Shoulder Impingement Specialist Singapore

Your doctor will chat with you and ask you more about the. A careful examination of the shoulder is then carried out. He (I will use “he” to refer to the doctor to simplify the discussion although clearly, there are many female doctors out there!) will need to visually inspect your shoulders, looking out for any asymmetry or wasting of the muscles.

He then feels around the shoulder looking for any tender spots which may give a clue as to the source of the problem. This may be particularly hard in large or muscular patients.

He then tests your shoulder movements. Typically, in RC tendinosis or impingement, shoulder range of movement is not significantly affected. Patients may encounter pain raising their arms but if they are able to put up with the discomfort, they usually are able to fully raise their arms.

Your doctor will then test the strength in each of the RC muscles. The most commonly affected tendon is the supraspinatus tendon and many patients with RC tendinosis will have decreased power in the supraspinatus due to pain.

Finally, he will usually carry out a couple of clinical tests designed to elicit discomfort, in an effort to clinch the diagnosis.

The 3 most common tests are:

1. Impingement sign: The arm is internally rotated while at the side of the body. The arm is then raised from the front, while keeping the arm fully internally rotated. Pain is elicited at the top of the movement.

2. Hawkins Test: The shoulder is held at the front of the body with the elbow flexed at 90°. The arm is then internally rotated. Pain is elicited if rotator cuff tendinosis is present

3. Jobes Test: The arms are held straight, raised 30° to the side of the body and brought forwards 30°, while fully internally rotated. Downward pressure is then applied to the arms while the patient actively resists the downward pressure. This causes either pain or weakness is detected by the doctor.

Your doctor should have a couple of suspicions as to what is ailing your shoulders at this point in time. He will often need to carry out some investigations to confirm his suspicions.

Tendinosis of the rotator cuff means “wear and tear’ of the rotator cuff tendon. The most commonly affected tendon (out of the 4 rotator cuff tendons) is the one that sits on top of the humeral head called the supraspinatus tendon.

Many patients are taken aback when I say “wear and tear” because they associate it with aging. But I often see tendinosis in patients in their early twenties! It is arguably the most common disorder I see in patients with “impingement syndrome”.

No, they are different. Let us look at the structure of a tendon in greater detail. A tendon is composed of an outer sheath which houses longitudinally arranged strands of collagen.

The collagen strands are then packed in increasingly larger bundles, bound together by protein and eventually form the final tendon.

Tendon cells (called tenocytes) are found distributed within the structure of the tendon. Their function is to produce more collagen and protein required for repairing the tiny damage that occurs in daily life.

Blood vessels travel between the bundles, bringing blood and nutrients to supply the tenocytes.

Many tendon disorders were previously thought to be secondary to inflammation. When a tendon is injured, the body launches an inflammatory response. Cells at the site of injury secrete chemical substances that result in proliferation and dilation of blood vessels.

In addition, these blood vessels also become more “leaky”, allowing proteins and fluid within the blood stream to leak out into the surrounding tissues. This results in swelling, redness, increased warmth and pain.

However, many researchers have found that typical inflammatory microscopic findings in patients with rotator cuff issues are puzzlingly absent. Instead, what they found was that the neat structure of a healthy tendon was lost and replaced by a disorganized tenocytes and collagen, with interspersed holes filled with mucoid substances, distorted and dead tenocytes, inappropriate deposition of calcium and microtears of the tendon structure.

As such, the term tendinosis is now being used to more accurately describe this disorder. Certainly, inflammation still occurs, but is usually seen in acute injuries in previously healthy tendons. In those cases, it would be accurate to describe the condition as tendinitis.

The bursa is usually a very thin membraneous sac that sits between the overlying acromion and the underlying rotator cuff tendon. As we raise our arms, the area where the rotator cuff attaches rolls under the acromion.

The bursa helps to reduce the amount of rubbing that occurs between rotator cuff and the acromion. If there is excessive chafing, the bursa starts to become injured and irritated. Inflammation follows, resulting in swelling of the bursa and eventually, thickening of the walls of the bursa.

This in turn causes pain with arm movements at the shoulder, particularly with overhead movements.

It is actually extremely common to see all these problems in a patient with shoulder pain. The bone spur refers to a sharp spike that is seen on the undersurface of some acromions. You may even hear doctors talking about whether you have a curved or a hooked acromion.

Most shoulder surgeons these days do not attach much importance on these terms anymore. The simplistic understanding previously was that the presence of a sharp bone spur physically grinds on the underlying rotator cuff and eventually tears the latter.

This theory has largely been debunked. The bone spur is often hidden within a ligament that sits in front of the acromion and does not physically contact the rotator cuff in most cases.

Having said that, on occasion, I do see bone spurs that arise from the acromion where it joins the clavicle (the acromioclavicular joint) and sometimes, these bone spurs do indeed appear to be indenting the underlying rotator cuff.

So while a bone spur abrading the rotator cuff is not as common as often described, it is not impossible or “fake news” and may occur in some patients!

‍In almost all cases of impingement syndrome, I generally start patients off with non-invasive treatment modalities first. If non-invasive options prove to be ineffective, I then move on to more invasive options.

The first thing to do is to modify one’s activities. The patient should avoid any activities that aggravate the pain. This may include taking a break from his/ her sport, avoiding carrying heavy loads, avoiding overhead lifting etc.

Due to the slow rate of repair of tendons, a period of rest of at least two to three weeks may be required.

Prolonged, complete rest, however may be counter-productive. Mechanical loading of the tendon has been shown to increase metabolism of tenocytes, hence this may stimulate the tendon to heal faster. As such, some judicious loading of the tendon, after a short period of rest, is prudent. This is where physiotherapy comes in.

Physiotherapy:
Physiotherapy is a common modality of treatment for the various conditions included under the umbrella of impingement syndrome. It can, however a somewhat “soft science”. Many physiotherapists have different philosophies and approaches.

Eccentric loading of the injured tendon has been found to be effective in treatment of tendon disorders. Many physiotherapists will incorporate various treatment modalities into their treatment, including ultrasound, radiofrequency, shockwave, deep tissue massages, various stretching and strengthening exercises etc.

Medications:
Medications are used mainly for alleviating pain. The two groups of medications used are painkillers (eg paracetamol, codeine, opiates etc) and anti-inflammatory medications (aspirin group of drugs).

Medications are generally not used as a “cure” for the condition, but rather to make the condition more bearable for the patient.

If a reasonable period of time has elapsed and the patient’s condition has not improved with non-invasive treatment options, invasive treatment options will have to be considered.

Invasive options comprise injections and surgery.

Injections:
Cortisone (steroid) injections are commonly given especially in cases where no rotator cuff tear has been identified on scans. Steroids suppress inflammation and are used in inflammatory conditions such as tendinitis and bursitis.

Steroids should not be injected directly into the rotator cuff tendon tissue, as this causes cell death and tendon atrophy, but they are often injected into the bursa that overlies the tendon. As steroids are anti-inflammatory, they result in reduced inflammation, hence reducing pain.

In recent years, however, the role of steroid injections has been increasingly controversial.

Since tendinosis has been shown to be a non-inflammatory process, the rationale for using steroids has been called into question. Worse, steroids have been shown to inhibit collagen synthesis so it might result in hindering tendon healing.

I generally avoid the use of steroids in patients with proven rotator cuff tears, and only use them in patients whose scans show inflammatory changes in the bursa. Anecdotally in carefully selected patients, steroid injections have been rather effective in bringing about pain relief.

It is my practice, also, to limit steroid injections to just a single injection. Should the pain recur, I would not administer another steroid injection.

Plate rich plasma (PRP) injections have also been used in impingement syndrome. The theory behind PRP is simple. Your blood contains many chemicals that your body produces to bring about healing. A small amount of blood is taken from you and spun down in a centrifuge. The blood separates into a lower intense red layer and clear top layer.

The clear layer is collected and injected into the area where healing is desired. Because this layer is rich in chemicals required for healing, theoretically, healing should occur more readily wherever it is injected.

As always, clinical practice is not as straightforward. Clinical studies have not convincingly shown that PRP injections work. So although PRP’s efficacy is questionable, it is at least a rather safe treatment modality with few minute risks.

As such, while I do not routinely prescribe PRP in the treatment of impingement syndrome, if the patient requests for it and is very keen on giving it a go, I would still accede to their requests.  
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Surgery:
Surgery is another somewhat controversial topic in impingement syndrome. In the past, it routinely involved removing the bursa and shaving off the bone spur.

This was based on the theory that the bone spur physically abrades the rotator cuff tissue resulting in inflammation and eventually, tears of the rotator cuff. As this theory has been conclusively debunked, the rationale of shaving off the bone spur has also been questioned. Many recent studies have not shown any benefit of shaving off the bone spur.

As such, this is not a surgery I routinely do for impingement syndrome, unless the patient’s scans convincingly show indentation of the rotator cuff by an unusually large bone spur.

All of the surgeries I perform for impingement syndrome are via minimally invasive techniques (keyhole surgery). I have found that in some patients with persistent pain from impingement syndrome and bursitis, surgical removal of the inflamed bursa does result in effective long-term pain relief.

Some surgeons add on procedures aimed at stimulating tendon healing. These may include making shallow cuts on the surface of the rotator cuff, or making small holes in the rotator cuff using a radiofrequency probe.

None of these procedures have been proven to be of any benefit, hence I do not perform any of them. For a more detailed description of shoulder surgery, please refer to the page on Keyhole Surgery.

For patients in whom a tear of the rotator cuff has been identified on scans, the decision-making process is a lot easier. As rotator cuff tears are a huge topic on their own, they will be discussed separately (please refer to the page on Rotator Cuff Tears).