Impingement syndrome

Impingement syndrome: description

The Impingement Syndrome (bottleneck syndrome) describes a painful entrapment of tendons or Gelenkkapselanteilen (soft tissues) within the joint space. As a result, the tendons can no longer glide unrestrictedly in the joint space. In most cases, this leads to degenerative changes, which are associated with limited mobility of the joint.

The impingement syndrome usually manifests on the shoulder joint. About ten percent of the German population (about the same age as men and women around the age of 50) are affected by this. Often, the impingement syndrome also occurs at the hip joint. Rarely do patients suffer from an ankle impingement syndrome.

Two forms of impingement syndrome

The impingement syndrome can be divided into two forms, depending on which structures are compressed:

The primary Outlet Impingement Syndrome is due to a change in the bony structures, such as a bone spur or an excessively inclined bone roof.

The secondary Non-outlet impingement syndrome is the result of another illness or injury that reduces the joint space. These include, for example, inflammation of the bursa (bursitis) as well as damage to tendons or muscles.

Impingement syndrome on the shoulder

Everything important about the congestion syndrome in the shoulder area read in the article Impingement – shoulder.

Impingement syndrome at the hip

Everything important about the bottleneck syndrome in the hip area read in the post
Impingement – hip.

Impingement Syndrome: Symptoms

The impingement syndrome causes different symptoms depending on the affected joint. In general, the patients suffer from pain that usually increases under stress and lead to a restraint.

Symptoms – shoulder joint

When the impingement syndrome occurs at the shoulder joint, early stage patients report acute onset of pain, which occurs discretely at rest and increases under exercise (especially over-the-head activities). Patients can often indicate a triggering situation (stress, cold influence, injury). The pain is described as lying deeply in the joint and often increases at night, so that lying on the affected side is hardly possible anymore. Raising the arm more than 60 degrees from the starting position (arm hangs loose) is no longer possible for most patients. In the further course, adhesions and adhesions of the bursa in the shoulder joint area (Bursa subacromialis) can occur, which aggravates the painful restriction of movement. Due to the pain-related reduction of muscle activity, the muscles disappear very easily, and the joint loses stability.

Symptoms – hip joint

The impingement syndrome often shows a very creeping onset of the hip at the hip joint. In the beginning, pain of the hip joint occurs only sporadically and is often described by the patient as groin pain. The pain, however, increases with physical activity and then emanate often in the thigh. In most cases, they are strengthened when the leg, which is bent at 90 degrees, is turned inwards (internal rotation with 90 degrees flexion).

Impingement Syndrome: Causes and Risk Factors

The impingement syndrome can have various causes. These are divided into bony structural changes and damage to the soft tissues (muscles, tendons, bursae). The risk of impingement syndrome increases with age, with hip-joint impingement syndrome also occurring in young athletes due to increased stress on the mobile joints. The joints are then less stable, and the heavy strain can swell the tendon – an impingement syndrome is the possible consequence.

Impingement syndrome at the shoulder: causes

The shoulder joint is the most flexible joint of the body. It is formed by the head of the upper arm (Caput humeri) and the articular surface of the scapula. The scapula has a bony prominence, the acromion, which is the highest point of the shoulder joint. Compared to the hip joint, the shoulder joint is much less protected by bony structures. It is surrounded by four cuffed muscles (rotator cuff). The tendons of the rotator cuff run beneath the acromion through the so-called subacromial space and contribute much more to the stability of the shoulder joint than the surrounding ligaments.

In the impingement syndrome of the shoulder, the constriction of the joint space may arise due to bony changes in the acromion or damage to the surrounding soft tissues.

In the outlet-impingement syndrome, the subacromial space is constricted by the surrounding bony structures. Reasons for this are usually growths of the bone (osteophytes in osteoarthritis, bone spurs or form variants of the acromion).

The non-outlet impingement syndrome, however, is caused by damage to the surrounding soft tissues. An inflammation of the bursa (Bursitits subacromialis) often causes a swelling and thus narrows the joint space. A lesion of the rotator cuff as part of a tendinitis (tendinitis) can also lead to painful movement restrictions within the joint space. In most cases, the tendon of the supraspinatus muscle is affected. When there is a complete tendon rupture of a rotator cuff muscle, the head of the upper arm (humeral head) is no longer properly stabilized and is called an “instability impingement syndrome”.

Impingement syndrome at the hip: causes

In most cases, an impingement syndrome of the hip is caused by a deformation of the hip socket (acetabulum). The acetabular cup belongs to the pelvic bone and presents itself as a cup-shaped socket, which together with the femoral head forms the hip joint. If bone spurs form on the edge of the acetabulum or the femoral head (pincer deformity), a painful restriction of movement may occur, especially when turning inwards (internal rotation) and bending (flexing) of the hip joint. The bony changes often occur as a result of increased physical stress, which is why young athletes often suffer from a hip joint impingement syndrome.

Impingement syndrome: examinations and diagnosis

The right contact for suspected impingement syndrome is a specialist in orthopedics and trauma surgery. The detailed description of your symptoms will provide the doctor with valuable information about your current state of health. For example, the doctor may ask you the following questions:

• Do you remember a heavy strain or injury at the time of onset of pain?
• Is the pain dull and radiating from the joint?
• Does the pain increase at night or if you lie on the affected side?
• Do you have movement restrictions in the affected joint?

Following this medical history (medical history), the doctor will examine you physically. He will test the flexibility of the joint by asking you to move your arm or leg to different positions. With the “painful arc”, an active lifting of the arm between 60 and 120 degrees (level above the shoulder plane) is not possible. In addition, the doctor will want to measure the strength of the affected side of the body and ask you to move against resistance arms and legs.

An X-ray of the affected joint, an ultrasound examination (sonography) and magnetic resonance imaging (MRI) support a reliable diagnosis.

Impingement syndrome: X-ray examination

The X-ray examination is the diagnostic tool of choice in impingement syndrome. It is a cost-effective method for displaying a joint overview. If your treating orthopedist does not have an X-ray machine himself, he or she will probably refer you to a radiology practice and then discuss the findings with you. The radiograph shows typical bony structural changes.

Impingement Syndrome: Sonography

With the help of an ultrasound examination (ultrasound), any fluid accumulation within the bursa can be detected. In addition, sonography helps to detect muscular thinning. However, bony structures can not be adequately visualized by ultrasound. Ultrasonography is a cost-effective and easy-to-carry examination method, which, however, is usually performed only in addition to X-ray diagnostics due to the mentioned restriction.

Impingement Syndrome: Magnetic Resonance Imaging

Magnetic Resonance Imaging is far superior to ultrasound because it allows much more accurate imaging of the soft tissues (muscles, tendons, bursae). Cartilage and bone bulges are also shown very accurately. Before any planned joint reconstruction surgery, a magnetic resonance imaging should always be taken in order to make a reliable diagnosis. In addition, the good visual overview of the soft tissues allows a more accurate planning of the surgical procedure.

Impingement syndrome: treatment

Impingement Syndrome Therapy involves several options. The conservative therapy with protection, analgesics and physiotherapy should initially be in the foreground. To achieve a permanent cure, the cause of the impingement syndrome must be surgically repaired (causal therapy).

Conservative therapy

In the early stages, the so-called conservative therapy is in the foreground. The affected joint should be spared, and pain-enhancing stress factors (exercise, strenuous work) should be avoided. Anti-inflammatory analgesics (ibuprofen or acetylsalicylic acid) can relieve the pain but do not affect the causative agent. Physiotherapeutic measures usually also help well to reduce the pain.

Causal therapy

Causal therapy is a medical treatment that seeks to treat and remove the causes of a disease, in this case the impingement syndrome. An operation can help to eliminate the structural changes and thus the mechanical tightness. The surgery is especially recommended for young people as it significantly reduces the risk of joint stiffness. The minimally invasive arthroscopic surgical procedure is now being used more and more frequently; it largely replaced the open operation.

Impingement Syndrome – Arthroscopy: Arthroscopy is a minimally invasive surgical technique that involves inserting a camera with an integrated light source and special surgical instruments into the joint over two to three small incisions. This method of surgery allows the doctor to examine the joint for damage and gain an overview of the entire joint.

Following this, an operative supply can be made directly. Any bony prominences that restrict the freedom of movement of the joint can be abraded. If cartilage damage already exists, these can also be removed. In an advanced impingement syndrome, tendons may already be torn: they can be sutured and reconstructed during arthroscopy. The skin incisions are then sewn with a few stitches and leave behind much more subtle scars than an open operation.

Impingement syndrome: exercises

Let a physiotherapist show you how to strengthen your muscles. The strengthening of those muscles, which is needed for joint rotation to the outside (external rotators), should definitely be trained specifically. The external rotators help to effectively enlarge the joint space. In addition, muscle-building exercises should be performed even after successful surgery to counteract muscle atrophy.

Impingement syndrome: disease course and prognosis

The impingement syndrome should be treated unconditionally to counteract serious consequences. The prognosis and course depend very much on the cause of the impingement syndrome. If a physiotherapeutic treatment takes place, it should be carried out continuously and over a longer period of time. It often takes weeks to months until symptoms improve.

The impingement syndrome can lead to inflammation and signs of wear in severe constriction. Furthermore, with prolonged compression of nerves and tendons increases the risk of cracks and tissue death (necrosis). Both too long immobilization and an operation involve the risk of joint stiffness. Even after a Impingement Syndrome After successful surgery, patients should subsequently perform physiotherapy exercises.