Arthroscopic Repair of Shoulder Impingement

What Is Shoulder Impingement Syndrome (Subacromial Impingement)?

At the top of the shoulder joint, there is a bony projection called the acromion, which is part of the shoulder blade. There is a narrow space (the subacromial space) between this bony projection and the head of the arm bone (humerus). The tendons of the important muscles that move and stabilize the shoulder (rotator cuff tendons) and a fluid-filled sac that provides lubrication over these tendons (subacromial bursa) pass through this space.

Shoulder Impingement Syndrome occurs when, upon raising the arm, this subacromial space narrows and the rotator cuff tendons and/or bursa passing through it become compressed, rub, and become irritated between the acromion bone and the head of the humerus. This repeated compression and friction can, over time, lead to inflammation of the bursa (bursitis), swelling of the tendons (tendinitis), and even, in advanced cases, tears in the rotator cuff tendons.

Factors that can cause this narrowing include:

• Bone spurs (osteophytes/spurs) forming on the underside of the acromion bone.
• The congenital shape of the acromion (e.g., a “hooked” type acromion).
• Thickening and inflammation of the subacromial bursa (bursitis).
• Thickening or tendinitis of the rotator cuff tendons themselves.
• Thickening of the ligaments around the shoulder joint.

Causes and Risk Factors of Shoulder Impingement

The main factors that play a role in the development of shoulder impingement syndrome are:

• Structural (Anatomical) Factors: The shape of the acromion bone (especially types with a hooked, downward-facing tip) or bone spurs that develop over time can narrow the subacromial space.
• Functional Factors:
  
  • Repetitive Overhead Activities: Occupations such as painting, plastering, and ceiling work, or sports such as swimming, volleyball, and tennis can cause persistent impingement in the shoulder.
  • Poor Posture: Shoulders that slump forward can narrow the subacromial space.
  • Muscle Imbalances: Weakness or uncoordinated function of the rotator cuff muscles or the muscles controlling the shoulder blade can disrupt the normal movement of the humeral head, leading to impingement.
  • Rotator Cuff Problems: Mild wear in the tendons or tendinitis (inflammation) can also increase impingement.
• Age: The risk of bone spurs and tendon wear increases with advancing age.

What Are the Symptoms of Shoulder Impingement?

Shoulder impingement syndrome usually presents with symptoms that develop gradually:

• Shoulder Pain: The most common symptom. It is usually felt at the front or side of the shoulder. The pain increases particularly when raising the arm (e.g., reaching for something on a shelf), when bringing the hand behind the head, or when lying on the shoulder. The pain may sometimes radiate down the arm.
• “Painful Arc”: Pain typically appears or increases at a certain angle (usually between 60-120 degrees) when raising the arm to the side.
• Weakness: Weakness may be felt, particularly when raising the arm or rotating it outward.
• Restricted Movement: Shoulder movements may be restricted due to pain.
• Noise: Clicking, crackling, or a grinding sound may be heard during shoulder movements.

How Is Shoulder Impingement Diagnosed?

An accurate diagnosis is important to rule out other shoulder problems (frozen shoulder, osteoarthritis, cervical disc herniation, etc.) and to plan appropriate treatment. Prof. Dr. Murat Bozkurt uses the following methods in the diagnostic process:

• Detailed Patient History: When and how the pain started, which movements increase it, your occupation, sports habits, and any previous shoulder problems are reviewed.
• Physical Examination: The shoulder’s range of motion and muscle strength are assessed. The doctor performs specific tests aimed at eliciting impingement (such as the Neer test and Hawkins test). Tender points around the shoulder are identified. A neck examination is also performed to investigate whether the pain originates from the neck.
• Imaging Methods:
  
  • X-ray: Requested to assess the shape of the acromion bone, bone spurs, the joint space (signs of osteoarthritis), and other bony problems.
  • Ultrasonography (USG) or Magnetic Resonance Imaging (MRI): These methods show soft tissues (rotator cuff tendons, subacromial bursa, ligaments) in detail. They reveal tendon wear (tendinopathy), whether there is a partial- or full-thickness tear, inflammation and thickening of the bursa, and signs of impingement. An MRI is frequently requested, especially if surgery is being considered.

Treatment Options: Non-Surgical Methods First

In the treatment of shoulder impingement syndrome, the first choice is always non-surgical (conservative) methods. The great majority of patients benefit from these treatments.

• Activity Modification: Temporarily avoiding or modifying overhead activities and strenuous movements that trigger pain.
• Medication: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs, such as ibuprofen or naproxen) may be used under a doctor’s supervision to control pain and inflammation.
• Physical Therapy and Exercise: The cornerstone of treatment. The goal is to:
  
  • Strengthen the rotator cuff muscles and the muscles around the shoulder blade.
  • Maintain or improve the shoulder joint’s range of motion.
  • Increase flexibility and teach proper shoulder mechanics.
  • Correct posture.
• Subacromial Injection: A corticosteroid (cortisone) injection into the subacromial space can rapidly relieve pain by reducing inflammation and swelling in the bursa and around the tendon. It can also help confirm the diagnosis (if the pain resolves with the injection, the problem is most likely impingement). However, because of the potential side effects of cortisone, the number of injections is generally limited (2-3 times a year).

Surgical Treatment: Arthroscopic Subacromial Decompression (and Rotator Cuff Repair)

If the patient’s complaints persist despite at least 3-6 months of regular conservative treatment (particularly effective physical therapy), or if the MRI shows a significant structural problem causing impingement (a large bone spur, severe bursitis) or an accompanying rotator cuff tear, surgical treatment may be considered. Today, shoulder impingement surgery is usually performed using an arthroscopic (closed) technique.

• Arthroscopic Subacromial Decompression (ASD):
  
  • How Is It Performed? A thin camera (arthroscope) and specialized surgical instruments are inserted into the shoulder joint through a few small (approximately 0.5 cm) incisions. Guided by the camera image, the surgeon views the inside of the joint and the subacromial space in detail.
  • Procedures:
    
    • Bursectomy: The inflamed, thickened subacromial bursa tissue is removed.
    • Acromioplasty: The bone spurs on the underside of the acromion bone that are causing the impingement are shaved down and corrected with a specialized shaver. This widens the subacromial space and allows the tendons to move freely.
• Rotator Cuff Repair (The “Repair” Part):
  
  • Chronic impingement syndrome can, over time, cause wear and tears in the rotator cuff tendons.
  • If a full-thickness or significant partial-thickness rotator cuff tear is identified during arthroscopy, this tear is usually repaired in the same session.
  • How Is It Performed? The ends of the torn tendon are prepared and reattached to the bone (the head of the humerus) using special suture materials and small screws or anchors (suture anchors) placed into the bone.

Prof. Dr. Murat Bozkurt successfully performs arthroscopic surgical techniques in Ankara for the treatment of shoulder impingement and accompanying rotator cuff tears.

Risks, Benefits, and Recovery Process

• Benefits: The goal of a successful arthroscopic surgery is to relieve impingement-related pain, restore the shoulder’s range of motion and function, improve quality of life, and prevent further damage to the rotator cuff tendons.
• Risks: As with any surgical procedure, there are risks of infection, bleeding, and anesthesia complications. Risks specific to shoulder surgery include postoperative shoulder stiffness (development of frozen shoulder), nerve damage (rare), persistent pain, insufficient relief, and recurrence of the rotator cuff tear (if a repair was performed).
• Recovery Process: The recovery time and rehabilitation protocol vary significantly depending on whether only decompression was performed or whether rotator cuff repair was also added:
  
  • If Only Subacromial Decompression Was Performed:
    
    • Recovery is generally faster.
    • An arm sling is generally used only for comfort, for a few days or 1-2 weeks.
    • Passive and active shoulder movements begin early.
    • Physical therapy lasts a few weeks/months, with range-of-motion and strengthening exercises.
    • Return to normal daily activities is usually possible within a few weeks, and return to more demanding activities within 2-4 months.
  • If Subacromial Decompression + Rotator Cuff Repair Was Performed:
    
    • Recovery is much longer and more limited.
    • To allow the repaired tendon to heal to the bone, an arm sling is generally worn continuously for 4 to 6 weeks.
    • Only passive or assisted movements are allowed for the first 4-6 weeks.
    • Active movements and strengthening exercises are introduced later, in a gradual, staged manner.
    • Physical therapy lasts for months (6 months or longer).
    • Full functional recovery and return to demanding activities/sports can take 6 to 12 months or longer.
  • In both cases, fully adhering to the physical therapy program is vital for the success of the surgery.

Shoulder Impingement Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Shoulder pain and impingement syndrome are a common problem affecting the daily life and productivity of many people living in Ankara. Prof. Dr. Murat Bozkurt follows this approach in treating these patients:

• Accurate Diagnosis: He carefully listens to the patient’s complaints, performs a comprehensive physical examination, and confirms the diagnosis with the necessary imaging methods (X-ray, MRI/USG), ruling out other possible causes of the pain.
• Priority on Conservative Treatment: He views surgery as a last resort and first tries to resolve the problem through activity modification, medication, injections, and especially an effective physical therapy program.
• Appropriate Surgical Decision: He decides on surgery when conservative treatment has failed or a structural problem (such as a tear) has been identified, and thoroughly informs the patient about the surgical process.
• Minimally Invasive Arthroscopic Techniques: When surgery is necessary, he prefers minimally invasive arthroscopic methods for treating shoulder impingement and any accompanying rotator cuff tears. These methods provide smaller incisions, less pain, and potentially faster recovery.
• Importance of Rehabilitation: He emphasizes the critical role of rehabilitation for a successful postoperative outcome and follows up on the process by referring patients to experienced physiotherapists.

Prof. Dr. Bozkurt provides expert care to patients experiencing shoulder impingement syndrome in Ankara, from accurate diagnosis through the determination and implementation of the most appropriate treatment method (conservative or surgical).

Shoulder impingement syndrome is a condition that affects quality of life but can usually be treated. With early diagnosis and the right treatment approach, it is possible to relieve your pain and regain your shoulder function. You can benefit from the expertise of Prof. Dr. Murat Bozkurt for your shoulder problems in Ankara.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt by phone at 0312 502 70 74.