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Shoulder impingement occurs when the soft tissue structures within the shoulder joint become compressed during shoulder elevation. This movement provokes painful symptoms from the irritation of the rotator cuff or bursa (fluid filled sac) in the subacromial space. Without appropriate diagnosis and management, the consequence of abhorrent movement patterns can create longstanding damage to the rotator cuff, changes to the structure of the shoulder joint or persistent pain.

Signs & Symptoms

  • Pain: Often felt at the front or side of the shoulder, especially during overhead activities like reaching or throwing.
  • Weakness: Reduced strength, particularly when lifting or rotating the arm.
  • Reduced Range of Motion (ROM): Difficulty performing movements like reaching behind the back.
  • Painful Arc: Pain is often most pronounced between 60° and 120° of arm elevation.
  • Night Pain: Discomfort can worsen when lying on the affected side, disrupting sleep.
  • Clicking or Catching: Sensation of catching during movement may occur in more severe cases.

Causes and Contributing Factors

Shoulder impingement is often multifactorial, with several underlying causes and contributing factors.

Structural Causes

  • Anatomy: A naturally narrow subacromial space or the presence of bone spurs can increase the risk of impingement.
  • Posture: Rounded shoulders or forward head posture reduces the subacromial space and alters biomechanics.

Functional Factors

  • Muscle Imbalance: Weakness in the rotator cuff or scapular stabilisers can lead to abnormal movement patterns.
  • Repetitive Overhead Activities: Sports or occupations requiring frequent overhead motion (e.g., swimming, painting) can cause overuse and inflammation.
  • Tightness: Stiffness in the shoulder joint or surrounding muscles (e.g., the pectorals) can impair normal movement.

Other Contributing Factors

  • Age: Degenerative changes are more common with increasing age.
  • Poor Technique: In sports, improper form can increase strain on the shoulder joint.

The presence of structural changes that reduce the joint space would be classified as a primary impingement, versus secondary impingement arising from discrepancies in motor control, scapula movement and overall shoulder mechanics.

Prognosis

The prognosis for shoulder impingement is generally positive, especially with early intervention. Most cases respond well to conservative management, including physiotherapy. Chronic or severe cases may require surgical intervention, but even these typically achieve good outcomes with proper rehabilitation. Recovery times vary:

  • Mild cases: Improvement within 4–6 weeks with physiotherapy.
  • Moderate to severe cases: May take several months to achieve full function.

Treatment

Effective management of shoulder impingement includes a combination of non-surgical and surgical options, with physiotherapy being the cornerstone of treatment.

Non-Surgical Management

Physiotherapy

  1. Pain Relief:
    • Gentle ROM exercises to reduce stiffness and discomfort.
    • Modalities like heat, ice, or ultrasound (evidence supporting these is mixed).
    • Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) may be recommended to reduce pain and inflammation.
  2. Strengthening:
    • Focus on rotator cuff muscles (e.g., supraspinatus, infraspinatus) and scapular stabilisers (e.g., serratus anterior, lower trapezius).
    • Mobility: Target tight structures, such as the pectorals or posterior capsule.
    • Exercises to improve thoracic extension and correct rounded shoulders.
    • Movements to enhance scapular control, such as wall slides or serratus punches.
  3. Manual therapy:
    • A 2024 systematic review conducted by Tauqeer, S et al. demonstrated a reduction in pain scores and increased range of motion from the addition of manual therapy to an exercise program versus and exercise program alone.
  4. Education and Activity Modification:
    • Avoiding aggravating movements and gradually returning to activities.
    • Ergonomic advice for work or daily activities.

Injections

  • Corticosteroid injections into the subacromial space can provide temporary relief for persistent symptoms. However, repeated injections should be avoided due to potential tendon weakening.

Surgical Management

Surgery is considered for cases that do not improve with conservative management after 6–12 months or when significant structural damage (e.g., rotator cuff tears) is present. Common procedures include:

  • Subacromial Decompression: Removal of bone spurs or reshaping of the acromion to increase space.
  • Rotator Cuff Repair: In cases of associated tendon tears.

Post-operative physiotherapy is crucial to restore ROM, strength, and function.

Information is provided for education purposes only. Always consult your physiotherapist or other health professional.