People over 50 should not overlook shoulder impingement syndrome.

Advanced age is an independent risk factor for the development of bone and joint diseases. With increasing age, bone degeneration and other forms of bone damages e.g. fractures regulate the body to take calcium from blood to repair the damaged areas including shoulders. As a consequence, thickening or calcification of the affected bones can eventually lead to shoulder impingement syndrome, resulting in pain, weakness and loss of movement at the shoulder. Since pain and loss of shoulder function caused by impingement syndrome substantially disturb daily life and activities, if warning signs and symptoms present, medical attention must be sought as soon as possible. 

Shoulder pain and difficulty reaching up behind the back

Shoulder pain especially when the arms are extended above the head is a common symptom typically caused by certain conditions e.g. abnormal structure of shoulder e.g. oddly shaped bones, shoulder instability and referred pain from the neck or chest and abdominal cavity. Wide range of pain might vary among different conditions. In addition, primary causes of shoulder pain include frozen shoulder, shoulder instability, shoulder arthritis, rotator cuff tear and impingement syndrome of shoulder. 

Impingement syndrome is a common shoulder problem usually seen in active adults, especially as they get older. When bones are damaged or broken, the body induces the calcification process to repair broken bones by using calcium. Irregular calcification mechanism eventually leads to abnormal calcified bones which can occur in any parts of the body. This condition is closely related to shoulder bursitis and rotator cuff tendinitis. It may occur alone or in combination.

Causes of impingement syndrome

Impingement syndrome of shoulder and calcified tendonitis, a disorder characterized by deposits of a crystalline calcium phosphate in any tendon of the body. It is most commonly found in the tendons of the rotator cuff. Impingement syndrome is typically caused by:

1) Advanced age and degenerative conditions of the shoulder

An increasing age, especially over 50 substantially leads to degenerative conditions including bones and joints which are susceptible to be damaged due to reduced bone mass density. If bones are damaged or broken, calcification process at the affected bones takes place as normal mechanism of the body in order to repair the broken parts. As a result, calcified bones grow irregularly and cause the compression and pinching of muscle, nervous tissue or bursa between the bony structures of the shoulder. This condition leads to irritation and inflammation of the soft tissue surrounding the shoulder. Friction and pressure may eventually produce micro-tears within the tissues.

2) Overuse/ overworked and repetitive strain of the shoulder

• Overuse of shoulder causing repetitive strain potentially induces shoulder tear which can occur in the tendons, the muscles or the labrum, a rim of fibrous tissue that lines the glenoid cavity in the shoulder. If shoulder tear left untreated, the body mechanism automatically repairs the damaged areas by developing calcification process causing calcium deposits on the torn tendons of the shoulder. The tissues around the calcium deposits can become inflamed, causing chronic shoulder pain.
• Acute and overuse injuries of the shoulder in certain sports such as weight lifting, tennis and badminton. 

3) Rotator cuff tear

The rotator cuff is a group of muscles and tendons that surround the shoulder joint. Rotator cuff injuries might be the result of a substantial injury to the shoulder e.g. sports and progressive degeneration or wear and tear of the tendon tissue. Rotator cuff injuries occur most often in people who repeatedly perform overhead motions. Repetitive overhead activity or heavy lifting over a prolonged period of time irritates and damages the tendon, eventually leads to rotator cuff tear. 

In the beginning, a rotator cuff injury can cause a dull ache in the shoulder which regularly disrupts sleep at night time, particularly getting worse when lying on the side of affected shoulder. In progressive stage, tendon tear is found presented with difficulty to reach behind the back accompanied by arm weakness.

4) Frozen shoulder

Frozen shoulder (adhesive capsulitis) is a condition that commonly found in people aged between 50-60, particularly in women. It is characterized by stiffness and pain in the shoulder joint. The bones, ligaments and tendons that make up the shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule becomes inflamed and it thickens and tightens around the shoulder joint, resulting in restricted shoulder movement. People who have prolonged immobility or reduced mobility of the shoulder e.g. broken arm are at higher risk of developing frozen shoulder.

Frozen shoulder exhibits shoulder pain with limited shoulder’s range of motion e.g. inability to cross hands at the back. If condition progresses, shoulder becomes stiffer and more difficult to use. If any mentioned symptoms present, it is highly recommended to seek medical attention as soon as possible in order to receive accurate diagnosis and timely treatments.

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Diagnosis and treatment of impingement syndrome

Diagnostic tests and procedures include medical history taking, physical examination, range of motion evaluation (active and passive range of motion) and imaging tests such as X-ray or/and MRI scan (magnetic resonance imaging) to visualize detailed structure of surrounding areas and identify abnormal findings in the shoulder e.g. degenerative conditions and tendon injuries.

Treatment options of shoulder impingement syndrome include:

1. Non-surgical treatment: Patients diagnosed with early stage of shoulder impingement syndrome without rotator cuff tear, primary treatments include medication e.g. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), corticosteroid injections and physical therapy program. In order to strengthen shoulders, lifestyle modifications are highly advised including shoulder resting, avoiding activities that trigger the pain, limiting heavy lifting or overhead activity and regular shoulder exercise to prevent muscle malfunctions caused by prolonged shoulder immobility. Duration of treatment and response might vary among individuals. Nevertheless, if non-surgical treatments fail, surgical approach might be further considered.
   
   
2. Surgical treatment: Due to the advancements of orthopedic surgery, surgical approach does not seem to be frightening as it might previously be. Arthroscopy is a minimally invasive surgical procedure widely used by orthopedic surgeons to visualize, diagnose and treat orthopedic problems inside the joint through small incisions. 

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Minimally invasive surgery for impingement syndrome

Minimally invasive surgery has been widely accepted as the standard treatment option for impingement syndrome accompanied with rotator cuff tear. Instead of having an open cut that is required in an open surgery, by performing minimally invasive technique, swollen tissue and bony growths in the shoulder can be successfully removed and torn part of tendon can be repaired through small incisions. The superior advantages include smaller incisions, reduced traumatic injuries of surrounding tissues, less blood loss and lowered rates of infection as well as decreased postoperative complications compared to an open surgery as a conventional approach. 

After surgery, patients might start moving their shoulders on the same day or the second day after the surgery. In conventional surgery that open cut is required in order to reach and fix the torn tendon, it takes several weeks for the patients to fully recover and start mobilizing their shoulders. Minimally invasive surgery only requires tiny incisions allowing arthroscope, a small camera to be inserted into the damaged joint. After insertion of other surgical equipment, the camera displays pictures on a television screen thus orthopedic surgeon can perform operation with high degree of precision, accuracy and safety. Due to less damaged to adjacent areas, patients experience less pain and shorter hospital stay with a faster recovery and quick return to daily life.

Pain relief by using high energy radial shockwave therapy 

Shockwave therapy is a modern non-invasive solution for musculoskeletal pain. It is used to relieve pain caused by inflammation and calcification of tendon and muscle in the shoulder. Shockwave is an acoustic wave which precisely carries high energy to painful spots and tissues. High energy promotes regeneration and reparative processes of the bones, tendons and other soft tissues. Shockwave therapy accelerates the destruction of calcified areas, enhances blood circulation, strengthens surrounding muscles and tissues, reduces inflammation process and increases the range of motion of the shoulder to get back as normal as possible. 

Prevention of impingement syndrome

To minimize the chance of developing impingement syndrome, recommendations include: 

1. Weight control, if obese. 
2. Appropriate diet consumption especially protein, vegetables and fruits. 
3. Regular and appropriate exercise. Exercise requires dancing or moving arms must be avoided since shoulder might be overworked, causing shoulder inflammation or tendon tear. 

The appropriate exercise for overweight/ obese or elderly people may include the gentle walk up to 15 minutes and gentle stretching of the shoulder in order to gradually increase range of shoulder motion. In athlete groups, special warm-up techniques and duration in different sports must be strictly followed.