The jolt, pain or impingement of the shoulders is an often-overlooked medical issue. The wear and tear or injury of the shoulder is known as shoulder impingement syndrome (SIS).
Prakhyath Mohan, a 36-year-old IT professional from Mangaluru, Karnataka, was diagnosed with SIS a few months ago. He always wanted to learn martial arts and boxing.
When gyms re-opened after the pandemic, Mohan enthusiastically enrolled for mixed martial arts programme. However, a few months into the training, he developed a slight pain in his left shoulder. This, however, didn’t stop him. He continued with his training.
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“A little pain is good, I thought. Gradually, the pain shifted to the right shoulder as well. Eventually, it turned into a nagging pain. I was unable to even wear a shirt or comb my hair,” Mohan remembers.
Dr Bishwaranjan Das, physiotherapist, Kasturba Medical College Hospital, Mangaluru, who has treated numerous cases of SIS also treated Mohan for his pain.
During Mohan’s treatment, Dr Das found that he could not perform any mid-range movements (i.e., movements that required the arms to be raised between 60-120 degree). The X-ray confirmed wear and tear of his shoulder bones. Mohan was also asked to take a diabetes test, and he was found to be living with diabetes.
“Mohan’s was a classic case of SIS. Usually, a person with SIS is likely to also have diabetes,” says Dr Das.
Elaborating on the link between diabetes and shoulder impingement, Dr Sagar Umerjikar, an orthopaedic surgeon from Kalaburagi, Karnataka, informs that uncontrolled diabetes could result in tendon inflammation. “This increases the chances of shoulder impingement,” Dr Umerjikar reasons.
“In uncontrolled diabetes, lean muscle mass gets replaced with fat, increasing the chances of shoulder impingement,” adds Dr Das.
What is shoulder impingement syndrome?
“In shoulder impingement, the rotator cuff muscles and tendons are torn or affected. Specifically, the supraspinatus tendon (one of the rotator cuff tendons) is affected the most.
This tendon runs through acromion (a flat bony growth at the tip of the shoulder blade) till the clavicle (collar bone). In the face of injury or tear, this muscle can be pressed against acromion during the overhead movements,” explains Dr Das.
Talking about the early signs of shoulder impingement, Dr Umerjikar elaborates, “When the rotator cuff is injured or torn, a tissue called bursa, which is beneath the acromion, is inflamed.”
How is it different from a frozen shoulder?
Dr Das says that impingement could lead to frozen shoulders. However, both conditions have a differential diagnosis.
Shoulder is a dynamic joint with a 360-degree movement capacity. Different shoulder muscles work in a coordinated fashion to make the musculoskeletal movement smooth.
The degrees of movement in the shoulder can be divided into three ranges (estimated in degrees): 0-60 degree, 60-120 degree, and 120-180 degree.
“If the shoulder is impinged, the mid-range movement (60-120 degree) is affected. There is a painful arc in the mid-range, hence it is also known as painful arc syndrome.
If the shoulders are frozen, all these ranges are affected and the shoulder movement is zero,” says Dr Das.
Signs and symptoms
Early signs should never be neglected. “One must visit the doctor to arrest and reverse the condition at the earliest,” suggests Dr Umerjikar.
He enumerates the signs:
- A dull, nagging and persistent pain for about 1-3 months with no history of injury.
- Difficulty in overhead movements such as, wearing a shirt or tying/combing one’s hair or difficulty in reaching for an object over the shelf.
In 2005, researchers Michael C Koester, Michael S George and John E Kuhn from the Vanderbilt Shoulder Center, Vanderbilt Sports Medicine, Nashville, Tennessee, US, said that people with this condition could experience:
- Heightened pain at night while the body is at rest (due to lying on the involved shoulder, or sleeping with the arm overhead)
- A general loss of strength and weakness, and in some cases a fall too for individuals over 40 years of age.
Risk factors
Dr Das says SIS is largely seen among:
- Athletes involved in sports that demand larger overhead movements, such as basketball, badminton, and swimming.
- Those who are overweight, lead a sedentary life and are above 40 years of age.
- Those who have weak shoulders and above 40 years of age.
- Those with controlled or uncontrolled diabetes.
Dr Das also adds that women who have crossed 40 are more likely to develop this condition than men.
The underlying rationale could be that women are more prone to develop weakness in the shoulders than men due to hormonal changes such as menopause.
Secondly, they are more engaged in domestic chores that demand more mid-range shoulder movements, thus, increasing the chances of wear and tear.
A research by Department of Trauma, Shoulder and Hand Surgery at Agatharied Hospital Hausham, Germany, stated that one is more prone to develop SIS after the age of 60.
Coexisting comorbidities with shoulder impingement
Dr Umerjikar says impingement can co-exist with other pathology:
- Arthritic changes in the shoulders of elderly people could lead to adverse effects in the shoulder musculature, bone and cartilage
- Periarthritis (a medical condition involving a painful swelling around the joints). This is very common among diabetic patients.
Treatment for SIS
Living within a window: The 2005 study conducted at the Vanderbilt Shoulder Center, Vanderbilt Sports Medicine, strongly suggests avoiding activities that demand overhead movements until symptoms diminish.
In “living within a window” those affected consciously attempt to keep their hands within an area in front of their body during any activity. The “window” should be from chest to waist and 2 to 3 feet wide, allowing the patient to avoid reaching overhead, away from the body, or behind the back, all of which will exacerbate their symptoms.
Dr Das says that alongside the above procedure, physiotherapy and steroids are also recommended (the latter depending on the severity of the case).
Physiotherapy: Ultrasound therapy, says Dr Das, is very effective in reducing the inflammation in the bursa tissue. This therapy involves stimulating the affected tissues with heat (thermal regulation) as a healing technique.
Collagen supplements: Dr Das informs that this is a fairly new development in medical sciences. When administered under supervision, it can help heal the tendon faster and replenish it.
Steroids and surgery: Dr Umerjikar says, “Only 20-30 per cent of the affected people may be administered with steroids when physiotherapy alone doesn’t help reduce the inflammation.
Of these, surgical intervention is recommended for less than 10 per cent. It could be either acromioplasty (a surgical process that involves cutting off the acromion) or subacromial decompression (an arthroscopic procedure deigned to cure shoulder impingement).
Dr Das tells Happiest Health, in Mohan’s case, the first line of treatment was controlling diabetes through consulting an endocrinologist. This was followed by avoiding overhead activities, strengthening rotator cuff muscles and bringing about lifestyle changes such as dietary restrictions.
In a span of two months, Mohan’s shoulder impingement was cured. However, he was advised to watch his blood sugar and diet and be regular with his physical exercises for life-long prevention of SIS.
Preventive measures
Athletes and younger population: Dr Umerjikar comments, “The younger population, who suffers from SIS, gets it largely due to injury from playing various sports. As their tolerance for pain is high, they often ignore the pain. Instead, if they seek help immediately, accurate diagnosis, physiotherapy and mild medications can do wonders.”
Diabetes and shoulder impingement: SIS can be largely prevented among older people by controlling diabetes, say experts.
Exercises and strength training: Dr Umerjikar suggests, “Range of movement exercises can help to avoid periarthritis, which is again commonly seen in diabetic patients. Rotator cuff strengthening exercises are also beneficial.”
