Shoulder Impingement Syndrome

Shoulder Impingement Syndrome


Overhead activity of the shoulder, especially repeated activity, is a risk factor for shoulder impingement syndrome and may be more prominent in those with underlying bone and joint abnormalities. With impingement syndrome, pain is persistent and affects everyday activities. Motions such as reaching up behind the back or reaching up overhead may cause pain. Over time, impingement syndrome can lead to inflammation of the rotator cuff tendons (tendinitis) and bursa (bursitis). If not treated appropriately, the rotator cuff tendons can start to thin and tear.

What is it? Impingement is when the rotator cuff rubs against the arch created by ligament and bone. The rotator cuff, biceps tendon and subacromial bursa must pass under the arch when the arm is moved, especially overhead. The subacromial space is formed by the coracoacromial ligament, the acromion and the head of the humerus. When the space is made smaller either by changes in the shape of the acromion, increased rigidity of the ligament, or swelling in the rotator cuff tissue, the rotator cuff is forced to rub against the arch.’

What Causes Impingement?

There are 3 types of impingement;

• Primary external impingement due to acromial shape or osteophytes

• Secondary external impingement due to an anterior tilt of scapular

• Internal impingement due to rotator cuff dysfunction from repetitive microtrauma

Each type of impingement can lead to further complications in the shoulder such as bursitis or rotator cuff tendinopathy. This may occur during repetitive arm elevation activities, overhead activities, reaching activities away from the body, activities involving rotation of the shoulder, lifting (especially overhead), pushing or pulling activities, placing weight through the affected arm or lying on the affected side. Patients with muscle imbalances, shoulder instability, poor posture, or poor scapula control also have an increased likelihood of developing shoulder impingement.


• Pain, pinching and stiffness in the shoulder, worse with overhead activity.

• Sensation of catching or clicking in the shoulder.

• Often gradual onset with no history of injury

How is it Diagnosed?

A complete shoulder examination, including a neurovascular evaluation, must be done to rule out other causes of shoulder pain. A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose shoulder impingement however an x-ray can also be used to detect osteophytes and evaluate the shape of the acromial arch. An MRI examination may be ordered to examine the integrity of the rotator cuff. Ultrasound scan may be useful to visualise dynamic impingement and detect associated any associated injuries such as shoulder bursitis, rotator cuff tears, calcific tendonitis or shoulder tendinopathies.


Physiotherapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence in all patients with shoulder impingement. Treatment is designed to improve function and return the patient to full activities and an optimal outcome. Particular emphasis is placed on relationship biomechanics of the shoulder.

Aims of Treatment

• Reduce pain

• Restore Scapula kinesis

• Restore normal flexibility and strength to the shoulder

What’s Involved in Treatment?

Most cases of shoulder impingement settle well with appropriate physiotherapy. The success rate of treatment for this condition is largely dictated by patient compliance. One of the key components of treatment is that the patient rests from any activity that increases their pain until they are symptom free. However this should always be relative rest and exercising in pain free range is vital. Activities which place large amounts of compressive forces through the rotator cuff and subacromial bursa should be minimised, these may include: arm elevation or overhead activities, reaching away from the body, throwing, heavy lifting, pushing or pulling and sleeping or lying on the affected side. Resting from aggravating activities ensures that the body  can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.

Manual  “hands-on” therapy from the physiotherapist may include:

• soft tissue release – massage, trigger point releases

• joint mobilisation & manipulation • stretches • graduated stability & strengthening exercise

• taping

• dry needling

• electrotherapy

Particular emphasis is placed on improving scapular stability, posture and rotator cuff function. The treating physiotherapist will advise which exercises are most appropriate for the patient and when they should be commenced especially in relation to appropriate muscle groups working in appropriate postures. This will include training with co-contractions and in functional kinetic chain positions. In the final stages of rehabilitation, a gradual return to activity or sport can occur as guided by the treating physiotherapist provided there is no increase in symptoms.

Other intervention for shoulder impingement

Despite appropriate physiotherapy management, some patients with this condition do not improve adequately. The best course of management may include further investigations such as X-rays, ultrasound, MRI or CT scan, pharmaceutical intervention, corticosteroid injection. In patients with significant pathology involving major rotator cuff pathology and/or bony spurring, orthopaedic surgery may be considered to improve the condition.

Peter Hogg

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