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What is it?
Impingement syndrome is one of the most causes for pain in the shoulder. It may be due to natural attrition of blood vessels within the tendon or as a result of the “pinching” of the tendons at the top of the shoulder. Pinching occurs due to narrowing of the space where the tendons glide during various shoulder movements. The structures that get affected are the fluid filled sac called subacomial bursa, the muscle-tendon unit of supraspinatus and to some extent the biceps tendon. It may be due to the formation of a bone spur and/or thickening or loss of ligaments resilience. As a result of this pinching, the tendons get scuffed and swell due to inflammation which narrows the space further making the problem worse. This may eventually lead to tendon tear.
Symptoms - Classic “painful arc syndrome”
Pain is typically felt around the shoulder and is brought on by certain movements. It may often start after a minor trauma or sometimes following activities like racquet sports or a DIY job. Typically, one may feel the pain when the arm is lifted forwards or to the side beyond 60 degrees and may completely disappear when the arm is lifted higher (hence the painful arc). In addition, moving the arm behind the body, say to reach the hip pocket or when reaching for the seatbelt in a car, may reproduce the pain.
It is not uncommon to get ‘referred pain’ in the upper arm along the deltoid muscle or along the biceps muscle. Sometimes one may also develop intermittent pins & needle sensation in the fingers, pain at night or a dull ‘tooth ache’ like pain are often described. It is usually deep seated and cannot easily be pin pointed. The arc
may be at higher range when there is arthritis in the acromioclavicular joint. (ACJ = joint between shoulder blade and collar bone).
In the majority of patients, simple measures will ease the pain. These include activity modification (see self-help leaflet for addressing the pain in the shoulder), avoiding overhead activities, rest and a course of anti-inflammatory tablets. A well-directed physiotherapy may give good pain relief. In some instances, one may need injection of cortisone (steroid) and local anaesthetic mixture into this tight space to settle the inflammation and swelling. Improvement is usually gradual and may take place over many weeks or even months. If the pain returns, then occasionally the injection can be repeated. It my usual practice to offer surgical intervention if no significant benefit is obtained after 1 or 2 injections.
Overall, a third get better with activity modification, tablets and physiotherapy and a third get better with injections. Those who do not get better may require surgical intervention especially when the quality of life is affected.
Occasionally, when decompression is done, no obvious tendon tear is noticed. Neither there could any indication of tendon damage on the investigations. However, if the pressure on the tendon has gone past a tipping point, then even after a successful decompression, a rotator cuff tear can develop in future. This is very much like boiling milk which can spilling over even when the heat is stopped. (Milk = tendon, heat = pressure, turning off = decompression)