Shoulder Impingement
1. Introduction
The shoulder joint is a ball and a shallow socket joint. It is formed from a ball on the top of your arm bone and a shallow socket which is part of the shoulder blade. Above the ball and socket joint is a ligament that is attached to a bony prominence (‘acromion’) on your shoulder blade. This forms an arch. The area between the shoulder joint and the arch is known as the subacromial space. Running through this arch are a group of muscles called the rotator cuff that work to keep the ball centred on the socket when you move your arm.
During the normal movements of the shoulder, narrowing of the subacromial space occurs. However, if the fine balance that regulates the shoulder control is compromised, the humeral head travels upwards more than normal, further narrowing the subacromial space and increasingly compresses the rotator cuff and bursa resulting in pain (6). The supraspinatus tendon is most affected and it is thought this could be due to a reduced blood supply.
“Shoulder impingement”, also known by other names such as “subacromial pain syndrome” or “rotator cuff related shoulder pain”, commonly presents with pain in the anterolateral (front and outside) aspect of the shoulder and sometimes midway into the upper arm (7). Pain is reported as worse on lifting the arm over shoulder height, taking the hand behind the back such as doing a bra strap and difficulty sleeping on the affected side. Typically, the pain comes on gradually but can also be sudden as the result of acute injury (8).
Previously, shoulder impingement syndrome was thought to be a sole diagnosis itself but it is now considered to be a cluster of symptoms and anatomic characteristics (3). The term “impingement” refers more to a mechanism where the subacromial space (space between the top of humeral head and bottom of acromion) narrows causing increased compression/rubbing of the rotator cuff (muscles of the shoulder) resulting in “inflammation” and degeneration. Over time this repeated compression (“impingement”) can cause changes in the soft tissues that lead to pain and movement problems.
Frequently Asked Questions
- Shoulder impingement is an umbrella term used to describe a variety of conditions that can cause pain in the shoulder.
- It is a very common condition affecting the tendons of the shoulder, also known as the rotator cuff.
- Up to 44% – 65% of all shoulder pain reported (3).
- No.
- Shoulder impingement is usually reversible with exercise treatment alone (2).
- With the right rehabilitation, between 70% – 90% of patients with shoulder impingement will recover with physiotherapy (1).
- Anyone who performs repetitive overhead activity as a job, or sports such as tennis, volleyball and swimming.
- The likelihood of developing shoulder impingement increases with age and the most common age group is 60-70 years old (4).
- Pain in the top and outer side of your shoulder (3).
- Pain that is worse when you lift your arm, especially when you lift it above your head.
- Pain or aching at night, which can affect your sleep.
- Weakness and stiffness often result secondary to the pain.
- Avoid aggravating activities, for example throwing a ball overhead.
- Avoid using a sling and keep the shoulder moving.
- Try to carry on with your normal daily activities as much as possible so your shoulder does not become weak or stiff.
- Advice from a qualified physiotherapist will be helpful in most cases.
- This will depend upon several factors including, but not limited to, medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation, etc.
- There is no agreed timeline for resolution of shoulder impingement, but it has been reported that between 70%-90% of patients with shoulder impingement will recover with physiotherapy (1).
- Some patients may require prolonged rehabilitation or require surgery.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain located over the lateral acromion, frequently with radiation to the lateral mid-humerus.
- Pain upon lifting the arm, trying to put a hand behind your back.
- Night-time pain prevents you from sleeping or laying on the affected side.
- Weakness and stiffness often result secondary to the pain.
- Gradual or insidious onset, typically developing over weeks to months.
- Pain alleviated by rest but returns with activities overhead.
3. Causes
The exact cause of shoulder impingement is not always fully understood. The problem appears to be within the tendon and it starts to fray and split, but what leads to this is multifactorial (2, 6). There are many theories as to what causes shoulder impingement or damage to the tendons. It is not clear yet if the damage to the rotator cuff tendons leads to the impingement, or if the impingement causes the damage to the tendons (6). Mechanical triggers such as changes in posture or activity where the tendon is stressed may then cause episodes of pain.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing shoulder impingement. It does not mean everyone with these risk factors will develop symptoms.
- Age – natural ageing process makes tendons more susceptible and higher risk (5).
- Gender – men are more prone than women.
- Manual jobs/sports requiring prolonged overhead position of the arm (builders, electricians, hairdressers, swimming, volleyball, handball, etc).
- Poor posture – suboptimal mechanics for shoulder muscles.
- Genetic factors – including diabetes and rheumatoid arthritis.
5. Prevalence
It is quite a common condition being reported; up to 44% – 65% of all reported shoulder pain can be because of this condition. Its prevalence is especially high in repetitive overhead sports such as swimming, volleyball and handball, and manual jobs requiring prolonged overhead position of the arm (builders, electricians, hairdressers, etc) (6). The likelihood of developing shoulder impingement increases with age and the most common age group is 60-70 years old (4).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) or ultrasound scan are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
Early recognition and subsequent management are important as this can help reduce the risk of impingement progressing in the form of increased pain, reduced activity or potential partial, or even complete, rotator cuff tears (2). Initially, there is evidence to suggest that in the very early stages of developing shoulder pain both oral and local NSAIDs for short-term use of 7-14 days was an effective treatment. However, complications associated with these drugs warrant caution in their longer-term use (2).
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your shoulder impingement. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
Shoulder impingement is usually reversible with exercise treatment alone (2). It is reported that conservative management in the form of physical therapy targeted at strengthening the rotator cuff and scapular muscles, non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections provide satisfactory results within 2 years in 60%-90% of patients.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing shoulder impingement. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point, as well as clearly highlighting exercise progression.
9. Shoulder Impingement
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
Goals in the early phase would be to relieve pain and inflammation and normalise the range of motion via establishing muscular balance, postural work and patient education such as avoiding aggravating activities (8). This should not exceed any more than 4/10 on your perceived pain scale.
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- 910
This is the next progression. More focus is given to progressive loading of the rotator cuff through range and general upper limb strengthening. Gradually increasing muscle strength as well as activities with the involved arm while maintaining a reduced level of pain. This should not exceed any more than 4/10 on your perceived pain scale.
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- 910
This programme is a further progression with challenging progressive loading of the rotator cuff muscles, as well as the scapula and postural muscles. Goals at this stage are to return muscle strength and endurance to preinjury levels with a continued gradual increase in functional activity. This should not exceed any more than 4/10 on your perceived pain scale.
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- 910
10. Return to Sport / Normal life
For patients wanting to achieve an elevated level of function or return to sport, we would encourage a consultation with a physiotherapist as you will require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should have achieved a full unrestricted range of motion of the shoulder and be symptom free while you are performing the desired movements of your sport.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Corticosteroid injections should only be considered as a last resort if appropriate and progressive conservative management has failed. Even if conservative management does not achieve a 100% improvement, careful consideration is heavily encouraged as in some cases they cause more harm than good including, in rare instances, tendon rupture.
Surgery – if there is any structural pathology that has not responded to targeted physiotherapy, this may be an option once all other treatment attempts have been exhausted.
References
- VanBaak, K., Aerni, G., (2020). Shoulder Conditions: Rotator Cuff Injuries and Bursitis. FP Essent. 491:11-16. PMID: 32315143.
- Khan, Y., Nagy, M.T., Malal, J. and Waseem, M. (2013). The painful shoulder: shoulder impingement syndrome. The open orthopaedics journal vol. 7 347-51.
- Creech, J., Silver, S., (2021). Shoulder Impingement Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554518/
- Randelli, P., Randelli, F., Ragone, V., Menon, A., D’Ambrosi, R., Cucchi, D., Cabitza, P. and Banfi, G. (2014). Regenerative medicine in rotator cuff injuries. BioMed Research International.
- Consigliere, P., Haddo, O., Levy, O., Sforza, G. (2018). Subacromial impingement syndrome: management challenges. Orthop Res Rev. 10:83-91. [PMC free article] [PubMed].
- Garving C, Jakob S, Bauer I, Nadjar R, Brunner UH. (2017). Impingement Syndrome of the Shoulder. Dtsch Arztebl Int 10;114(45):765-776. [PMC free article] [PubMed].
- Lewis, J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther; 23:57-68. doi: 10.1016/j.math.2016.03.009. Epub 2016 Mar 26. PMID: 27083390.
- Escamilla, R., Hooks, T., Wilk, K., (2014). Optimal management of shoulder impingement syndrome. Open Access J Sports Med. 28; 5:13-24. doi: 10.2147/OAJSM.S36646. PMID: 24648778; PMCID: PMC3945046.
Other Conditions in
Shoulders
Whiplash Disorders
An injury which typically occurs following a road traffic collision, often affecting the soft tissues of the neck.
Thoracic Outlet Syndrome
A condition presenting with pain in the arm as a result of compression of structures around the neck/shoulder.
Shoulder Osteoarthritis (OA)
Age and activity related changes to the joints of the shoulder which can lead to pain and stiffness.
Shoulder Dislocation
An injury in which your upper arm bone ‘pops out’ of the cup-shaped socket of your shoulder blade.
Rotator Cuff Tendinopathy
Pain and weakness affecting the shoulder and limiting function.
Frozen Shoulder
An insidious (no clear cause), painful/stiff condition of the shoulder persisting for more than 3 months.
Calcific Tendinopathy
A rare condition causing pain and loss of free movement in tendons and joints.
Biceps Tendinopathy
A tendon-related issue affecting the long bicep tenon at the front of the shoulder.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Acute Torticollis
Sometimes referred to as “wry neck”, this is a condition causing muscle spasms and associated neck pain.
Acromioclavicular Joint Injury
Injury to a small joint at the end of the collar bone (clavicle)/top of your shoulder.