Chapter 10: Impingement Syndrome

When Kim Cheolsu first entered the Orthopedic Department’s consultation room, he glanced around before the patient arrived.

The layout was just like Hongcheon Hospital’s Orthopedic Department. A human skeleton, shaped like a bone, hung on the white wallpapered wall.

Kim Cheolsu felt a surge of emotion, no less than when he first returned to the military hospital. It was a strange feeling to be sitting here as a doctor in the orthopedic consultation room he had always come to as a soldier.

Determined to become a good doctor for his patients, he welcomed his first patient.

“Where does it hurt? Come in quickly. Don’t just stand there.”

The soldier, seemingly nervous, hesitated but then entered at Kim’s words.

Kim Cheolsu gently touched the painful leg and began the examination.

“You say your leg hurts? Let me take a look. Oh dear, why is it so swollen? You’ll have to be admitted. You’re staying in today. Our nurse officer will call your unit.”

“T-Thank you, Major! Thank you!!”

Time flew by whenever Kim Cheolsu was seeing patients. Suddenly it was 4 p.m., and the doctors from consultation rooms one and two had already left for the day. Yet at 5 p.m., the lights in room three remained on.

Orthopedic Department Chief Jang Kihoon sat on the chair outside the consultation room, watching Kim Cheolsu’s examination, secretly surprised.

‘Huh? He’s only dealing with simple cases so far, but he’s not doing badly. I’m annoyed at how easily he admits patients, but I’ll hold my tongue for now! He’ll slip up soon enough. What does he even know about orthopedics…’

Whatever Jang thought, Kim Cheolsu calmly continued with the consultations.

Next came a patient who had broken his leg bone, wore a cast for a month, and had just had it removed.

“Hmm, you had your cast off today, right? How does your leg feel? Can you go back to your unit and start training immediately?”

“Well… it still hurts, sir. I don’t think I can train right away. What should I do?”

“That’s understandable. Removing the cast doesn’t mean it’s fully healed. Stay admitted for another week. Then you’ll recover completely and can participate in training normally.”

“T-Thank you, Major! Truly, thank you!”

As Jang Kihoon watched Kim Cheolsu’s examination, veins started bulging on his forehead. No matter how much he tried to overlook it, he felt the admissions were excessive.

He spoke to Captain Son Woohyun beside him.

“Admitting so many patients is just too much. That patient should be fine returning to the unit after the cast is removed, right?”

“Due to the nature of the military, rushing back into training often worsens injuries. Major Kim seems to take that into account.”

When Captain Son subtly sided with Kim, Chief Jang snapped.

“Who are you siding with? Are you saying my policy is wrong? Should we discharge everyone immediately after cast removal?”

“…Not exactly. But Major Kim seems to prioritize the patient’s condition over the military’s organizational concerns. Honestly, I don’t think he even considers the patient’s original unit. The longer these patients stay admitted, their units will hate them for it.”

In reality, military doctors often treated patients harshly due to pressure from their units.

Commanders disliked sending soldiers to the hospital because it reduced their unit’s manpower and weakened discipline.

Military doctors, considering this, tended to be strict when deciding on admissions.

But Kim Cheolsu seemed to disregard all that, which Son found remarkable.

How could someone think only about the patient?

Hearing Son’s words, Jang Kihoon’s worry deepened. Had he been too strict on patients all along? He reflected on himself.

“Hmph! Still, military hospitals are different from civilian ones! Where would we get beds if everyone was admitted? Because of that Kim Cheolsu, we don’t have a single empty bed in our orthopedic ward today.”

“But it feels good inside. Honestly, sending patients back to the unit just because they’re a little better isn’t humane. The hard training and military life waiting for them… I honestly felt uncomfortable with that for some time.”

“Oh? So you’re a bit soft-hearted too. Military doctors need to be tough! But there is something strange. That guy is too precise for someone new to orthopedics. Suspicious. He’ll slip up eventually. Here comes a tough patient now. Handling that one will be difficult. It’s always harder to diagnose mild cases accurately!”

At that moment, a sturdy-built patient entered consultation room three.

“Salute, Sergeant Hwang Himchan reporting.”

“An NCO, I see. Please have a seat. What brings you in today?”

“My shoulder hurts.”

“When did it start hurting?”

“About a week ago, while swimming, I felt numbness in my right arm. Since then, it’s been hard to lift my shoulder, and the pain worsened.”

The symptoms reminded Kim Cheolsu of the patient from his dream. Both swimming and badminton require raising the arm above the head. If the sports are similar, the diagnosis might be the same.

Kim found it intriguing that a patient with symptoms matching his dream had come, and said,

“First, I’ll perform a physical exam starting with the NEERS TEST. Relax your arm, and just let me move it.”

Approaching the patient, Kim held his right arm and internally rotated it.

The patient didn’t feel numbness.

Then, keeping the arm rotated, Kim lifted it upwards. Usually, when patients are told to lift their arm, they tense up, so Kim lifted it himself to prevent this.

“Ah…! It hurts, Major.”

“Hmm… The range of motion isn’t significantly impaired. It looks like early-stage impingement syndrome. Since the pain occurs at the highest angle, it seems bone spurs are just beginning to grow.”

“Bone spurs? What exactly are those…?”

Hearing something growing inside his body, Sergeant Hwang’s expression darkened.

Kim smiled reassuringly.

“Shoulder impingement syndrome occurs when lifting the arm upward damages the shoulder muscles, narrowing the subacromial space between the rotator cuff and the shoulder bone. When this space narrows, the bones rub against each other, causing injury. The smooth bone surfaces become rough, and spiky growths—called bone spurs—form. When these spurs develop between the joints, lifting the arm causes pain.”

“It definitely hurts.”

“The spiky bone spurs catch on the rotator cuff, causing shoulder pain. Bone spurs shouldn’t normally exist. Think of them like fish bones stuck in a person’s throat, hindering joint movement.”

Because he had the knowledge in his head, the explanation came easily.

Chief Jang Kihoon, watching from a distance, was startled and even stammered.

“How… how does that guy know so accurately about the cause and physical tests of impingement syndrome? That’s not something a general surgeon would know.”

Son Woohyun also looked surprised and chimed in.

“Maybe before coming here today, he crammed orthopedic studies last minute…?”

“Hey, you idiot! Orthopedics requires a ton of study. Are you saying he learned it all in such a short time? Then he’s a genius! A genius! Who would believe that?”

“Actually, Major Kim Cheolsu is a genius. Didn’t you know? He earned his doctorate at S University Medical School.”

“…That’s not the point. Still, he’s impressive. How can he know so much about impingement syndrome, and explain it clearly to patients? Comparing bone spurs to fish bones in the throat… that’s a brilliant analogy anyone can understand.”

Chief Jang felt his opinion of Kim shifting. He had thought Kim was clueless and meddlesome, but now it seemed he was quite knowledgeable.

With that level of knowledge, his orders to admit Joo Kyungshik were not incomprehensible.

Chief Jang watched eagerly to see how Kim would handle the NCO patient.

“Hmm…”

Kim Cheolsu frowned, looking at the patient’s pained face. He judged that injecting steroids into the shoulder would aid healing.

Steroid injections have anti-inflammatory effects.

‘Why would future Kim Cheolsu avoid steroids? High-potency steroids have strong anti-inflammatory effects no matter where injected… but is stronger always better?’

As he pondered, an idea flashed through his mind.

Kim smiled and said to the patient,

“First, to be sure the pain comes from the subacromial space, I’m going to give you an injection.”

“Steroids?”

“No, it’s lidocaine. A local anesthetic.”

“Why anesthetic?”

“If we numb the subacromial space and you don’t feel pain when moving your arm again, then we can be sure the pain originates there. It’s to rule out pain from other areas.”

“Okay…”

After injecting lidocaine into the subacromial space and moving the arm, the patient said he no longer felt pain.

Fortunately, there was no pain from any other area.

If the problem is only in the subacromial space, diagnosis becomes easier.

Kim breathed a sigh of relief.

“You’ve only been hurting for about a week, so this isn’t chronic. If you avoid using your arm and refrain from movement, there’s a good chance it will get better.”

“Aren’t you going to give me steroids? Other doctors usually start with a strong steroid injection. One powerful shot would probably cure me.”

Kim initially thought so too, but after deep consideration, he found the right answer.

High-potency steroid injections are effective, but injecting them into the subacromial space can be risky.

Only doctors with long clinical experience can make such judgments, but Kim reached the same conclusion quickly.

His genuine care for the patient and medical genius were evident.

Now with a more relaxed expression, Kim explained,

“Injecting very strong steroids into the subacromial space might actually cause rotator cuff tears. The rotator cuff is a fragile structure. So I’ll use a mild-strength steroid injection instead.”

After saying this, Kim felt relieved. He was certain future Kim Cheolsu would have said the same.

Suddenly curious, he wondered what kind of world the future Republic of Korea would be, where drug abuse didn’t exist.

Though that future was sure to come someday, Kim learned a lot today.

‘Long-term beneficial treatment for the patient is key.’

Sometimes, instead of aggressive treatments that immediately relieve symptoms, treatments that consider the patient’s prognosis and future are better.

“It’s all done, Sergeant.”

After receiving the mild steroid injection in his shoulder, Sergeant Hwang said,

“I didn’t know what was causing my arm pain and was worried, but you’ve clearly identified the symptoms and causes, so I feel at ease. I feel much better after the injection. Thank you!”

“Don’t do activities like swimming or badminton for a while. And avoid lifting your arm overhead. Checking too often to see if you’re better can prolong the pain because the bone spurs get irritated by movement.”

“Such clear instructions. I understand completely. I’ll be careful and won’t exercise my arm. Thank you!!”

That last patient marked the end of the day’s consultations.

As Sergeant Hwang walked out, both Jang Kihoon and Son Woohyun were amazed.

The idea of using lidocaine injections to pinpoint the pain area was innovative…

And the decision to use mild steroids was impressive.

Chief Jang, still surprised, said to Son Woohyun,

“He really saw every patient until the end—what determination. But I’ve never seen treatment like that before. Is it some new foreign method? Have you ever seen it? Numbing the subacromial space with lidocaine to confirm the pain area… truly amazing.”

“I’ve never heard of it either. But it’s definitely innovative. I want to try it someday too.”

Kim Cheolsu approached them, offering a friendly smile and bowing to Chief Jang.

“Thanks to you, I gained great clinical experience today. I’m happy to have helped many patients not usually seen in general surgery. Thank you for giving me this opportunity, Chief Jang.”

When Kim spoke so sincerely, Jang naturally smiled back.

Maybe he had misunderstood Kim.

He extended his hand for a shake.

“I’ll keep consultation room three open anytime you want to see patients. It lightens our workload, and you get to see orthopedic cases. What do you say? Will you accept?”

Surprised by the unexpected offer, Kim looked to Shin Seyoung beside him.

She cheerfully said,

“Since you’ll be managing the patients you admitted anyway, you should accept—I’ll help you too.”

Feeling grateful for the many colleagues supporting him, Kim’s heart warmed.

When he first came to Hampyeong Hospital, he was alone, but now he had many comrades.

Choked up, he grasped Chief Jang’s outstretched hand.

“Yes. I will! Chief Jang.”