Understanding shoulder impingement
Shoulder impingement can have multiple causes and multiple diagnoses that can include:
- Rotator cuff tendinopathy
- Subacromial bursitis
- Partial rotator cuff tears
- Full rotator cuff tears
- And proximal biceps tendinopathy
These are all related to the tissues under the acromion (see image). A way to think of this area of your shoulder is to picture a small hole where you run multiple cables and cords through. Within this space, you’ll find rotator cuff tendons, subarcomial bursa (fluid sac to reduce friction), the long head of the biceps, a portion of the joint capsule, and ligaments.
There are three types of shoulder impingement. Below, we’ll outline the three types, who is often affected by it, and how it can impact your life if you have it.
The people who are most likely to have shoulder impingement or rotator cuff issues often have a hooked or curved anatomy of the acromion.
The only way to confirm if you have a hooked or curved is by radiologic images, which often isn’t necessary unless you have tried all conservative treatment approaches without success.
What should you look for with shoulder impingement?
Shoulder impingement can affect your quality of life, making it difficult or painful to do normal, daily routines such as washing your hair or lifting your hand over head. You might feel
- Sharp pain
- Dull pain
- Pain sleeping on your side
- A pinching pain in your shoulder
Who is susceptible to shoulder impingement?
The age range can vary, but it is most common in adults between the ages of 25-45, particularly for rotator cuff injuries or pain. Young athletes who do repetitive shoulder motions might also experience shoulder impingement.
Often, in Physical Therapy, we’ll treat people for current shoulder pain who’ve had an injury in the past, such as from youth sports, but we also see shoulder impingement frequently in people who use their arms and shoulders as part of their jobs and people who might have poor posture.
The three types of shoulder impingement
Primary impingement occurs due to a degeneration of the rotator cuff tendons. This happens when there is rotator cuff weakness, chronic inflammation of the tendon or fluid sac (bursa), normal age- related degeneration of the tendons, or potential tightness in the joint capsule.
There also might not be an exact mechanism to have happened that led to your pain. It can be due to repetitive/overuse, genetic predisposition, or even postural influences. Most often, individuals with primary impingement symptoms will have symptoms due to compression in the subacromial space of the rotator cuff tendons between the other structures in the joint.
Primary impingement rarely comes on suddenly. Rather, the pain and discomfort build gradually and often from repetitive overuse of the joint.
Secondary impingement can happen due to an underlying instability of the shoulder (ball & socket) joint. Instability refers to having too much motion in the joint.
Think of a seal balancing a ball on its nose. It’s not very stable and it takes control and work to keep it steady. The same is true for your shoulder joint. It’s naturally not very stable, and the rotator cuff muscles act as the stabilizers. When excess demand is placed on structures within the shoulder such as the rotator cuff musculature, your shoulder mechanics can be compromised. The compromised mechanics can cause too much forward translation of the joint, making you more likely to feel impinging or pinching in the area where the tendons are. If this is not addressed, secondary impingement can lead to rotator cuff tears if instability & impingement continue.
Secondary impingement is often seen in people who have traditionally been hypermobile in their shoulder joints, but usually in their 30s or 40s, they start having shoulder pain from asking their shoulders to do too much.
Posterior “undersurface” Impingement occurs primarily due to undersurface tearing of the rotator cuff and generally happens to young athletes. If an individual has shoulder instability and is frequently using their arm for overhead movements (such as pitchers), the rotator cuff musculature gets caught and begins to rub on the undersurface. This predisposes an individual to compression, and in turn, impingement or pain on the back side of the shoulder.
This pain is felt on the backside of the shoulder when someone goes into the overhead position.
Can all types of shoulder impingement be resolved with conservative management?
Absolutely! Physical Therapy is a wonderful place to start your journey of conservative care. We will provide you with an evaluation that is detailed & leads a systematic approach to identify the root cause to your shoulder pain. The goal of physical therapy is to manage your pain, restore joint mobility, address postural influences, & improve the way you move so you can safely return to your desired activity.
Most people will see a 50%-60% reduction in symptoms within the first 6 weeks of PT, and over 12 weeks, you’ll gradually build up strength and continue to see improvements in different tasks.
If you’re having shoulder pain, don’t ignore it! The earlier you can seek PT, the better. The earlier you seek treatment, the better you will be at preventing the pain from developing into a bigger problem.