Introduction 

Shoulder impingement

Shoulder impingement, sometimes referred to as subacromial impingement, was the term given to painful pinching of the muscles, tendons, or other structures between the bones (tip of the shoulder blade) and ligaments of the shoulder. 

The name came about from the belief that the subacromial space –  the area under one of the bones (the acromion) that makes up your shoulder joint – was reducing (impinging), thereby causing pinching of the rotator cuff tendons, rotator cuff muscles and other structures (e.g. the bursa) and causing pain and dysfunction.

Symptoms 

  • Pain anywhere from the front of the shoulder, upper arm to the side of the arm
  • Aggravated with lifting and reaching movements
  • Pain worsened by throwing or serving a ball in overhead activity (e.g. tennis players due to repetitive overhead serving)
  • Pain at night
  • Loss of strength and range of motion
  • Difficulty doing activities that place the arm behind the back, such as fastening or unfastening a bra.

Is impingement more myth than fact?

We see a lot of clients complaining of shoulder pain as a result of shoulder ‘impingement’, having been given a diagnosis by a health practitioner elsewhere. What’s interesting is the research evidence has shown and continues to show, that impingement might in fact be more of a myth than anything. There are two big holes the research pokes in the diagnosis ‘shoulder impingement’; 

Fact #1 – You can’t test for impingement

You can’t properly test for impingement, and a scan can’t tell you if this is the cause of your pain.

The tests many surgeons, specialists and therapists out there are using to try and diagnose ‘impingement’ have been shown to have “ insufficient evidence” for “shoulder impingements” (Hanchard et. al 2013).

This basically means, they can’t tell us if you’ve got impingement or not. A scan of any description unfortunately can’t give you clarity around the cause of your pain either, but it is likely to detect a bunch of things that are present in pain free people and aren’t of significance in your management.

Fact #2 – Impingement isn’t always where you think it is

Our shoulder is ‘most impinged’ in positions that aren’t usually reported to be painful by people with ‘shoulder impingement’.

Classically, people experiencing pain as a result of shoulder impingement are said to experience pain through the mid range of movement as they raise their arm to the side and above their head. 

Interestingly though, in a study from 1996 by Brossman et al. they found that shoulders have the ‘most impingement’ or pinching in positions that aren’t in this position at all.

Doesn’t quite make sense that ‘pinching’ or ‘impinged’ tissues would be giving you pain with this movement then, does it?  Resultantly, we can say with a high level of certainty impingement isn’t really a thing.

As such, there’s a shift in the health sector and sports community to stop calling shoulder pain “shoulder impingement” or “subacromial impingement” not only for the fact that, we know this doesn’t accurately represent what’s going on, but because it conveys there’s something wrong with your shoulder that needs surgical intervention to be “fixed”.

Treatment for shoulder ‘impingement’

You need to understand shoulder ‘impingement’ in order to address it properly

 We see a lot of clients who tell us that they feel the only thing that will fix their shoulder pain is if someone goes into their shoulder and surgically gives them more room for things to move. Firstly, his isn’t true, and secondly, unfortunately this belief results in worse outcomes for you, the client.

Remember, pain is a multifactorial experience influenced by a multitude of things including your beliefs and how you feel about your shoulder symptoms.

As such, the worse you feel about your pain and symptoms, the more pain you experience (this is research proven through mountains of literature – for more on the other causes of pain, you can check out this video here).  Because of this, it’s SUPER important to reduce the emphasis on something being structurally ‘wrong’ or ‘impinged’ with your shoulder that needs to be “fixed” rather than rehabilitated in order to achieve the outcome you want.

We know you’re probably a little confused at this point. Someone’s told you your shoulder pain is a result of impingement, and we’re conveying the research that says that’s not really a thing.

Rest easy that in the treatment of pain of any joint in the body, we first seek to to rule out sinister or serious conditions (cancer or similar) through thorough questioning and assessment. Once we’re confident the common causes nasty conditions are off the table, no matter the structure giving you your pain (which we can only hypothesise about, regardless of what a scan says), treatment follows a similar pathway.

We look to educate you on all the things you want to know, before getting you started on a supervised exercise programme that is research proven to improve your condition.

Exercises (Physio) vs Surgery

Firstly, the research shows people who undergo surgery for this so called ‘impingement’ do not get better results in terms of pain or function than those who do exercise therapy;

“There was moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Because of surgery’s higher costs and susceptibility for complications compared with costs and risks of conservative treatment, conservative treatment can be recommended as a first choice of treatment of shoulder impingement” Saltychev et al 2014

What can Physiotherapy do for shoulder impingement?

Physiotherapy (specifically supervised exercise) is REALLY useful for reducing pain and improving function.

A 2012 study by Holmgren T et al. demonstrated;

 A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula (shoulder blade) stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.” 

As you can see, it’s well established exercise is really effective in the treatment of shoulder impingement. Which exercises exactly are useful in the treatment of this condition? Let’s discuss.

Exercises for shoulder ‘impingement’

The bad news (only slightly) is that there’s no research that says exactly which exercises are particularly effective. This is where a good physiotherapist can be particularly useful in providing you with a program that’s tailored to your function, pain, and physical capacity. 

The aim is always to get you back doing what you love, whether that be sports, resistance training or day to day activities.

We exercise the shoulder using a variety of push, pull, raise, carry and lift movements depending on the exact nature of your shoulder symptoms. Starting with gentle exercises if you are in a lot of pain and progressing to more challenging exercises as your strength improves and pain decreases.

Activity Modifications

In conjunction with a tailored exercise program, activity modification can be really important in allowing your symptoms to settle somewhat in the interim. This means altering, reducing or modifying things that might be making your shoulder more sore.

As a general rule, if an activity is bearable to do during (<5/10 pain) and doesn’t exacerbate your pain for hours afterwards, it should be okay. If it does, it likely needs some modifying.

Conclusion

Okay, so you’ve made it to the end of this blog post, you understand that impingement isn’t really a thing and probably isn’t giving you your shoulder pain, but you still want a diagnosis? It’s likely, you’ve got the SHITS (something hurts in the shoulder – Adam Meakins).

The shoulder joint is an extremely complex joint and anyone who says they can tell you the exact cause of your shoulder pain is lying! Remember, outside of sinister causes like cancer and a few select conditions (dislocation in the young population for example), it doesn’t matter and you should get great improvements in pain and function with a supervised exercise program from an experience physiotherapist. 

Frequently asked questions about shoulder impingement

How can I live with shoulder impingement?

You don’t need to! Seek help from a knowledgeable physiotherapist.

Will an MRI show shoulder Impingement?

It can show signs of impingement, but remember, shoulder ‘impingement’ has shown to be more myth than fact and so isn’t likely the reason you have shoulder pain.

When are corticosteroid (anti inflammatory) injections helpful?

Cortisone (A strong anti inflammatory) injections can be useful when you’ve undertaken a minimum of 12 weeks of supervised exercise and have no change in your symptoms or function.

Alternatively, if your symptoms are so severe that you aren’t sleeping and your life is being heavily affected, a cortisone injection may be useful for short term relief. Remember, cortisone doesn’t ‘fix’ the issue.

Who suffers shoulder impingement syndrome?

Anyone of any age can experience symptoms that might appear as ‘impingement’.

Why does shoulder impingement hurt more at night?

This can be for a few reasons. Firstly, there’s a hormone called melatonin that’s released by our body at night that plays a role in pain modulation. Secondly, it could be due to exacerbation of your symptoms with activities during the day that irritates your shoulder and leaves you more sore into the evening.

Do I need surgery for shoulder impingement?

See above for the research relating to surgery for shoulder impingement. It has not better than exercise according to high quality research studies.

Will massage help?

Massage can play a role in providing short term pain-relief, but won’t address the real cause of your shoulder pain to get long term results.

We hope you’ve found this post informative. We treat LOTS of shoulder pain at the clinic, and love helping people take control, get past pain and get back to the life they want. Feel free to reach out with any questions, or book a time online for a consult here