Shouldering the pain

Madam Y, a housewife in her 50s, has been having right shoulder pain for the past six months. It first started after she carried a bag of heavy groceries, and felt worse whenever she did heavy housework. The pain was more acute whenever she lifted up her arm (abduction).

Although the pain is tolerable at rest, it has restricted her from doing housework. She has sought treatment with traditional massage and herbal medicine, with minimal relief.

Mr G is a 65-year-old retired policeman. He continues to keep fit by doing gym workouts. On one occasion, after a heavy bench press, he felt a sharp pain in his dominant right shoulder. He insists he is still fit and healthy, although he occasionally feels pain whenever he exerts his shoulder. He noticed he has had to reduce the weights he lifts as his right arm is "not as strong as before".

If you are experiencing pain in the shoulders like the patients above, you are not alone. It is estimated that one in eight adults has experienced shoulder pain in the past few months. Pain around the shoulders is not a new symptom; the paradigm the medical world is witnessing is an increased awareness of injuries of the shoulder joint, better diagnosis, and improved surgical techniques to repair these injuries.

The shoulder joint

The shoulder joint is highly mobile, with the ball of the shoulder (humeral head) articulating with the small glenoid bone. This structure is similar to a golf ball on a tee. Surrounding the joint are tendons and muscles, which not only protect and stabilise the joint, but are also critical to moving the arm.

Together, the tendons (almost) totally surround the joint like the cuff of a sleeve, hence the name rotator cuff tendons.

Injuries to the tendons of the shoulder joint can result from injuries, falls or any trauma. More commonly, they result from overusing the shoulder, like carrying heavy bags and lifting loads overhead.

These patients usually present with pain deep in the shoulder, made worse when sleeping on the affected side.

A particularly disturbing trend is the number of patients who remember experiencing this pain after carrying clothes to dry on poles outside their flats.

Often, the pain is associated with weakness that affects activities of daily living. Female patients may find it difficult to brush their hair or undo their bra. Male patients describe difficulties reaching their back pocket or lifting things overhead.

Most of them seen in the clinic are above 50 years old, and there are slightly more females than males.

Diagnosis and treatment

Diagnosis and treatment

After a thorough examination, an X-ray may be carried out to exclude bony injuries, fractures or dislocations.

More important, however, is to image the tendons to confirm or exclude tears. Either an ultrasound or MRI of the shoulder may be done.

Patients are often started on analgesics and physiotherapy on their first visit. If the ultrasound confirms a moderate or large tear, then they are counselled for surgery.

A small tear or chronic inflammation with no tear does not require surgical intervention; patients are then continued on physiotherapy and medications.

Surgical repairs of cuff tendons are done by key-hole (arthroscopic) techniques requiring about three one centimetre-sized skin incisions.

Arthroscopic surgical repair of the cuff tendons is increasingly more popular with improved techniques, instruments and implants. Arthroscopic repairs enable patients to recover more quickly as muscles are not cut; they are only pierced to enable special instruments to be inserted to repair the torn tendon. Torn tendons are repaired by tying them to the bone using absorbable or metallic anchors.

The dual-row repair

Torn tendons are usually repaired using one or two anchors arranged in a single row. A new development in arthroscopic cuff repair is to modify the deployment of the anchors.

By arranging the anchors in two rows, the torn tendons are not just reattached to the original attachment, a portion of the tendon is pressed down to enable better healing of the tendon to the bone.

Dual-row repairs have been proven to be stronger, heal better, and have better outcomes with lower re-tear rates.

A study of 150 patients was carried out in 2009, comparing patients who had single-row repairs and those who had dual-row repairs. Smaller tears were usually repaired with a single row of anchors, whilst patients with larger tears required a more secure repair using the dual-row technique.

Despite the larger size of the tears, patients who had dual-row repairs recovered as quickly as those with smaller tears (about six weeks), and were able to return to work and sports just as quickly.

The significant difference was that dual-row repairs enabled patients to recover strength quickly, and were on average 10-20 per cent stronger than those with single-row repairs.

The stronger repair also meant that there were fewer recurrences of re-tears - after two years, the single-row repair had 30 per cent higher recurrence rate than the more secure dual-row repair.

Below are some tips on minimising cuff injuries:

·Do not brush off pain in the shoulder as muscle ache; recognise that this pain could be due to more serious injuries of the tendon.

·Do not engage in overhead lifting or carrying heavy loads if you are not used to it, especially if you are more than 50 years of age.

·Do warm exercises if you plan to do overhead sports like racquet sports.