Understanding Shoulder Impingement: Types, Symptoms, and Physical Therapy Management
Impingement is one of the most common shoulder complaints. It refers to a compression of the structures at the top of the shoulder, in the subacromial space (see photo). It is a condition linked to many others as it can eventually lead to (or be caused by) SLAP tears, rotator cuff tears, and recurrent instability. Shoulder impingement can affect anyone regardless of age or activity level. It is strongly influenced by posture and poor biomechanics. This post will delve into the different kinds of shoulder impingements and how they can be effectively managed through physical therapy. Additionally, we'll explore various stretches, strengthening exercises, and manual therapy techniques that can aid in recovery and prevention.
Types of Shoulder Impingements
Primary Shoulder Impingement refers to a decrease in the subacromial space as the result of a structural abnormality like a curved acromion or a bone spur. This is seen more often in older clients and is most often associated with an external impingement. Running the risk of being too technical, external impingement happens just under the acromion, impacting the subacromial bursa and/or rotator cuff tendons
Secondary shoulder impingement is caused by altered shoulder mechanics whether due to a weak rotator cuff, laxity of the capsule, contraction of the posterior capsule, or scapular instability. Instability or weakness in the shoulder then leads to improper positioning of the shoulder blade and humeral head, which causes the deeper structures to become impinged. This type of impingement is more often seen in younger clients as well as overhead athletes and is usually considered an internal impingement. Internal impingements are compression under the rotator cuff at the labrum and glenoid rim.
Neither is a good time, but physical therapy can provide significant relief.
Signs and Symptoms
Pain- Typically felt on the front and side of the shoulder, often worsening with overhead activities or lifting.
Limited Range of Motion- Difficulty in moving the arm, particularly in lifting side or overhead, or reaching behind the back.
Weakness - Noticeable reduction in shoulder strength, especially during lifting or pushing motions.
Tenderness- Pain or tenderness when pressing on the shoulder.
Swelling- In some cases, there may be visible swelling in the shoulder area.
How can we help?
Effective management of shoulder impingement involves a comprehensive approach that includes pain relief, manual therapy techniques, restoring mobility, strengthening the shoulder muscles, and restoring coordination and biomechanics.
Depending on the severity, advice will be provided on the amount of relative rest required for healing. We will search for the main drivers of the impingement so that these can be avoided for the short-term (ie. painting the ceiling, playing beach volleyball, throwing kids in the air). Then we look for any other factors that are creating an environment that breeds impingement - think workstation setup, poor postural habits, and sleep position. It’s best to sleep in a way that doesn’t compress the shoulder in order to maximize blood flow and thereby enhance recovery.
The treatment will be contingent on our examination to determine what is being pinched and why. Here are a few examples:
Patient A is a pitcher. Due to the extreme shoulder rotation required in the pitch, the front of the capsule has stretched out to allow for the wind up. The humeral head has now migrated forward in the joint and over time the posterior capsule has contracted. To stretch out the posterior capsule, we would do joint mobilization in the direction of the tension. Then, we might prescribe a sleeper stretch followed by neuromuscular re-education to maintain the posterior position of the humeral head and then layer on some rotator cuff stabilization exercises.
Patient B is a desk worker Monday through Friday, and beach volleyball player on the weekend. She has poor postural habits which have compromised the scapula position on her ribcage and altered her scapular mechanics when reaching overhead. Now, instead of the scapula rotating up to allow the arm to move, it shifts sideways or migrates up and the humeral head bangs up against it while trying to spike the volleyball over the net, over and over. For her, we will employ some serious manual therapy techniques to restore thoracic extension mobility, lengthen the lateral scapular border and re-educate normal upward rotation of the shoulder blade. Check out the force couple required for upward rotation here.
Patient C is a guy in his 30s who decides to buy a dog and throw balls to the dog as hard as humanly possible without ever having played a sport in his life. Due to pure rotator cuff weakness, the shoulder can’t stabilize in the joint, the deltoid takes over, and the rotator cuff tendons become inflamed in the subacromial space. For him, we might educate in great detail, dry needle the rotator cuff muscles to manage the trigger points, and provide a number of rotator cuff strengthening exercises that fit into his lifestyle. There are a plethora of rotator cuff exercises- here are a few of our favorites.
Shoulder impingement is somewhat of an umbrella term as it can have a wide variety of causes and varying degrees of pain/dysfunction. No matter what, it can significantly impact daily activities and quality of life, but with the right approach, it is manageable. Physical therapy plays a crucial role in alleviating pain, restoring function, and preventing recurrence. Incorporating targeted stretches, strengthening exercises, and manual therapy techniques into your routine can help maintain shoulder health and prevent future impingements. If you suspect you have a shoulder impingement, consult with a PT for a tailored treatment plan.
