What is Shoulder Impingement Syndrome? What Are the Symptoms? How Is It Treated?

Shoulder impingement is the most common cause of shoulder pain. If you feel pain when lifting your arms and this pain radiates from the shoulder to the arm, you should seek the answer to what shoulder impingement syndrome is. Pain that intensifies, especially at night, can reduce your sleep quality. Symptoms of shoulder impingement include restricted movement, weakness, and swelling. In this article, you will find what you need to know about shoulder impingement diagnosis and treatment.

What is Shoulder Impingement Syndrome?

Impingement syndrome is a painful condition that occurs when the tendons and soft tissues in the shoulder joint are compressed between bony structures. This syndrome is responsible for 44% to 85% of shoulder pain complaints. In 1972, Neer defined this condition as the mechanical compression of the rotator cuff tendons under the anterior-inferior portion of the acromion.

Shoulder Anatomy and the Rotator Cuff

The shoulder joint consists of three different bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The round head of the upper arm bone fits into a socket on the shoulder blade called the glenoid.

The rotator cuff is a structure composed of the tendons of four muscles that surround the shoulder joint. These muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. The rotator cuff muscles ensure that the arm bone stays properly within the shoulder socket. They play an active role, especially when the arm is lifted upward, or rotated outward and inward.

The supraspinatus tendon passes under the acromion bone at the top of the shoulder. This tendon is responsible for lifting the arm sideways into the air. Above the rotator cuff, between it and the acromion, is a soft sac called the bursa. This sac produces lubricating fluid, allowing the tendons to glide freely.

Subacromial Space and the Impingement Mechanism

The subacromial space is the range of motion area of the shoulder. The structures limiting this space are the acromion and coracoacromial ligament at the front, the acromioclavicular joint at the top, and the humeral head and greater tubercle at the bottom. This area is normally 1.0 to 1.5 cm wide.

When you lift your arm upward, reach forward, or rotate it inward, the humeral head moves upward. During this movement, the humeral head approaches the lower border of the acromion. Impingement occurs when this space, which is normally sufficient, narrows.

After impingement, the pressure exerted by the humeral head on the rotator cuff and subacromial bursa causes pain. Repetitive impingement brings about degeneration and chronic narrowing in the region. This process results in tendon inflammation.

Types of Shoulder Impingement

Shoulder impingement is classified in different ways. In external (subacromial) impingement, soft tissue structures mechanically enter the space between the humeral head and the acromion. In internal impingement, the rotator cuff tendons enter between the humeral head and the glenoid rim.

The shape of the acromion is one of the leading factors causing impingement. According to acromion morphology, it is divided into three types:

• Type 1 (Flat acromion): Flat structure, low risk of impingement
• Type 2 (Curved acromion): Forward-sloping structure
• Type 3 (Hooked/hook type): Hook-shaped, seen more frequently with rotator cuff degeneration and tears

Neer defined shoulder impingement in three stages. In Stage 1, edema and hemorrhage are seen after impingement. Stage 2 is characterized by fibrosis and irreversible tendon changes. Stage 3 refers to tendon tears, chronic pain, and a prolonged fibrotic process.

What Are the Symptoms of Shoulder Impingement?

Symptoms of shoulder impingement appear slowly and worsen over time. In the early stages, you may feel mild discomfort in the shoulder area. Symptoms can start suddenly or develop gradually.

Pain and Localization

Pain is the most common symptom of shoulder impingement. The pain is usually felt in the front or side of the shoulder. Pain starting in the shoulder radiates to the arm, sometimes progressing to the fingertips. It exhibits a sharp and stabbing pain character.

The pain increases especially when you lift your arm upward. This condition, called the "painful arc," appears at a specific angle when you lift your arm sideways. Usually, the pain becomes prominent or increases between 60-120 degrees.

You may hear a crunching, clicking, or grinding sound during shoulder movements. You will feel tenderness to the touch in the front region of the shoulder. In some patients, the pain also radiates to the neck and back area.

Restricted Movement

Impingement in the shoulder joint makes your movements difficult. You cannot fully lift your arm upward or open it to the side. You have difficulty pulling your shoulder backward.

Your daily activities are affected. You experience pain while combing your hair. Women have complaints of shoulder pain while fastening a bra. The movement of bringing your hand to your mouth becomes painful.

You cannot lift weights. Your pain increases significantly when you try to lift weights. You have difficulty reaching your hand to your waist area, for example, in movements such as putting a wallet in or taking it out of your back pocket. You become unable to use your problematic shoulder and arm as comfortably as the other.

Night Pain and Sleep Problems

Pain intensifies at night. Your pain increases when you lie on your shoulder. You feel pain or aching, especially when lying on the side of the affected shoulder.

You experience a feeling of aching that affects night sleep. Your sleep quality is lost. You complain of pain that increases when you sleep with your arms above your head. This situation leads to sleep disturbance.

Weakness and Loss of Function

A feeling of weakness develops in your shoulder. You experience loss of strength in the arm. Weakness is felt especially when lifting the arm upward or rotating it outward.

Weakness occurs in the muscles surrounding the shoulder. The normal functioning of the muscles is hindered. Your daily activities are affected, and the strength of your shoulder decreases.

You may experience a feeling of numbness and tingling. The occurrence of numbness in the arm is another symptom of impingement. As the condition progresses, the uncomfortable state in the shoulder area increases.

Causes and Risk Factors of Shoulder Impingement

After the question of what shoulder impingement syndrome is, understanding why it occurs is important in the treatment process. This condition occurs when multiple factors come together. While innate structural features pose a risk for some people, lifestyle and working conditions act as triggers for others.

Anatomical Factors

The shape of the shoulder bone directly affects the risk of impingement. The lower surface of the acromion bone is hook-shaped in some people. This structure creates a predisposition to impingement from birth.

There are flat (Type 1), curved (Type 2), or hook-shaped (Type 3) types of the acromion. In individuals with Type 2 and especially Type 3 acromion types, the space in the shoulder cavity narrows. Tendons are more easily compressed in this narrow area.

In some patients, the space between the lower surface of the acromion and the top of the shoulder head is quite narrow. Bone spurs or congenital anatomical abnormalities also pave the way for this condition. Bone spurs that form over time can narrow the subacromial space.

Repetitive Movements and Overuse

Constant use of the shoulder in an overhead position irritates the tendons. Activities such as swimming, painting, and shelf organizing cause impingement over time.

Shoulder impingement is a common problem among athletes. Sports such as swimming, volleyball, and tennis can cause constant impingement in the shoulder. Those involved in sports like handball, basketball, and baseball encounter this condition more frequently.

Occupations that require working above head level for long periods increase the risk. Occupational groups such as painters, carpenters, and electricians can be cited as examples of this condition. Construction workers, market employees, and those doing plastering work are also at risk. With repetitive arm movements, tendons and the bursa can become inflamed, swollen, and potentially torn.

Using incorrect techniques during sports or overtraining can cause shoulder tendons to become irritated. Excessive and strenuous use, and wear and tear due to overuse are common causes.

Injury and Trauma

Blows to the shoulder area, falls, or sudden strains can cause tissues to thicken. This increases mechanical impingement.

As a result of injury and trauma, swelling and tearing occur in the tendons in the shoulders. Tearing or swelling of the rotator cuff tendon leads to impingement. Irritation and inflammation of the bursa are also among the causes.

Traumas occurring in the shoulder joint can pave the way for this condition. Sudden and uncontrolled movements of the shoulder can cause traumatic injuries. It can occur as a result of direct blows to the shoulder area or falling on the shoulder.

Age-Related Changes

As age progresses, elasticity in shoulder tendons decreases. This increases friction and paves the way for rotator cuff tears.

The loss of elasticity of the tendons and the wear of the joints are among the factors that increase the risk of impingement. Along with the aging process, degeneration occurring in the rotator cuff tendons paves the way for development.

Anatomical abnormalities seen in advanced old age are among the triggering factors. Tissue wear and tear due to aging play a role. With advancing age, the risk of bone spurs and wear in tendons increases.

As age progresses, the risk of developing impingement syndrome increases. This condition is observed more frequently, especially in women in their 50s and 60s. Additionally, diabetic patients are at approximately 5 times higher risk compared to other individuals in terms of the likelihood of experiencing shoulder pain.

How Is Shoulder Impingement Diagnosed and Treated?

The path to the right treatment goes through the right diagnosis. For shoulder impingement diagnosis, your doctor first performs a detailed examination, then confirms the diagnosis with imaging methods. The treatment method is determined according to the severity of your complaints, your age, and your daily activity level.

Physical Examination and Diagnostic Tests

Your doctor first checks your shoulder's range of motion, muscle strength, and tender points. By lifting your arm to certain angles and rotating it, they try to understand at which point the pain is triggered.

Special tests are applied to reveal the impingement. During the Neer test, your scapula is stabilized and your arm is brought into maximum passive shoulder flexion. If your shoulder pain reappears, the test is considered positive. The Hawkins test and Jobe test are other physical examination methods used in the diagnosis of impingement syndrome.

In addition, a neck examination is performed to investigate whether the pain originates from the neck. A detailed examination is required to rule out other shoulder problems (frozen shoulder, osteoarthritis, neck hernia).

Imaging Methods

X-ray films provide information about bone structure. Questions such as osteoarthritis, whether the acromion bone is hooked, and whether the joint space has narrowed are sought in the X-ray.

However, X-rays do not show soft tissues. Magnetic Resonance Imaging (MRI) is the gold standard for evaluating structures that actually cause pain, such as tendons, muscles, and the bursa. With MRI, the inside of the shoulder is examined slice by slice. Details such as the quality of the tendon, the size of the tear, and the extent of the edema become clear.

Ultrasonography is a dynamic method that can show impingement during movement. It allows you to watch live how the tendon passes under the bone while you lift your arm and at what angle the impingement occurs. Everything may look normal on an MRI because the patient is lying down with their arm by their side. The moment of impingement can be captured with ultrasound.

Physical Therapy and Exercises

Physical therapy is the cornerstone of shoulder impingement treatment. It aims to strengthen the rotator cuff muscles and the muscles around the shoulder blade, maintain or increase the range of motion of the shoulder joint, increase flexibility, and teach correct shoulder mechanics.

The physiotherapist initially focuses on reducing pain. Later, the treatment process continues with exercises aimed at achieving normal shoulder range of motion and strengthening the muscles. Exercises are designed to strengthen shoulder muscles, increase flexibility, and ensure the stability of the shoulder.

Exercises recommended in the first stage include shoulder pendulum exercises and table-top sliding exercises. With physical therapy, shoulder pain can be significantly reduced in the short term, and the functional capacity of the shoulder can be increased.

Drug Therapy and Injections

Non-Steroidal Anti-Inflammatory Drugs (such as ibuprofen, naproxen) can be used under doctor supervision to control pain and inflammation. Drugs such as ibuprofen and aspirin are effective in reducing pain and swelling.

If your complaints continue despite rest, medication, and physical therapy, your doctor may consider applying an injection to the shoulder. A corticosteroid injection made into the subacromial space can rapidly relieve pain by reducing inflammation and edema in the bursa and around the tendon.

Injections performed under ultrasound guidance have higher success rates. By seeing the tip of the needle, vessels, nerves, and tendons, the medication is delivered to the problematic area with millimeter precision. However, cortisone injections should not be applied frequently, because when used repeatedly, they can cause cartilage and tendons to weaken.

Surgical Treatment (Arthroscopic Intervention)

In cases where your pain does not subside despite regular conservative treatment lasting at least 3-6 months, surgical treatment may be considered. In shoulder pain that does not pass with non-surgical treatments, if there are findings of pressure on the tendon or chronic impingement on MRI images, arthroscopic subacromial decompression surgery is recommended.

In this surgery performed under general anesthesia, a camera and surgical instruments are inserted into the shoulder joint through two small incisions of approximately 1 cm. First, the shoulder joint is viewed in detail. Whether there is a tear in the supraspinatus tendon is evaluated. The subacromial bursa is cleaned, and the tendon is clearly revealed.

If there is pressure on the tendon under the acromioclavicular joint, it is removed. If necessary, the coracoacromial ligament is removed. Finally, the acromion bone is filed with a special device, and the impingement is eliminated. Bone spurs causing impingement are shaved, the subacromial space is widened, and the tendons are ensured to move comfortably.

Recovery Process and Expectations

Hospitalization is not required; you can be discharged on the same day. Incisions usually heal in 1 week. Ice application for the first 1 week is effective in reducing pain and edema. A shoulder sling is used for about 10 days.

If only subacromial decompression was performed, recovery is usually faster. Passive and active shoulder movements are started in the early period. Return to normal daily activities can usually be within a few weeks, and return to more strenuous activities can be within 2-4 months.

If a rotator cuff repair was also performed, recovery takes much longer. An arm sling is usually used continuously for 4 to 6 weeks. Physical therapy lasts for months (6 months or longer). Full functional recovery and return to strenuous activities can take 6 to 12 months or longer.

Regardless of which treatment method is applied, supporting it with physical therapy and exercise is essential for permanent recovery. After the pain passes, strengthening the muscles around the shoulder and correcting posture disorders is the only way to prevent the recurrence of impingement.

Frequently Asked Questions About Shoulder Impingement

When patients experience shoulder pain, many questions come to their minds. Questions such as which specialist should I consult, how long will it take to recover, and who gets this condition are among the most curious ones.

You should definitely see a doctor when symptoms of shoulder impingement do not pass for a few weeks. You can ensure the problem is solved by making an appointment from the Orthopedics and Traumatology or Physical Therapy and Rehabilitation department.

If your shoulder pain started as a result of a sudden trauma, the first department you should apply to is Orthopedics and Traumatology. Orthopedics specialists deal with structural damage in bones, joints, tendons, and ligaments.

If your shoulder pain started gradually and there is no history of trauma, a Physical Therapy and Rehabilitation specialist may be the right choice for you. In muscle, bone, and joint disorders, both specialists apply treatment methods according to the patient's anatomical structure.

The recovery time varies according to the treatment method applied. In physical therapy, it passes within a few weeks when regular exercise is done. In this process, the complete disappearance of shoulder impingement symptoms is expected within a few months.

Injection therapy allows painkillers to act quickly on the area. Relief in the shoulder is achieved within a few days, but the full recovery time can take a few weeks. If surgical intervention was performed, the incisions heal within 1 week. In surgical treatment, shoulder impingement symptoms pass within about a few months.

Lifestyle, age, and other factors are also effective in the passing of shoulder impingement.

It occurs more frequently in individuals who actively use the shoulder area. It is highly likely to be seen in people who are active in sports branches such as swimming, volleyball, tennis, and baseball. Handball and basketball athletes are also at risk.

Occupational groups such as painting, construction, and those who constantly make overhead movements are in the risk group. Those who constantly use their arms for the same movement and work in jobs that require carrying loads are affected. Housewives and tennis players are among the people frequently encountered.

In elderly people, it can occur in cases of deformity, tears, and osteoarthritis. It is seen more frequently in individuals over 40 years of age due to changes in tendon structure and a decrease in joint fluid.

If not treated, there is a high probability of inflammation of the tendons and bursa. Along with this, rotator cuff tendons are exposed to deformities such as thinning and tearing.

The disease, which could be treated with simple medications, injections, and physical therapy at the beginning, causes the rotator cuff to tear over time. Situations requiring operation may develop. Pain and restricted movement become increasingly severe. The quality of daily life is significantly impaired.

In Summary, Shoulder Impingement

If your shoulder pain affects your daily life and you have difficulty lifting your arm, do not take this situation lightly. Thanks to early diagnosis, your problem can be solved with simple physical therapy and exercises. Delays can lead to tendon tears and situations requiring surgery.

Especially for shoulder pain that keeps you awake at night, be sure to consult a specialist. With regular exercise, the right treatment method, and lifestyle changes, shoulder impingement can be completely cured. Staying loyal to the physical therapy program recommended by your doctor ensures that you achieve permanent results. To protect the health of your shoulder, do not remain inactive, take the necessary steps today.

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