in group S (without laser)"

"the postoperative Constant score for group L was significantly better." (54.7-79.8 vs. 50.3 - 68.7)

"The greatest improvement in the laser group was seen in the area of pain with activity, pain at night, activity and movement at 1 week and at 6 weeks"

Study in Adelaide 1997

Thirty four patients were followed throughout there hospitalisation and for the following 6 weeks to assess the pain levels they experienced during their episode of treatment . Visual analog scales (VAS) were recorded at 1,2,3,6,12,18 hours after surgery and again 3 & 6 weeks after discharge and the pain scores compared for those who had the advantage of the LASER and those who didn't. The following graph represents the results demonstrating that with the use of the LASER pain was reduced by 50% while in hospital and by in 66% in the early rehabilitating period allowing earlier return of function (i.e.. return to work).

We believe that the reduction in pain experienced with the LASER decompressions may be explained by the fact that there is much less bleeding therefore there is no need to distend all the tissues with pressurised fluid to stop blood from clouding vision in the operating field. Swelling of the shoulder is markedly less after surgery and therefore nerve endings less irritated.

In addition no drainage tubes are necessary (as there is no bleeding) and so immediate movement of the joint in hospital is much less painful - allowing for physiotherapy to start in the recovery room after surgery, full movement being easier to achieve before discharge.

Because the anaesthetic is shorter (reduced operating time) and less pain relief (narcotics) are needed the patients in general do not feel so unwell and have more pleasant memories of the episode of treatment, many coming back early for treatment of their other shoulder.