Subacromial impingement syndrome
First Person Account
I am writing this as a first-person account of dealing with this particular syndrome. I see a lot of information on the web from treating doctors but not much from a patient point of view. When I was dealing with atrial fibrillation, patient accounts were very helpful.
I have some technical knowledge as I have been in active chiropractic practice since the early 1980s but I can’t think of any specific cases like the one I experienced myself so hadn’t spent much time learning the particulars of the subacromial joint. I have been learning it now, however, as you might guess.
Left Shoulder Panic
First a little background. My left shoulder had been a problem for about 40 years but with regular exercise, I have been able to keep any symptoms at bay. By exercise, I mean mostly working posterior muscle groups by doing things like rows, pull-downs, upright and bent over flies with some biceps and chest work thrown in for balance.
We had one of the two garage door springs break so the automatic door opener would start the door opening process but would fail after raising it a foot or so. The answer was to have someone push the door opening button and then manually assist in the process with the handle at the bottom of the door. My pre-teen granddaughter was helping out and when I was ready to lift the door, she pushed the button and up the door went. When it got to the top, she mistakenly pushed the button again and so it started down. Instead of letting go, I tried to stop it from going down while yelling to push the button again which she did and the door went up again. At this point, garage door is open and all seemed OK.
Incredible Pain From Routine Walk
I used to run a lot but running doesn’t feel so good on this 71 year-old body anymore so my wife and I walk a few miles a day with our border collie. The next day on a routine walk, the first symptoms showed up and the pain in the shoulder quickly went from zero to 10 in a matter of 100 yards or so of the walk. Fortunately, I was close to home and just barely made it to the couch. I tried desperately to get into a comfortable position and proceeded to lie there in that pain, which I call exquisite, for a couple of hours. I have nice interferential electric stim unit at home and used that seemed to help.
At this point I am confused as to the source of this sudden pain. I couldn’t recall that type of pain before in spite of being involved in football, wrestling, track etc for about 6 years in junior high and high school.
Rule Out Fracture, Tumor, Nerve Impingement Etc
Did I have a fracture, a tumor, some nerve impingement or something else? The pain calmed down and seemed to disappear only to reappear if I tried to do anything at all. Just a walk up the stairs would be enough to leave my panting in pain for 20 minutes. Then as quickly as it came, it would disappear until I tried to do anything else.
I realized that doing nothing works fine for the very short run but over time, this was going to lead to other problems.
Pain Makes a Sudden Move From Shoulder to Forearm
The pain in the shoulder seemed to calm down after a few days so I wasn’t too worried at that point but then the pain reappeared in the elbow and forearm with the same type of pattern and same intensity. Since the pain was more persistent, I made a call to my local GP to see about getting some pain meds. She gave a muscle relaxer and tramadol. The muscle relaxer didn’t seem to help as much as I had hoped. I cut the tramadol in half and took as few as possible but definitely needed them to get through the next week or so along with Excedrin Migraine and ibuprogen.
One Sunday, about three weeks out, I woke up with terrible pain the elbow and forearm and decided a trip to the ER was in order. I was hoping for a CT scan at least to help rule out things like bone cancer like osteochondroma that could have a similar pattern, that is pain worse in the mornings and mornings for me were definitely worse.
They did a bunch of X-rays of the shoulder, elbow and forearm and all came back negative. I really thought something would show up. They said they don’t routinely recommend CT scans in the ER so that would have to wait for my appointment with an orthopedist to figure that out.
I had requested a referral to the orthopod with my GP, knowing that if the symptoms improved enough, I could always just cancel. Turned out that the symptom picture hadn’t really changed so I kept the appointment that fell at about 4 weeks from the injury date.
First Trip to Orthopedist
The orthopedist looked around a little, X-rayed the humerus as the ER didn’t get that bone to his satisfaction and then ordered the MRI. The MRI schedule most everywhere was backed up about 2-3 weeks. We found a place that could fit me in within a couple of days so went with that. They imaged the shoulder and humerus. This was my first time in an MRI. I know some people freak out in those so I took ½ a CBD gummy (I think it had a little THC too) and found the experience mostly relaxing even though it took an hour.
I was able to get a copy of the report due my health-care license status and all seemed to be negative except for inflammation in the subacromial joint.
I will pause here for a moment to say that throughout this entire ordeal, I would go from feeling like nothing at all was wrong as the left shoulder and arm would sometimes, at rest, feel totally great like nothing had ever happened. Then I would do something like pick up some leaves to put into a garbage bag and be confined to the couch for two hours as the pain had flared up.
I should also comment that these bouts of pain had a long-lasting effect and I would feel a sort of hungover for many hours afterword. If the pain rose to a 9 or 10, the rest of the day would be one of fatigue and brain fog.
Why Is Walking Such a Potent Trigger????
I wouldn’t have been quite so frustrated if I could have at least taken a walk. Most times, just walking across the street would be enough to set the pain off. As time went on the recovery time got shorter and shorter but pain still came on quickly and the brain fog would persist, non-the-less.
During this entire ordeal I took as few of the opiates as possible. The ER doc prescribed hydrocodone with codeine and some prescription strength ibuprofen and acetaminophen. I didn’t bother to pick up the last two as I figured I could manage dosing with OTC pain killers. I did get through about ½ of the hydrocodone. As time went on, I relied less and less on the Excedrin Migraine and Advil but still at 7 weeks out, I took 1 Aleve last night to help with pain while I sleep (I like to switch the OTC pain killers) and took 1 Excedrin Migraine and 1 Advil this morning early.
Decent Relief With Excedrin Migraine and Advil
I should emphasize that I got decent relief with Excedrin Migraine with Advil. Acetaminophen and ibuprofen do different things and we had recommended that combination many years ago when we had a spinal rehab clinic. Aleve seemed to do nothing for pain relief for me.
I always was conscious of need to achieve the ideal balance between keeping the inflammation at a low level, pain at a reasonable level and health of kidneys and liver. As part of my general health picture, I always try to keep my glutathione levels up as this is the primary detox agent of the body. To that end, I religiously take NAC (BetterGenix NAC 500mg), ALA (Protocol for Life Balance Alpha-Lipoic Acid 250 mg) and use some LifeWave Glutathione Patches.
I also used a type of CBD pain relief cream (the particular one isn’t available as far as I know) and a prescription form from a compounding pharmacy (5% ketoprofen, 2% amitriptyline and 2% carbamazepine). I think these helped some but they do take some time to do their magic.
As you can read from other sources, the subacromial space houses the tendons of the long head of the biceps and the suprascapularis and a bursa (a fluid filled sack). The error I see on many diagrams is labeling the suprascapularis as the rotator cuff. The rotator cuff consists of 4 muscles and the suprascapularis is just one of those.
This is significant because the pain in this case seems to be from irritation of the biceps tendon and not the suprascapularis. I had virtually no problem with the top of the scapula on that side. The pain in biceps, anterior shoulder and elbow and forearm are all consistent. The attachment of the biceps in on the upper forearm so that could explain the elbow and forearm pain. Of course, sometimes the pain was just in the biceps itself.
The fact that the pain was moving around was a good sign in my opinion. Pain in just one spot that doesn’t move is often worse. Pain from a tumor or a fracture doesn’t usually move around, in my practice experience anyway.
How I Manage Home Care
As I write this at about 7 weeks, the pain is the best it has been. I have been using the electric stim (not a tens) two times a day with cold laser at the subacromial joint. My impression is that that cold laser is speeding the healing nicely.
Cold lasers aren’t expensive anymore. I have a small, battery operated one that costs about $100 on Ebay many years ago.A good electric stim unit costs about $700.
When I got back to the orthopedist’s office, we talked about the MRI and it appeared that the most logical conclusion was a diagnosis of subacromial syndrome. I quickly gave my assent for an injection.
The next day was really bad after the injection, probably just from the insult of the needle. The day after was like magic and I thought that I had really turned a corner. The following day, not so much and it felt like I had gone back a few steps. I couldn’t walk anywhere again with having to stop every 50 yards or so and wait for the pain to calm down. I could live with a pain of 2-4/10 but a 7, 8 or 9 was something else and I would still get those moments.
This has been a rambling account and I want to be more clear about how to rehab this type of problem.
It is important to keep the joint moving without hurting it.
At first you should start with isometrics. This is a good way to get the brain body connection working without stressing the joint with weighted motion. Look for a good source of information about isometrics and rehab.
I have been working both arms as working the good arm speeds healing of the bad arm. It has to do with the way the brain maintains its side of the body. Just take my word for it at this point.
Once you are ready for a weight workout the following should be a general guide.
Keep weight lighter on the affected side.
Overhead press-don’t go all the way up with the affected arm to avoid pinching the subacromial space
Row-I use exercise tubing connected to a wall bracket and do one arm at a time with lower resistance on the bad side
Bent over rows-be careful about putting pressure on arm while exercising the good arm.
Standing flies-Do one at a time and don’t go up too high with bad side
Bent over flies-Keep weights down by waist at first
Biceps-seated curls-different weights for each side at first
Use the laser two times a day for 10 minutes
Use a good pain reliever cream if possible. Your prescribing doc might be willing to order the formula that I listed above.
2022 12 6
12/7/2022 (seven weeks)
Last couple of days has been up and down as far as pain goes. Pain cut my walk short this a.m. and I had to lie down for about 20 minutes to get it to calm down. I am still using electric stim and laser. Some days this seems to help right away and some days it seems to aggravate things. I will continue to use it anyway as the odds are high that it will be beneficial in the long run.
Yesterday a.m. saw pain rise to the 7-8 level with the brain fog that often comes with the pain.
I did my workout this a.m. with weights and tubing. It takes me longer to workout than it used to as I have to stop often to rest and have the building pain calm down.
Pain level for early morning short dog walk was about 2. Took 2 Excedrin Migraine and 2 Advil about 5:45 a.m. Pain subsided nicely. Was able to do a mile walk, got Christmas stuff down from storage (hanging racks in garage) and then was able to do complete neck and shoulders yoga session (Jessica Smith DVD). This is a very good day as none of these activities led to a pain level of a 7 or 8 or more. This is first time I have been able to do that neck and shoulders yoga since the injury in mid October.
I suppose I should mention that any sexual activity was mostly out of the question. Any position quickly led to serious pain (8-9/10) within about 40 seconds.
I now have real hope that this condition is capable of rehab to a normal state again.
Yesterday walked to the park and threw the ball for Piper the border collie. Forgot the fanny pack that I keep the leash, pickup bags, etc in so jumped on mountain bike and rode the 4 blocks round trip. Could barely make it the last two blocks for the intense pain even riding one handed. Ended up having pain most of the night. Had to sleep sitting up on the couch for a few hours and took ½ of the tramadol along with the Excedrin and Advil. Easy to set this progress back a few weeks with just one ill-conceived activity.
12/23/2022 (9 weeks)
Had laid off the workouts for a week or so due to the pain. Back at it again the last couple of days.
Doing pull downs, bent over rows, biceps curls, reverse flies, overhead press, bent over triceps along with sit-ups, bridges, side planks and regular planks. That last group is really important for the low back.
Still pain mostly in the mornings. I take the dog out for a short walk and can do that but sometimes when I get back up stairs to the bedroom, the pain begins. Could only do a ¾ mile walk or so this a.m. with about 5 or 6 stops to let the pain calm down.
12/28/2022 (10 weeks)
Able to do my basic yoga workouts without too much trouble. Mostly using Jessica Smith Gentle Yoga DVD and sessions Neck and Shoulders, Total Body, Energizing Flow and some Hips and Knees.
My cautious workout consists of:
Pull downs using rubber tubing with handles attached to a wall bracket as mentioned above
Overhead press with free weights.
Chest press with exercise tubing (one arm at a time)
Bent over rows with free weights
Reverse flies with free weights
Seated biceps curls
Bent over triceps extensions with free weights
Sit-ups using alternating arms and knees
I can do the above workout with little or no pain but then again I took 4 Excedrin Migraine and 4 Advil about 4 a.m. due to pain that woke me up.
I am able to walk around the local park that is probably about ¾ mile. I have to stop about 6 times for 20 seconds or so for the arm pain to quiet down. I tend to feel some pain on the entire walk but it builds sometimes to a 7 or so that motivates a pause.
I am using the cold laser (JSE 5 diode) twice a day for about 10 minutes. I stopped using the interferential a couple of weeks ago. Seemed like it would too often take me from asymptomatic to symptomatic too often. The laser doesn’t seem to have that effect. I know for 20+ years experience with the laser in my clinic that it should speed the healing.
I will add updates as they become relevant.