This leaflet aims to help you understand the problem you have with your shoulder. To make things clearer the phrase shoulder impingement syndrome will be used to describe the above problems. It is one of the most common causes of shoulder pain (20% of people will have symptoms at some point in their lives).
It happens most often in middle age, around 45-65. Shoulder impingement syndrome can be split into three main problems.

1. rotator cuff tendonitis
2. rotator cuff impingement syndrome
3. rotator cuff tear

Most people with shoulder impingement syndrome find that the problem improves with a mix of:
rest painkillers physiotherapy exercises, and occasionally steroid injections

The picture on page below shows the bones and muscles of the shoulder joint. The shoulder is a ball and socket joint and there are three main bones in the shoulder region.

1. the clavicle or collarbone
2. the humerus or upper arm bone
3. the scapula or shoulder blade

Your shoulder blade has two areas of importance.

1. the acromion (forming and arch above the upper arm bone) and,
2. the genoid

The sub-acromial space is the area between the shoulder joint and the arch/acromion. Your Rotator cuff muscles can also be seen in the picture. They control the position of your upper arm in the socket. The supraspinatus tendon actually sits in the subacromial space. A small fluid filled lining or bursa helps cushion the tendon from the roof of the arch. If the tendon becomes inflamed it will fill more of the space, which can result in impingement.

Some people are more susceptible to wear and tear in the tendon. It can often start to fray and split.
Mechanical triggers and change in activity or posture can cause the tendon to stress and you may feel an
increase in pain.

Symptoms

The main complaint is pain usually felt on the outside of your upper arm. It can also be painful when you lift your arm out to the side or if you try to twist the arm to put on your coat. Some people have pain at night or at rest.

It is important to report any pins and needles or numbness in your arm to your doctor. This can be a sign of problems at the neck or with the nerves in your arm.

Most people find their symptoms settle without the need for an operation.

Non-surgical treatments (conservative care)

Injections

These are given into the sub-acromial space. They are usually a mix of steroid and local anaesthetic. Increased pain is sometimes felt for the first 24hours, but usually settles and improves symptoms.

Physiotherapy

If you are referred to physiotherapy the physiotherapist will:

assess your shoulder, and give you advice and an exercise programme to work on. These tend to include:
strengthening exercises for the muscles around the shoulder blade and rotator cuff, and postural exercises
You may find these exercises are hard work and you may feel the shoulder stretch but they should not be painful.

'self-help' ideas:

This is about changing your activities. The aims are:

1. To reduce the stress on the tendon(s) so that your body can try and heal
2. Break the pain cycle

1. To reduce the stress on the tendon

Try to stop the activity that causes pain or try to find a different way of doing it. For example you may find it very difficult to raise your arm up to put something in the cupboard. To avoid this you could try using steps to raise yourself up or keep your elbow in and raise your arm and palms upwards. This may feel awkward at first but if it reduces the pain it might be worth practicing.

Working on your posture is very important to your shoulder blade, which makes up half of your shoulder joint. Try to look at your shoulder blade position in the mirror. If it is different on the affected side then try some of the exercises in the leaflet to improve its position.

If you are involved in a sport or profession where repetitive movements are constant then seek advice on
technique or posture. Again, the exercises will help you stretch out and strengthen some of the important areas in your shoulder.

2. Breaking the pain cycle

Some of the ideas in section 1 should help reduce the pain but using the following may help.

• pain medication - it is important to discuss this with your pharmacist or doctor. They can be effective at controlling bouts of pain. They can also stop the pain getting so bad that you are not able to do everyday tasks
• using anti-inflammatory cream or gel over the area. Again, it is important to check with your pharmacist or doctor to see if you are able to use these. These can be effective as they target the area where the pain is.
• using a wet ice-cube and massaging over the tender area. Try for 10 minutes watching that the ice-cube stays wet and you avoid an ice burn. Always allow the skin to return to normal temperature before putting the ice on again.

If you have not already tried some of these ideas it is worth doing so now. Use the ones that suit you. This could make a big difference to your everyday life.

Trying the exercises below is also useful - follow the advice and monitor your symptoms.

These exercises may help with your shoulder problem. They may feel hard work and a little achy but they should not be painful. They focus on improving your posture and shoulder movement.

1. Lie on tummy with arms resting at sides
2. Pinch shoulder blades together
3. Now, raise arms off floor as shown
4. Hold 5-15 seconds and slowly lower
5. Repeat 3-5 times, 2-3 times a day

1. Stand with arms at sides
2. Pinch shoulder blades together as shown
3. Hold 10-20 seconds
4. Repeat 5-10 times, 2-3 times a day

Stand or sit...

Stretch one arm over to the opposite shoulder by pushing it at the elbow with your other arm. Hold the stretching for about 20 seconds and relax. Repeat 3-5 times.

Lying on your back with elbows straight. Use one arm to lift the other arm up keeping it as close to the ear as possible. Repeat ___ times.

Stand tall with good posture. Become aware of the position of the shoulder and bring the shoulder up and back. Gradually bring your arm out to the side as shown in the picture -only go as far as you can while still keeping control of your shoulder blade position. If it starts to move then lower your arm. Hold this position for a couple of seconds repeat 10 times, 2-3 times a day.

Stand tall thinking about keeping your shoulder blade back and down. The aim of this exercise is to help you control the shoulder blade while moving the arm up in front of you.

Keeping your shoulder blade back and down, gently lift your arm up to about shoulder level. Don't allow your shoulder blade to move. If it does lower the arm to a position where you can still control this and work in this range. When you are able to get your arm up to shoulder height without moving your shoulder blade then you can move onto the second exercise.

Still keeping a good starting posture raise your arm up as far as you are able. When the arm gets to shoulder height you will feel the shoulder blade start to move. This is fine - try to keep control of this so it does not raise up too much and you don't use it to gain more movement. Sometimes it is useful to stand against a wall so you can feel what is happening at your shoulder blade. Repeat 5 times, 2-3 times a day