Have you ever felt a sharp pinching pain in your shoulder that makes your whole arm feel weak? Pain that spreads around the front and side of your shoulder and down your upper arm, making it hard for you to do the easiest things like putting on a jacket. Sleeping on your side is simply too sore and just the thought of picking up your child or picking up your handbag is too much. You feel like you want to cradle your arm next to your body, because it feels much better if you don’t move. If you feel any of these, you could have shoulder impingement syndrome. Also known as subacromial impingement or rotator cuff impingement.

Shoulder impingement happens when there is less space for the shoulder (rotator cuff) muscles to move when you lift your arm. It leads to impingement (pinching) of these muscles and other soft tissue. You might try to rest and refrain from using your arm to keep your pain under control, but the moment you try to move or even exercise, you feel like you’re back at square one. It is vital that you get help to get to the root of the problem and get the right treatment for your shoulder impingement, from the start.

Let’s look at all the structures that can be involved in shoulder impingement syndrome.

Bones and joints

Your shoulder is formed by three bones namely: the humerus (upper arm bone), the scapula (shoulder blade) and the clavicle (collarbone). Joints are formed at the points where the different bones meet. The clavicle and scapula form the tip of your shoulder and this joint is called the acromioclavicular joint (AC joint). Just below that, the humerus and scapula form a ball-and-socket joint called the glenohumeral joint. This is the joint where most of your shoulder movement takes place and you can compare this joint to a golf ball resting on a tee. The scapula forms the shallow socket (tee) into which the head of the humerus fits (golf ball).

This shallow ball-and socket joint is actually very unstable, but has a few other structures to help improve it’s stability.

Joint capsule, labrum and ligaments

Your glenohumeral shoulder joint is covered by a layer of tissue, called the joint capsule. Together with the shoulder ligaments it helps to hold the joint together and keeps the joint fluid inside. Inside the shoulder joint, you have an extra layer of cartilage that forms a ring around the ball of the joint, called the labrum. Altogether, these structures improve the stability of your shoulder joint and they are called static stabilisers (because they cannot move out of their own).

Shoulder muscles

Muscles around your shoulder provide stability, and movement. They are called dynamic stabilisers, because they can move and work together in force couples to keep the head of the humerus in the correct position inside the shoulder joint. The rotator cuff muscles, together with assistance from the shoulder blade muscles and the long head of the biceps muscle are the main dynamic stabilisers.

There are four rotator cuff muscles:

1. Supraspinatus is the muscle most commonly injured in shoulder impingement syndrome. It helps with lifting your arm sideways.
2. Infraspinatus helps to rotate your arm outwards.
3. Subscapularis helps to rotate your arm inward (to be able to reach behind your back).
4. Teres minor helps to rotate your arm outwards.

All four muscles originate on the shoulder blade, go through a small opening (called the subacromial space) and attach onto the upper arm bone (humerus).

Other muscles

It is worthwhile looking at the other muscles around your shoulder because they will also be affected by shoulder impingement syndrome.

• Trapezius elevates your shoulder and helps to move your neck.
• Deltoid helps with lifting your arm sideways.
• Pectoralis major and minor helps to move your arm across your body by pulling the shoulder forward.
• Rhomboids and serratus anterior helps to stabilise your scapula and to pull your shoulder back.
• Lattisimus dorsi and triceps helps to extend your arm backwards and turn your arm in.
• Biceps bend your elbows and helps to lift your arm in a forward direction.

Bursa

A bursa is a small fluid-filled sac. You have plenty of bursae in your body and they are usually located close to a joint. Their main job is to decrease the friction of muscles and tendons as they rub over a bone. Inside your shoulders, you have one called the subacromial bursa. When your supraspinatus muscle lifts your arm sideways, there is direct pressure and friction on your subacromial bursa.

Subacromial space

Just below your acromioclavicular (AC) joint, there is a space called the subacromial space. The subacromial bursa can be found here and your rotator cuff muscles run through this space. This is where shoulder impingement happens and where the different structures namely bones, bursa and muscle tendons can be pinched (impinged) when you move your arm.

That is why the condition can also be called subacromial impingement or rotator cuff impingement.

Your shoulder is the one joint in your body with the biggest range of motion. It connects your arm to your upper body and provides your arm with a stable base to move from.

Because it is such a mobile joint, you are able to move your arm in almost all directions:

• Reaching forward and down to pick up a bag or your child.
• Lifting your arm to reach something high up in your cupboard, paint the ceiling or trim a tree in your garden.
• Reaching your own face and mouth to eat and drink.
• Reaching back to pick up your handbag from the backseat of your car, or even to scratch your own back.
• Doing a circular movement like swimming or bowling a cricket ball.

With shoulder impingement syndrome, all of these movements will be painful and limited. You will feel like your shoulder has become unreliable and you’ll think twice about doing the easiest things.

That should be enough reason for you to get your shoulder checked out so you can get the right shoulder impingement treatment from the start.

Think of your rotator cuff tendons as a rope that has to glide through a small opening. The smaller the opening the more the friction on the rope. This continuous friction will ultimately lead to damage of the structure of the rope. Eventually, the rope will start to fray and one day it could tear off completely. That is how shoulder impingement syndrome works as well.

Shoulder impingement syndrome can be described as: the compression of soft tissue (rope), against the subacromial arch (opening). There are two ways that subacromial impingement could happen; the subacromial space could get smaller or the soft tissue underneath it could get bigger. Or both of these things could happen at the same time. Either way, it prevents soft tissue like your rotator cuff tendons to glide freely and causes pain, inflammation, swelling and impingement.

Shoulder impingement isn’t actually a diagnosis

The term impingement actually describes why you feel pain. Shoulder impingement syndrome describes a few different conditions that can be classified under it namely: subacromial bursitis, rotator cuff tendon calcification, rotator cuff tendinopathy, rotator cuff tears or even degeneration. These conditions have symptoms that overlap and all of them can cause impingement, but ultimately it is separate diagnoses. That is why it is so important to diagnose the real underlying reason for your shoulder impingement, because it will affect your treatment.

Subacromial impingement can be classified into external and internal impingement.

External Impingement (smaller space)

• Primary External Subacromial Impingement happens when there is a change in the structure of the surrounding bones which in turn narrows the subacromial opening. It is an abnormality that you can be born with or it could happen with time. Examples of this is: abnormal shape of the acromion or clavicle or an osteophyte (bone spur) growing into the space.

• Secondary External Subacromial Impingement is related to abnormal movement of your shoulder joint. With muscle weakness, instability or muscle imbalance your shoulder joint won’t be kept in a safe, neutral position. Instead, it might be pulled in a certain direction and when you move your arm it forcibly decreases the subacromial space.

Internal Impingement (increased soft tissue size)

• This type of impingement is caused by rotator cuff tendons against the upper side of the humerus and shoulder joint due to increased size of the tendons. Overuse, swelling or scar tissue in the these tendons could cause them to increase in size. The same way muscles get bigger with exercise, tendons get bigger when they work harder. However, the structure of the tendon gets damaged with overuse. In an attempt to heal a tendon, your body produces more new collagen cells. This leads to tendon thickening, loss of flexibility and ultimately weakening of the collagen structure. If the load isn’t reduced there is more and more damage to the tendon until it eventually fails and tears.

Compensating leads to more problems

With subacromial impingement, you’ll want to rest your arm. Because without movement, there’s no impingement. However, with more rest, your rotator cuff muscles get weak and your body compensates by using other muscles like your deltoid, biceps, trapezius or latissimus dorsi. An example of this would be when you lift your arm up to put on a shirt. If it is too painful, you’ll find ways to cheat. By tensing your neck muscles or bending sideways with your upper body, you’ll be able to lift your arm with more ease. However, these muscles will also become overworked and sore with time. Once you reach that point, your movement becomes very limited and tasks which should be easy daily things, becomes impossible to do. Combing your hair, drinking a cup of coffee, working behind a desk or even simply driving your car. It’s a vicious cycle that you don’t want to get stuck in.

Don’t let your shoulder impingement syndrome get to this point. You won’t be able to lift a finger

Intrinsic causes: (these things cannot be modified)

Age

With age we lose mobility in our tissues and joints and degeneration sets in. It could directly influence your shoulder muscles and shoulder joint. Eventually, it could lead to arthritis of your shoulder.

Tendon histology

The quality of the rotator cuff tendons will influence their ability to heal. With previous tears, scar tissue or degeneration, your rotator cuff tendons could heal poorly.

Genetics

You could be born with an acromion process that is more crooked or pointy than it should be. Or you could be more prone to inflammation, arthritis or osteophyte formation because of your genes.

Extrinsic causes: (potentially modifiable)

Muscle imbalance

A muscle imbalance emerges from repetitive movements in the same direction like practicing your tennis serve. If the muscles doing the opposite action are not strengthened as well, it leads to a muscle imbalance. Now, one muscle is overused and injured while the others are weak.

Muscle fatigue

Keeping your arm lifted up for a period of time will lead to fatigue of the rotator cuff muscles. What happens when muscles fatigue? Usually, you start to compensate by using other muscles like your trapezius to keep your arm up. Something as simple as working in front of your computer the whole day with your hand on the mouse, will lead to muscle fatigue. In turn this leads to compensation and ultimately brings you back to muscle imbalance.

Instability of the shoulder joint

If the humerus isn’t stabilised well enough it means that it isn’t positioned safely in the ball-and-socket joint. This can cause subacromial impingement if the humerus moves out of position as you move your arm.

Poor shoulder joint control

When you move your arm, the scapula and humerus are supposed to move in coordination with each other. Muscle imbalances or joint instability can disrupt this coordinated movement leading to subacromial impingement.

Posture

If you tend to struggle with your posture and you often sit hunched over, your shoulders will be pulled forward.. This makes normal shoulder movement much more difficult as your shoulder muscles struggle to work at the right angle.

Repetitive overload and overuse of your rotator cuff

Working with your arm overhead or doing sport with a lot of throwing or overhead resistance could lead to pain and problems in your rotator cuff muscles and tendons. Overhead activities include: painting, swimming, playing tennis, cricket bowling or even gym-based activities like pull-ups

Traumatic injuries

Falling directly onto your shoulder, picking up something way too heavy or dislocating your arm leads to injury of the soft tissue or bones in your shoulder. Broken arms or broken collarbones that healed in the wrong position can also make you more prone to subacromial impingement.

Mild – You can lift your arm higher than 120 degrees before you feel pain

You will feel like you still have full range of your shoulder movements and you might feel pain only when you’ve lifted your arm up all the way. The subacromial space still allows enough movement for the soft tissue below it, but at the end of the movement, it impinges. Inflammation of the rotator cuff tendons or subacromial bursa is still under control. These structures might be somewhat swollen, but not enough to really limit your movement. During this stage, your pain will probably not bother you a lot. Lifting your arm up all the way,  like when you reach for something in a cupboard, isn’t really something that you do too often.

Moderate – The pain gets bad from 70 degrees and you cannot go further than 120 degrees

Now, you feel shoulder pain more often. It is painful to put your handbag over your shoulder or to wash your hair or to pick up your child. At this stage, the inflammation has caused enough swelling in the subacromial soft tissue that it feels like it pinches each time you lift your arm and afterwards your arm feels weak from the pain. Sleeping on your side gets very sore and a bump against your shoulder makes you want to cry. At times the pain seems to be under control, especially when you do as little as possible with your arm. But, on the other hand, if you push through the pain and try to pick up that heavy bag, it feels much worse.

Doing more with your arm, leads to increased swelling and inflammation of the subacromial bursa or rotator cuff tendons. Maybe the subacromial space got smaller because a bone spur is sticking out into it. The combination of a smaller space and swelling inside, leads to more pain and pinching. This is a tricky phase indeed because you will feel better when you don’t move your arm. Unfortunately, that is no way to live and if you don’t manage it the right way, it can easily become more severe.

Severe – 70 degrees is the absolute highest that you can lift your arm

Now, your pain is constant and excruciating. You can’t sleep and you can’t eat (quite literally because it is too painful to lift your arm). The smallest movement is so sore that you feel weak from it. The subacromial space has become obstructed either by degeneration and bone spurs that significantly decrease the size of it, or severe inflammation and swelling. Thus, any movement causes impingement. 

The only way to improve is to get the inflammation and swelling down or open up the subacromial space. Then, subacromial impingement will decrease and your shoulder can move fully again .

Our physiotherapists are experts in human anatomy and movement, with the necessary experience to diagnose subacromial impingement. We fully understand how your shoulder joint should move and how your rotator cuff muscles work in coordination with surrounding structures. We can accurately diagnose shoulder impingement syndrome and whether the subacromial bursa, rotator cuff muscles or shoulder joint is affected. Doing a full clinical assessment and getting the necessary information about your pain is the starting point.

During your physiotherapy evaluation, we will stretch and stress your shoulder joint, test the strength of your rotator cuff muscles and evaluate your shoulder movement patterns. This way we’ll be able to know how your shoulder movements are affected. It is important that we evaluate movement of your neck and spine as well in order to eliminate the possibility that your shoulder pain could be referred pain.
Thorough evaluation makes our physiotherapists the best at diagnosing this type of problem.

Once your physiotherapy assessment of your shoulder is done, a diagnostic ultrasound (sonar) will be a helpful test to confirm the diagnosis of subacromial or rotator cuff impingement. It could show swelling and the presence of tendon pathology in your shoulder.

It is not compulsory that you get a sonar before you see your physiotherapist for the first time. However, if your physiotherapist feels it is necessary that you get one, you will be referred to the right place.

X-rays will only give us an image of the bones in your shoulder. None of the rotator cuff muscles or signs of bursitis will display on an x-ray. However, x-rays will show the integrity and alignment of joints in your shoulder. This will enable us to see if your subacromial impingement is caused by one of the bones in your shoulder or possibly a bone spur.

Your physiotherapist will refer you to get x-rays taken if necessary.

An MRI scan can image all of the structures in your shoulder, including bursae, muscles, tendons, joints and bones. However, you need a referral from a specialist to get an MRI scan and it is an expensive test.

It is unnecessary to get an MRI straight away, but if your physiotherapist feels it is necessary for you to get one, you will be referred to the right specialist.

Initially, your shoulder pain is caused by inflammation and swelling in the subacromial space, causing impingement when you move your arm. Resting seems to help, so you start to use your arm less. If you can’t move your arm fully and with ease, your muscles become weaker, joints become stiff and you compensate by using the wrong muscles at the wrong time.

It isn’t that easy to avoid using your painful arm. Through the day you might quickly need to pick up your laptop bag or handbag and before you know it pain shoots into your shoulder. Putting on a shirt, combing your hair or even picking up your cup of coffee worsens your pain. These movements causes irritation or impingement in the subacromial space and that leads to more inflammation and starts up the cycle of pain again. You become stuck in a cycle of pain, not knowing if it is safe to move or not.

Effective treatment of subacromial impingement needs to adress the underlying cause. Swelling of subacromial bursa needs to subside so that it can get back to its normal size. Rotator cuff tendons need conditioning to get used to the work they should do. The subacromial space needs to increase and bone spurs might need to be removed.

The sooner you sort out exactly what is causing the pain and impingement in your shoulder, the better. Certain treatments like medication might ease the pain, but it won’t prevent the pain from coming back if there is a deeper problem causing it.

You might feel frustrated that the pain in your shoulder isn’t easing, but it could be a sign that you need to pay attention. There is a risk of more critical and possibly irreversible damage to your rotator cuff muscles if you keep on pushing through your pain.

Waiting too long and not getting a proper diagnosis

A common problem we see is that patients wait too long before they seek help. By the time they see us for treatment of their shoulder impingement, they have had shoulder pain for months or even years. Now, the problem has become more advanced and it will take a lot longer to get better. It wastes a lot of time if you don’t get a proper diagnosis.

Trying out, but not completing different forms of treatment

Often, patients try to get relief by taking medication or getting a cortisone injection in the hopes that it will ease their pain. Medication and things like massages, foam-rolling, cupping or stretching might relieve some of your symptoms. However, these treatments will only be a temporary solution. 

Wearing a sling to ‘support’ your arm is regression. The sling might be giving your arm the rest it needs, but once you take it off, you sit with a weak and sore arm. Wearing a sling long-term is a big problem; before long you will depend on the support it gives.

And then, a lot of people tend to feel that the pain from their shoulder impingement is easing halfway through their physiotherapy treatment programme, so they stop. But, you need to get your shoulder mobility and stability on the level that it should be and you need to finish your rehabilitation process. Otherwise, your pain could simply come back. Patience is key.

Resting too much or too little

The pain that you feel doesn’t always stop you from doing things, so you press on and finish your task. However, pushing through the pain like this will get you to a point where you won’t be able to move at all. Over time, you’ll start to worry about your shoulder more and more and think twice before doing things that you love like gardening or playing with your kids. Moving too much causes extra irritation, inflammation or even injury to the rotator cuff muscles.
Finding the balance between resting and doing safe movements is key. That is something we can help you with.

We are confident that we can provide the best treatment for shoulder impingement syndrome. We understand that you want to have full use of your arm to be able to brush your teeth, pick up your child or lift weights at the gym. That is why we are here to provide guidance and answers on which movements you can do safely. As physiotherapists we will implement a very effective and structured plan of action that treats all the aspects of your shoulder impingement syndrome. Our physiotherapy treatment will help to decrease inflammation and swelling of the subacromial soft tissue and get your shoulder movement and strength back to normal.

The basic structure of our treatments:

1. Determine what is causing your subacromial impingement
2. Which structures has been injured?
3. Protect it from further injury
4. Give it time to heal
5. Improve range of movement and strength
6. Re-evaluate to monitor progress

We will be looking at different aspects, like your shoulder range of motion, strength and stability. Treatment of shoulder impingement syndrome includes: soft tissue massage, joint mobilisations, dry needling, strapping, laser therapy, nerve mobilisations and guiding you through a rehabilitation program of gradual strengthening and conditioning. It’s important that you commit to the treatment plan, as this improves your chances of successful long-term recovery.

Shoulder impingement syndrome can take anything from 6 weeks to 3 months to heal, depending on the severity of your symptoms. Impingement of the rotator cuff muscles is only a symptom of a deeper problem. Treating your shoulder pain without understanding why it is there in the first place will be inefficient.

You will need physiotherapy treatment twice a week for the first two weeks to work through the first phase of treatment. The aim will be to improve inflammation and get your shoulder movement back to normal. After this, your treatment sessions can be spread out to once a week or once in two weeks. This is when you will start to work on shoulder stability and strength. Remember, you only spend an hour at a time with your physiotherapist. How fast you recover will greatly be up to you. When you complete your physiotherapy treatment protocol, you should be able to recover completely and return to your sport.

At the end of your rehabilitation process, your shoulder should be able to handle the demands of everyday life and anything else you can throw at it.

• Your doctor might prescribe anti-inflammatory medication or give you a cortisone injection to decrease the inflammation and pain caused by subacromial impingement. Both of these medications will give temporary relief to the inflammation and impingement. However, it will not be the solution to your problem. Once the effect of the medication wears off and you try to get back to working or exercising, your pain could simply return.
• Getting your shoulder or neck ‘aligned’ or ‘clicked’ in the hopes of improving the pain will not improve the inflammation or the state of the soft tissue being impinged. It could even worsen or trigger an increased inflammatory response which will lead to increased impingement again.
• A biokineticist will be able to help you in the final stages of your rehabilitation programme or to get you back to actively training for your sport.
• Wearing a sling could be useful if your pain is severe. However, the sling puts your arm in an awkward position that interferes with normal movements, so it won’t be a solution to your problem at all. In fact, your shoulder muscles will become weaker when you wear a sling. It will only worsen your problem.
• Stretching your arm and your shoulder might ease some of your pain, but forcing your shoulder into painful positions in the hopes of stretching the pain away, could actually worsen your inflammation and shoulder impingement. 

Surgery is not something you need to consider straight away. If the pain from your shoulder impingement doesn’t respond to non-surgical treatment within 3 months, surgery could be an option. Discuss this with your physiotherapist and make sure you have the necessary information about the risks, expenses and long recovery time associated with rotator cuff surgery.

Before any surgery is done, an MRI should be taken to confirm the diagnosis. The procedure is usually done arthroscopically (keyhole surgery), so you will only have a few small incisions around your shoulder. The surgeon will remove any bone spurs that could be causing the subacromial impingement and repair any tears in the muscle tissue (if there are any). After surgery, you will have to wear a sling for 2-6 weeks (depending on the procedure)

With shoulder impingement syndrome, you will always have associated muscle weakness and problematic movement patterns. Even though surgery might fix the problem by removing a bone spur and increasing the subacromial space again, you will have to address the associated problems as well. Physiotherapy after shoulder surgery is vital to get you back to top form.

• Rotator Cuff Muscle Strain – An injury to the rotator cuff muscles around your shoulder that causes a tear in the muscle tissue. Usually due to overuse, lifting something too heavy or forceful throwing.
• Arthritis of the shoulder – You’ll experience pain and stiffness of your shoulder that feels especially worse with cold weather and when you get up in the mornings. Also known as shoulder osteoarthritis.
• Shoulder labrum injuries – Pain in the shoulder that includes ‘clicking’ or ‘popping’ noises or your shoulder feeling stuck in one position.  Also known as SLAP lesions.
• Bicep tendonitis – Inflammation of the bicep muscle tendon attachment to the front of the shoulder. Pain when lifting your up or picking up a heavy bag.
• Bicep muscle tear – Pain in your upper arm that feels worse when you bend or straighten your elbow. Picking up a handbag or doing bicep curls at the gym will be very painful.
• Frozen shoulder – It can also be known as adhesive capsulitis and it leads to extremely limited shoulder movement, stiffness and pain.
• AC joint sprain/ degeneration – pain over the outside of the shoulder exactly where the collar bone meets the shoulder.

• Shoulder impingement syndrome
• Rotator cuff impingement
• Subacromial impingement
• Subacromial bursitis
• Shoulder tendonitis
• Rotator cuff tendonitis