Shoulder Impingement Specialist Singapore

Dr. Bryan Tan

MBBS (SINGAPORE) MMED (ORTHO) FRCS ED (ORTH)

Many commonly used terms such as impingement syndrome, rotator cuff tendinosis, rotator cuff tendinitis, subacromial bursitis and bone spur can be broadly classified under the “umbrella term” of impingement syndrome. As such, these conditions will all be discussed in this article.

The term “impingement syndrome” was used because it was recognised that many problems with the rotator cuff could not be reliably differentiated on physical examination. In this article, I will not be discussing rotator cuff tears because that is a huge topic and will be discussed separately.

In order to understand this problem, some basic knowledge of the anatomy of the shoulder as well as the tendon structure of the is required.

What Is Impingement?

Shoulder pain is a common complaint that many patients present with and impingement syndrome accounts for between 40 – 60% of these patients. “Impingement syndrome” is a non-specific diagnosis which was coined to cover the range of rotator cuff disorders, back in the days when sophisticated and accurate investigations were not available.

Shoulder impingement occurs when your rotator cuff (a group of muscles and tendons surrounding the shoulder joint) rubs against the top of your shoulder blade (acromion), causing pain.

It is vital to understand your symptoms and seek medical treatment as soon as possible, as early diagnosis and management can reduce the complications of impingement.

What Causes Impingement?

  • Overuse of the shoulder
  • Injury
  • Wear and tear due to age
  • Bone spur

What symptoms might I experience?

The most common symptom that patients experience is pain. The pain is typically felt just beyond the shoulder, underneath the deltoid muscle. Any attempt to lift the arm to the sides of the body while keeping the elbow straight (a movement known as abduction) will cause a sharp pain.

This pain is sharp in nature and often occurs during a characteristic arc of movement between 60° and 120° (the painful arc).

Occasionally, patients may describe a sudden loss of power as a result of this sharp pain, which may result in them dropping loads while trying to hoist them overhead. I often hear patients mention that they are either unable to lift their luggage onto the overhead cabins of planes or have even dropped their luggage as a result, and further injured their shoulders!

The pain is often also aggravated by forced overhead movements. There is usually little to no pain at rest, but lying on the affected side often exacerbates the pain. This is especially bothersome to side sleepers.

Some patients may feel that their affected side is weaker than the unaffected side and this may be more noticeable if the affected side happens to be their master arm.

Many patients experience these symptoms after having suffered an injury to the shoulder. The mechanism of injury may vary widely from falls to motor vehicular accidents to “spraining” their shoulders while attempting to carry a heavy load.

In my daily practice, patients often tell me they injured their shoulder during sports but they did not think much of it, since the pain was very mild initially. The pain, however either persisted and in some cases worsened prompting them to seek help.

In the local context, many patients come only after having tried and failed traditional treatment modalities like massages, herbal medications, acupuncture, cupping, moxibustion etc.

How Is It Diagnosed?

Physical Examination

A physical examination of your shoulder and arm may be conducted to test their range of motion and check for symptoms such as pain or tenderness. Special physical examination tests can be performed to assess for signs of impingement.

X-Rays

Many doctors may begin their investigations with x-rays for the shoulder. X-rays are excellent investigations for viewing bony and joint problems. To me, x-rays provide me with a “bird’s eye view” of the problem.

Ultrasound

Ultrasound scans are generally more useful in the diagnosis of RC tendinosis and impingement syndrome than x-rays. In the hands of an experienced ultrasonographer, it is possible to differentiate between the common RC issues.

MRI Scan

An MRI (magnetic resonance imaging) scan is by far, the most informative scan, and it is my investigation of choice for RC problems. It gives excellent information regarding intra-articular structures like the cartilage and labrum. At the same time, it also yields excellent information with regards to the rotator cuff, presence of any tears of the RC tendons, state of the RC muscles etc.
​​Is Impingement Syndrome affecting your quality of life, and your ability to perform everyday activities such as working, playing sports and wearing your clothes?

Dr. Tan will assess your symptoms in detail before recommending the right surgical option for your specific injury.

What Are the Treatment Options?

There are various treatment options available, depending on the severity of your shoulder impingement. The goal of treatment is generally to alleviate pain and restore shoulder mobility and function.

Not all shoulder impingements require surgery. In minor cases, the following options will suffice to treat shoulder impingement and bone spurs:

  • Home remedies. Resting your shoulder by avoiding excessive movements and strenuous exercises can prevent further shoulder damage.
  • Physical therapy. Simple stretching and strengthening exercises can allow your shoulders to regain their full range of motion and mobility.
  • Medications. Taking over-the-counter pain relievers such as paracetamol, etoricoxib or ibuprofen can also help to reduce pain.

For more severe cases of shoulder impingement, surgery may be required.

A minimally invasive arthroscopic surgery to remove a sharp spike of bone spur under your acromion is usually performed. This surgery widens the space around your rotator cuff and minimises friction between your acromion and rotator cuff. 

Anatomy of the Shoulder Joint

The shoulder joint is made up of 3 bones: the shoulder blade (scapula), the humeral head and the collar-bone (clavicle).

Movements around the shoulder involve 3 separate articulations: the glenohumeral joint, the acromioclavicular joint and the scapulothoracic articulation. When the arm is raised, the majority of movement occur at the glenohumeral joint and the scapulothoracic articulation.

Four (4) muscles are attached to the scapula and send their respective tendons across the glenohumeral joint and attach to the humerus just beyond the humeral head. These 4 tendons are collectively known as the rotator cuff. You can think of the muscles as motors and their tendons as pulleys. Contractions of the muscles will hence bring about movement at the joint that their tendons cross.

Many patients do not know the difference between tendons and ligaments. Though structurally similar, the 2 structures have very different roles. Tendons arise from the end of muscles, cross a joint and attach to a bone beyond the joint.

Contractions of the muscles then bring about movements at the joint. Ligaments, on the other hand, connect 2 bones across a joint. They keep the joint together and prevents the joint from falling apart (dislocating).

A part of the scapula, known as the acromion, forms a roof over the humeral head and rotator cuff (see picture of bony anatomy of the shoulder). To reduce friction between the acromion and the underlying rotator cuff during shoulder movements, a thin sac containing a sliver of fluid sits on the superior surface of the rotator cuff. This sac is known as the bursa.

Frequently Asked Questions

What will the doctor do?
I am told I have tendinosis of my rotator cuff. What is that?
Is tendinosis and tendinitis the same thing?
I'm told I have bursitis as well. What is bursitis?
There's a bone spur as well! What is that?
How can impingement syndrome be treated?
What non-invasive treatment options are there?
What kind of invasive treatment options are there?

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