Shoulder Impingement Syndrome

Do you get an excruciatingly sharp pain in your shoulder when you brush your hair, put on clothes or tuck in your shirt?

How about when golfing or surfing or playing with the kids?

Yes? Then stop wearing clothes, stop doing everything you love and tell the kids they are on their own.

OR read on…

You might have a condition called Shoulder Impingement Syndrome (SIS), where the tendons of the rotator cuff muscles that stabilize your shoulder get trapped as they pass through the shoulder joint. Impingement happens with repeated pinching and irritation of rotator cuff tendons and the bursa (the padding under the shoulder bone) which can lead to injury and chronic pain.

Shoulder complaints are the third most common musculoskeletal problem after back and neck disorders. The highest incidence is in women and generally people aged 45–64 years. Of all shoulder disorders, shoulder impingement syndrome (SIS) accounts for 36%, making it the most common shoulder injury. The big issue is it can lead to worse problems.

What Causes Shoulder Impingement?

You shouldn’t experience impingement with normal shoulder function. When it does happen, the rotator cuff tendon(s) becomes inflamed and swollen, a condition called rotator cuff tendonitis. Likewise, if the bursa becomes inflamed, you could develop shoulder bursitis. You can experience these conditions either on their own, or at the same time.

Over time the tendons can scar due to repeated irritation, perpetuating the problem as the thicker tendons battle to glide through the narrow bony area between the arm and shoulder blade called the sub-acromial space. The tendons can even degenerate and change in structure, with decreased circulation within the tendon resulting in a condition called tendonosis. Additionally, if not treated, impingement can lead to calcific tendonitis (bone forming within the tendon), frozen shoulder or even partial and full tendon tears which may require surgery. No thank you.

Shoulder impingement has primary (structural) and secondary (posture & movement related) causes:

Primary Rotator Cuff Impingement is due to a structural narrowing in the sub-acromial space. Normal aging and wear and tear based changes can cause the growth of bony spurs, which narrow the space. Some people simply have anatomy with a smaller sub-acromial space which can make them more susceptible to impingement.

Secondary Rotator Cuff Impingement is due to an instability in the shoulder girdle or ball and socket joint. This means that there could be a combination of excessive joint movement, ligament laxity and muscle weakness around the shoulder joint. Poor stabilization of the shoulder blade is a problem because the rotator cuff is comprised of 4 small muscles that are all based from the shoulder blade. Other causes can include poor posture, injury from a fall, or overuse from overhead activities like throwing and swimming. You should also probably reassess excessively tucking in your shirt- its just going to come out again.

What are the Symptoms of Shoulder Impingement?

Pain in your shoulder. Duh.

But commonly rotator cuff impingement has the following symptoms:

An arc of shoulder pain approximately when your arm is at shoulder height and/or when your arm is overhead

Shoulder pain that can extend from the top of the shoulder down the arm to the elbow

Pain when lying on the sore shoulder, night pain and disturbed sleep

Shoulder pain at rest as your condition worsens

Muscle weakness or pain when attempting to reach or lift

Pain when putting your hand behind your back or head

Pain reaching for the seat-belt, or out of the car window for a parking ticket

How is Shoulder Impingement Diagnosed?

Shoulder impingement can be diagnosed by your friendly physical therapist, like this guy.

Using some specific manual tests after a comprehensive history, the causes of the postural and muscle imbalances can be identified. If the findings don’t point to impingement, other causes or conditions are in play. If it appears to be something more serious, then you and your physical therapist would discuss the findings with your physician. Imaging such as MRIs or X-Rays rarely provide useful information at the beginning of therapy. They only become necessary if there is an unusual finding on exam or there is a poor response to therapy.

There are many structures that can be injured in shoulder impingement syndrome. How the impingement occurred is the most important question to answer. This is especially important if the onset was gradual, since your static and dynamic posture, muscle strength, and flexibility all have important roles to play. It is essential the muscles around the thoracic spine and shoulder blade are also assessed and treated as these work together with the entire shoulder girdle.

What does the Treatment Involve?

The early stages of treatment will involve manual therapy, including massage to relieve pain and release tight structures as well as mobilization techniques to restore normal shoulder joint movement. Shockwave therapy is another effective treatment for shoulder impingement. As you move through the other stages of treatment your therapist will prescribe rehabilitation exercises specific to your shoulder, posture, sport and/or work demands.

Corticosteroid injections can be useful in the initial pain relieving stage if conservative (non-surgical) methods fail to reduce the pain and inflammation. It is important to note that once your pain settles, it is important to assess your strength, flexibility, neck and thoracic spine involvement to ensure that your shoulder impingement does not return once your injection has worn off.

Some shoulder impingements will respond positively and quickly to treatment; however many others can be incredibly stubborn and frustrating, taking between 3-6 months to resolve. There is no specific time frame for when to progress from each stage to the next. It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration. For more specific advice about your shoulder impingement, contact your local physical therapist.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case.