I still have pain after a rotator cuff repair - should I see my physiotherapist?

Q: I had a rotator cuff repair but I still have shoulder pain. It's right in the front of my arm and mostly hurts when I raise my arm up. Should I go back to the surgeon? See my physiotherapist? Give it some more time?  I can't quite figure out what to do.

A: Pain that lingers after a shoulder surgical procedure is not all that uncommon. But you are right to wonder what's causing it and what can be done about it. A follow-up visit to both your surgeon and your physiotherapist would be a good idea. They will each look for different potential causes of the problem. Together, you will be able to figure out what to do to resolve the issue.

From your description, it sounds like you could be experiencing a problem called coracoid impingement. Coracoid impingement refers to a pinching of the soft tissue structures by the coracoid process.

The coracoid process is a small hook-like structure at the top front part of the scapula (shoulder blade). The coracoid process works together with the acromion to stabilize the shoulder joint.

The patient's first inkling that something is wrong is a dull, aching pain along the front of the shoulder. As the arm moves forward and up, across the chest, or internally rotates, the coracoid pinches against the subscapularis tendon, subcoracoid bursa, and/or the biceps tendon.

Coracoid impingement is an uncommon problem and rarely occurs alone without some other change in the nearby anatomic structures contributing to the problem. For example, rotator cuff tears or degeneration or an unusual shape or length of the coracoid bone can lead to coracoid impingement. Calcium build up in the subscapularis bone or the formation of a ganglion cyst can also cause impingement in this area.

Coracoid impingement just doesn't occur by itself. There is usually another reason why this additional problem has developed. It should be considered as a possible cause of anterior (front) shoulder pain after shoulder surgery to repair a torn rotator cuff or relieve pressure under the subacromion.

The patient's history can offer helpful clues. There is often a previous history of fractures of the humerus, coracoid, or glenoid (shoulder socket). Prior shoulder surgery is another contributing factor.

The surgeon will search carefully for factors such as rotator cuff damage or degeneration, shoulder joint instability, or arthritis. A re-examination of the shoulder is next. The physician looks for tenderness over the coracoid process, pain when the arm is moved across the chest, and weakness of the subscapularis muscle.

Other signs and symptoms may include shoulder instability, pain on testing the biceps tendon, and generalized weakness of the rotator cuff. An arthroscopic examination (using a special scope to look inside the joint) is the best way to find out what's causing the problem. You may have had this done before (or as part of) the last surgery. It is a very helpful tool in diagnosing the cause of your pain.

The problem of coracoid impingement is rare and and occurs most often along with some other shoulder pathology. It may go unrecognized until the main problem is treated. It does require separate treatment before the painful symptoms resolve. Don't hesitate to make another appointment with your surgeon. Earlier follow-up is often better to avoid compensation patterns of movement and other problems developing.

Reference: Michael Q. Freehill, MD. Coracoid Impingement: Diagnosis and Treatment. In Journal of the American Academy of Orthopaedic Surgeons. April 2011. Vol. 19. No. 4. Pp. 191-197.