Shoulder Impingement Syndrome

Symptoms, Causes, Diagnosis & Treatments

By Mahnoush Rodriguez
Last Updated: September 9, 2018

❯ Shoulder Pain

Shoulder pain due to shoulder impingement is common among people of all ages.

In this article, you’ll get an overview of what a shoulder impingement syndrome is, what causes it and its symptoms and how it’s diagnosed and treated.

Important Note

DoctorsConvey does not provide medical advice, diagnosis or treatment. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. Learn more

CONTENTS


overview-click

Overview


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Causes & Risk Factors​


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Signs & Symptoms


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Diagnosis & Tests​


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Treatment Options​


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Home Care & Remedy​


overview-click

Overview


causes_risk_factors​-click

Causes & Risk Factors​


signs_symptoms-click

Signs & Symptoms


diagnosis_tests​-click

Diagnosis & Tests​


treatment_options​-click

Treatment Options​


home_treatment_remedy​​-click

Home Care & Remedy​

You can also download our free ebook to learn more about shoulder impingement syndrome.

Shoulder Impingement: Overview

overview-chapter1

What you learn in this chapter:

  • What is shoulder impingement?
  • Types of shoulder impingement
    • Subacromial impingement
    • Subcoracoid impingement
    • Shoulder internal impingement
  • Stages of shoulder impingement

What Is Shoulder Impingement?

Shoulder impingement syndrome occurs when the shoulder’s soft tissues such as rotator cuff tendons are entrapped in the shoulder joint region.

This condition can make it painful for you to raise your arm and may even impair your ability to work or do your daily activities.¹

It’s quite common

In the united states alone, shoulder pain is the reason for 4.5 million visits to a doctor office each year.
In those visits, 44% to 70% of people are diagnosed with shoulder impingement syndrome.²

This shoulder problem is more common among people over the age of 40

FREE eBook: Shoulder Impingement Syndrome

The more you know about your shoulder condition, the better prepared you are to improve it.

Get the ebook

Types of shoulder impingement

Based on the location of impingement, shoulder impingement syndrome is classified into three main groups:¹

  1. Subacromial impingement
  2. Subcoracoid impingement
  3. Internal impingement

① Subacromial impingement

Subacromial impingement syndrome encompasses a range of conditions that occur in the subacromial space, including:³

  • Rotator cuff tendinosis

Chronic degeneration of rotator cuff tendons without inflammation.

  • Rotator cuff tears

Complete or partial tears in one or more of the tendons of rotator cuff muscles.

  • Calcific tendonitis of the shoulder

Formation of calcium deposits inside or around the tendons of the rotator cuff or subacromial bursa.

  • Subacromial bursitis

Inflammation of the subacromial bursa, a fluid-filled sac over the supraspinatus tendon of the rotator cuff.

Also known as external impingement, subacromial impingement syndrome is by far the most common form of shoulder impingement.
It affects about half of the people with shoulder pain.⁴

Because of its high prevalence, shoulder impingement and subacromial impingement syndrome are often used interchangeably.
In this article, we mostly focus on this type of impingement syndrome.

How does subacromial impingement happen?

Let’s first take a look at the shoulder structure and go over some anatomical terms:

  • Shoulder bones and muscles

rotator_cuff_muscles_tendons

  • Subacromial

“Subacromial” basically means under the acromion.

  • Coracoacromial arch

The acromion, coracoacromial ligament, and the coracoid process form coracoacromial arch. This curved structure protects the glenohumeral joint (shoulder joint).

  • Subacromial space

The subacromial space is the space between the coracoacromial arch and the humeral head. Rotator cuff tendons run through this space. There is also subacromial bursa that protects the tendons from rubbing against acromion.

shoulder_subacromial_space_coracoacromial_arch

Knowing the shoulder structure, now we can better understand how subacromial impingement happens:

Subacromial impingement occurs when the rotator cuff and subacromial bursa are compressed between the head of the humerus and coracoacromial arch.⁵

Subacromial space is normally narrow, but it becomes even tighter when you elevate your arm on the side (abduction).⁶

Any condition that causes this space to abnormally narrow can further squeeze the soft tissues running through.⁶

shoulder_movement_abduction

In this case, the abduction of the arm squeezes the rotator cuff tendon between the bony parts of the coracoacromial arch and the humerus excessively.⁷

Repetitive compression and microtrauma caused by this narrowing can lead to subacromial impingement.⁸

Typically, when the rotator cuff tendon or bursa is pinched, it causes shoulder pain.

► Supraspinatus tendon

Supraspinatus tendon is the most commonly pinched tendon in the shoulder impingement.⁸
It is one of the four tendons that make the rotator cuff tendon.
The impingement usually occurs close to the area where this tendon attaches to the humeral head.⁸
supraspinatus_tendon_in_shoulder

② Subcoracoid impingement

Subcoracoid impingement is the impingement of the lesser tubercle of the humerus against the coracoid process.⁹

It can happen if the space between the tip of the coracoid process and the humerus narrows.

This narrowing can cause the soft tissues in that area such as subscapularis tendon to get squeezed.

This condition is a relatively rare cause of shoulder pain.¹⁰

subcoracoid_shoulder_impingement

③ Shoulder internal impingement

Internal impingement is a complex syndrome seen in painful thrower’s shoulder:¹¹

  • Typically affects young to middle-aged adults under the age of 40.
  • Mostly seen among throwing and overhead athletes such as baseball players.

This syndrome has two subtypes:

❯ Posterosuperior impingemen
❯ Anterosuperior impingement

❱ Posterosuperior impingement

There is a debate as to what causes posterosuperior impingement.

The cocking phase of throwing motion is considered as a possible cause of pain among athletes with this condition.¹¹
Impingement in this position happens between the supraspinatus and/or infraspinatus and the glenoid rim.¹²

► Glenoid labrum

Glenoid labrum, also called glenoid rim, is a ring of fibrocartilage tissue around the margin of glenoid cavity in the shoulder joint.

shoulder_joint_glenoid_labrum_ring

❱ Anterosuperior impingement

This is an impingement of subscapularis tendon between the humeral head and glenoid rim during forward flexion of the arm.¹¹
This type of impingement is rare compared to posterosuperior impingement.¹¹

Stages of Shoulder Impingement

There are several methods of shoulder impingement classification. One of the most common classification systems categorizes the syndrome development and progression into 3 stages:⁶·⁷·¹³

Stage 1: Edema and hemorrhage

  • Generally affects younger people under 25, but can occur at any age.
  • Causes edema and/or hemorrhage in the subacromial bursa. Edema is swelling caused by the accumulation of fluid in the tissue.
  • Frequently associated with excessive overhead activities in sports or work – e.g., baseball pitcher.
  • The syndrome is generally reversible at this stage, and shoulder can get back to its normal state with the right treatment.
  • The signs and symptoms may be identical to those of Stage 3.

Stage 2: Fibrosis and tendinitis

  • Generally affects people between 25-40 years old, especially athletes.
  • Continuation of Stage 1 but changes it to a more irreversible form.
  • The bursa can develop fibrosis and thicken.
  • The rotator cuff tendon can become swollen and cause more friction which perpetuates the problem.
  • The tendon can develop tendinitis causing tendon inflammation or irritation and fibrosis which is the formation of an abnormal amount of fibrous tissue in the tendon.
  • The shoulder functions normally with light activities but can become symptomatic after excessive overhead use – e.g., in throwing athletes.

Stage 3: Bone spurs and tendon rupture

  • Generally affects people above 40 years of age.
  • Can lead to tendon degeneration of the rotator cuff and biceps.
  • Can cause the appearance of partial or complete rotator cuff tears.
  • Can lead to bony changes in coracoacromial arch such as osteophyte formation – bony projections – which may also reduce the subacromial space.


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Shoulder Impingement: Causes & Risk Factors

causes_risk_factors​-chapter2

What you learn in this chapter:

  • What causes shoulder impingement?
    • Primary impingement syndrome
      • Rotator cuff defects
      • Coracoacromial ligament changes
      • Bone spurs
      • Type 3 acromion shape
      • Soft tissue inflammation
    • Secondary impingement syndrome
  • Shoulder impingement risk factors

Shoulder impingement causes

Shoulder impingement is usually caused by multiple factors that reinforce each other.

For example, when you move your shoulder, the rotator cuff tendons in the subacromial space can rub against the overlying acromion.
If the undersurface of acromion develops bone spurs, then it can narrow the subacromial space.
This narrowing can increase the mechanical contact between the rotator cuff and acromion thus leading to impingement and pain.¹⁴

Based on the mechanism of the underlying cause, subacromial impingement is classified into two broad groups:

  1. Primary impingement syndrome
  2. Secondary impingement syndrome

① Primary impingement syndrome

In primary impingement, the subacromial space narrows because of structural changes in the shoulder.¹

Some of the factors leading to this narrowing include ¹·⁶

  • Rotator cuff defects
  • Coracoacromial ligament changes
  • Bone spurs
  • Type 3 acromion shape
  • Soft tissue inflammation
  • Rotator cuff defects

❱ Tears
If the rotator cuff is injured or degenerated it can develop partial or complete tendon tears.

The tears can weaken rotator cuff muscles in a way that they may not be able to hold the humeral head in a proper position when you elevate your arm.

If that happens, it can cause the center of the humeral head to move up in your shoulder and reduce the subacromial space.
This narrowing, in turn, can lead to rotator cuff impingement.¹·⁶

rotator_cuff_supraspinatus_tendon tear

❱ Disuse
The rotator cuff muscles can also become weak from disuse.
If you have pain in your shoulder for any reason, it may prevent you from using your arm and shoulder.
This can weaken your rotator cuff and lead to humeral head displacement and impingement.⁶

  • Coracoacromial ligament changes

The coracoacromial ligament attaches the coracoid process and the acromion in your shoulder.

If the coracoacromial ligament calcifies, it can lead to impingement.
Acromioclavicular joint arthritis caused by trauma or osteoarthritis is often the reason for calcification.
Such calcification (ossification) hardens the coracoacromial ligament and makes it thicker and less flexible. ⁶

coracoacromial_ligament_calcification_ossification

  • Bone spurs

Bone spurs (osteophytes) may form on the acromioclavicular joint, underside of the acromion or at the point where the coracoacromial ligament attaches to the acromion.
The bone spurs can cause narrowing of the subacromial space and impingement.¹·⁶·¹⁵

shoulder_acromion_bone_spur

  • Type 3 acromion shape

The natural shape of acromion can also play a role in subacromial impingement syndrome.¹

There are 3 types of acromion:⁶

  • Type 1 (flat): Also known as normal acromion, it has a flat shape.
  • Type 2 (curved): It has a more downward curve.
  • Type 3 (hooked): It looks like a hook with a steep downward curve.

Whether the shape of the acromion is hereditary or acquired with age is a matter of debate.¹⁵

Type 3 acromion can narrow the exit for supraspinatus tendon in subacromial space and cause impingement.⁶

Even though type 3 acromion is generally believed to increase the incidence of rotator cuff tears and impingement syndrome, recent studies haven’t been able to confirm it.¹⁵

  • Soft tissue inflammation

Narrowing of subacromial space can also happen when the volume of subacromial soft tissues increases abnormally. This enlargement can be due to:¹

❱ Subacromial bursitis
Subacromial bursitis occurs when there is an inflammation or irritation in subacromial bursa.

❱ Calcific tendonitis
Calcific tendonitis or calcific tendinitis happens when your body forms calcium deposits inside or around the tendons of the rotator cuff.¹⁶

② Secondary impingement syndrome

The secondary impingement occurs when the humeral head is partially displaced and doesn’t move properly in the shoulder joint.

Shoulder instability, muscle imbalance and overload are among the reasons for this type of joint dysfunction.¹·¹⁷

Secondary impingement is more prevalent among young athletes involved in sports that require repetitive overhead arm motion and throwing.⁸·¹⁷

shoulder_impingement_humeral_head_displacement

How does secondary impingement happen?

Tendon degeneration in the rotator cuff can cause pain and weakness in supraspinatus.
If supraspinatus is weak and doesn’t function properly, it can not depress the humeral head in its place when you elevate your arm.
This can cause deltoid to pull up the humeral head and produce a secondary impingement of the cuff into the acromion.¹⁷

Secondary impingement can also happen due to glenohumeral ligament instability and failure to hold the humeral head in place.¹⁷

Shoulder Impingement Risk Factors

Other factors can increase the risk of shoulder impingement in addition to the underlying reasons discussed above.

Examples are:¹

  • Excessive coverage of the shoulder joint by acromion

If acromion covers more of the shoulder joint, it increases the risk for developing rotator cuff tears.

  • Smoking

Smoking can damage the rotator cuff and increase the risk of subacromial impingement syndrome.


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Shoulder Impingement: Signs & Symptoms

signs_symptoms-chapter3

What you learn in this chapter:

  • Shoulder impingement symptoms
    • Shoulder pain
      • Painful arc
    • Shoulder weakness and stiffness
  • Common instances of pain

Always seek the diagnosis from a medical professional.

Symptoms mentioned below are commonly associated with this condition but can also appear in other shoulder problems. So it is crucial you seek an accurate diagnosis from your doctor or other qualified health care professionals.

Shoulder Impingement Symptoms

Impingement symptoms typically appear gradually and over a period of weeks to months. But it is also possible you develop the symptoms after trauma to your shoulder.³

Some of the common symptoms of shoulder impingement include:

  • Shoulder pain

Pain is the primary symptom of shoulder impingement.
The pain can be present and persistent without any known prior trauma,
or
it can appear after a traumatic event or injury.¹⁵

The pain is usually felt in front of the shoulder and can radiate to the mid-arm.¹⁸

❱ Painful Arc​

If you have subacromial impingement syndrome, you may feel pain when raising the arm on the side in certain positions (abduction).

However, the pain is often felt between 60° and 120° range.¹

shoulder_painful_arc

  • Shoulder weakness and stiffness

Shoulder impingement can also cause weakness, stiffness, and loss of motion in the shoulder. But these symptoms are usually secondary to pain.¹⁸

When you have pain, it can restrict your shoulder movement. To avoid pain, you may use your shoulder less often. This can lead to more weakness, stiffness, and loss of motion.

In subacromial impingement syndrome, shoulder weakness mainly affects abduction or external rotation.¹

Common Instances of Pain

If shoulder impingement causes pain:

  • Reaching upward for overhead or over-the-shoulder activities may become painful.⁶


shoulder_pain_sleeping_arm_above_head

  • You may feel pain at night or if you directly lie on your shoulder or sleeping with the arm above your head.³
  • Forced movement above the head may cause pain.¹

shoulder_pain_above_shoulder_forced_movement

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Shoulder Impingement: Diagnosis & Tests

diagnosis_tests​-chapter4

What you learn in this chapter:

  • How is shoulder impingement diagnosed?
    • Medical history
    • Physical examination
  • Additional diagnostic tests
    • Conventional radiography (X-rays)
    • Magnetic resonance imaging (MRI)
    • Ultrasound
    • MR arthrography

Shoulder Impingement Diagnosis

To diagnose shoulder impingement, your doctor asks for your medical history and performs a thorough physical examination.

Many conditions can mimic the symptoms of shoulder impingement.⁶

Further diagnostic tests may be required for differential diagnosis.
This is done to confirm the initial diagnosis and rule out other conditions like arthritis as the cause of shoulder pain.

Medical history

Your doctor may ask about the nature, duration, and dynamics of the pain, whether you had any injuries or trauma before the symptoms appear and if you are taking any painkillers.¹

Physical examination

Your doctor performs a thorough physical exam of your shoulder joint.
He or she may also examine your neck to make sure the pain is not originated from your cervical spine.¹⁵

shoulder_doctor_physical_exam

During the physical exam, your doctor may:¹

  • Inspect the movement of your shoulder joint and the position of your shoulder blade during that movement.
  • Test the strength of your affected shoulder compared to the other one.
  • Examine your shoulder active and passive range of motion, the rotator cuff, and the painful arc.

Additional Diagnostic Tests

The medical history and physical exam may not always be enough to make a diagnosis.
In that case, your doctor may prescribe diagnostic imaging to get further information about your condition.

Common imaging tests include

  • Conventional radiography (X-rays)
  • Magnetic resonance imaging (MRI)
  • Ultrasound
  • MR arthrography

► X-rays

In this test, your body is exposed to x-ray radiation to take radiographic images.
Dense tissues in your body such as bones block the radiation and appear white in the image.
The less dense tissues such as muscles pass most of the radiation and appear gray.

The x-ray images can show your doctor:¹·⁶

  • State of joints in your shoulder
  • Position and status of the humeral head
  • Presence of arthritic changes and calcific deposits
  • Type of acromion shape

Above information can help your doctor rule out other causes of shoulder pain.⁶

shoulder_x_ray

► MRI

MRI or magnetic resonance imaging combines a powerful magnet and radio waves to create images by computer.
Instead of x-rays, MRI uses a magnetic field.

An MRI picture provides a high level of detail.

It is mainly used to get visibility into organs and soft tissues such as tendons and joints.

MRI helps your doctor to assess the joints, ligaments, bursae, rotator cuff, and changes such as muscle atrophy.¹

mri_scan_diagnostic_imaging

► Ultrasound

Ultrasound or sonography is an imaging method that uses high-frequency sound waves instead of radiation.
The procedure can display images in real time revealing tissue movements or blood flow.

It is often used to show internal organs, blood vessels and soft tissues such as tendons, ligaments, and muscles.

Ultrasound helps your doctor to investigate the underlying causes associated with shoulder impingement such as bursitis and tendon changes and tears.¹

ultrasound_sonography_diagnostic_imaging

► MR Arthrography

Magnetic resonance (MR) arthrography is a two-step imaging technique that uses contrast dyes to highlight the joint when taking images.

1. First step
During the first step called arthrogram, a contrast solution is injected into the joint to increase visibility into its structure. 

2. Second step
The second step is to take MRI images of the joint.

mr_arthrography_diagnostic_imaging

This imaging technique allows your doctor to better detect shoulder defects such as partial rotator cuff tears or biceps tendon abnormalities.¹


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Shoulder Impingement: Treatment Options

treatment_options​-chapter5

What you learn in this chapter:

  • Shoulder impingement treatment
    • Conservative treatment versus surgery
  • Shoulder impingement conservative treatment
    • Pain management
    • Gradual shoulder mobility
      • Shoulder cortisone injections
      • Shock-wave therapy
      • Electrotherapy
    • Shoulder mobilization and exercise
  • Shoulder impingement surgery
    • Subacromial decompression (acromioplasty)
    • Bursectomy
    • Coracoacromial ligament release
    • Rotator cuff reconstruction
  • Prognosis

Always seek treatment from a medical professional.

Numerous factors affect the treatment choice. Your doctor will pursue a course of treatment that’s suitable for your individual health needs and risk factors.

Subacromial impingement syndrome is the most common form of shoulder impingement. In this chapter, treatment options for this type of impingement are discussed.

Shoulder Impingement Treatment

The primary goals of treatment are to relieve pain and restore joint function by solving the mechanical problem causing the impairment.¹⁹

There are two main options for treating shoulder impingement:

  1. Conservative treatment
  2. Surgical treatment

Conservative treatment versus surgery

The treatment strategy varies according to the stage of the condition.¹⁹

Currently, no high-quality clinical study indicates who would benefit from conservative treatment or from surgery.¹

Lack of clinical evidence supporting the superiority of surgical outcomes persuades many doctors to take a conservative approach initially.
If the individual doesn’t respond to the non-surgical treatment, then an operation may be considered.¹⁵

FREE eBook: Shoulder Impingement Syndrome

The more you know about your shoulder condition, the better prepared you are to improve it.

Get the ebook

Shoulder Impingement Conservative Treatment

If there is no significant structural damage in the shoulder, a conservative treatment for 3–6 months is usually considered.¹

The treatment often includes below steps:¹

  • Addressing pain
  • Restoring the passive and active range of motion
  • Improving strength and coordination

Conservative treatment options

A wide range of treatment methods is used to manage and improve shoulder impingement.
Examples are:¹

  • Immobilization
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Cortisone injections
  • Physical therapy
  • Ultrasound
  • Application of heat and electricity
  • Manual therapy
  • Elastic therapeutic tape
  • Acupuncture

► Pain management

Rest and painkillers may be prescribed to relieve pain and inflammation.

❱ Immobilization

Your doctor may advise you to rest your shoulder and avoid activities that cause you pain.
You may also be asked to avoid overhead movements and lifting heavy objects.¹

❱ NSAIDs

To reduce pain, your doctor may prescribe anti-inflammatory drugs for a short period of time, like 1 to 2 weeks.¹

► Gradual shoulder mobility

Once the acute pain subsides, your doctor may recommend a gradual increase in joint mobility.¹

There are various options available to reduce pain and improve shoulder mobility such as¹

  • Loosening massages
  • Application of heat or cold
  • Exercise in the pool
  • Shoulder cortisone injections
  • Shock-wave therapy
  • Electrotherapy
❱ Shoulder cortisone injections

Cortisone shot with a local anesthetic may be prescribed in the first 8 weeks.
It is injected in the vicinity of the tendons in the subacromial space or the shoulder joint.
The aim is to relieve pain and improve shoulder function and mobility.
However, to prevent tendon damages, the shots should not exceed 2–3 times.¹

cortisone_shot_injection

❱ Shock-wave therapy

One of the associated conditions with impingement syndrome is calcific tendonitis.
In chronic calcific shoulder tendonitis (tendinitis), shock-wave therapy may be prescribed to ease pain and enhance shoulder function.
In this therapy, high-energy shock waves are used to disintegrate calcium deposits in the rotator cuff tendons.²⁰

Low-energy shock waves can also be used for pain relief. However, it is not part of impingement treatment.¹

❱ Electrotherapy

Electrotherapy such as iontophoresis may be prescribed to reduce pain and improve function.¹

Electrotherapy modalities are types of physical therapy that function by increasing energy (electrical, sound, light, or thermal) in the body.²¹

Several types of electrotherapy techniques or modalities exist. Below are some examples:²¹

  • Iontophoresis

In iontophoresis treatment, an iontophoretic device is used to facilitate delivery of topical medication through the skin.

This is done via a low-intensity electrical current.

The current is believed to help the movement of positively and negatively charged drugs into the skin.

  • Phonophoresis

In phonophoresis treatment, a therapeutic ultrasound device is used for transdermal delivery of medication.

It is believed it can increase the absorption of topical drugs.

  • Transcutaneous electrical nerve stimulation (TENS)

TENS therapy is done by using a device called TENS unit.

In this therapy, TENS unit electrodes are placed near the source of pain to send electrical pulses to the skin. 

The electrical stimulation activates underlying nerves to reduce pain.

  • Therapeutic ultrasound

In ultrasound therapy, ultrasonic sound waves are transmitted to deep tissues.

The aim is to increase tissue temperature and induce non-thermal physiological changes such as cell growth.

This is believed to promote soft tissue healing and muscle relaxation.

  • Low-level laser therapy (LLLT)

In this method, a beam of light with a particular wavelength is directed to the skin to deliver the light energy.

This technique is believed to relieve pain by reducing inflammation.

However, its effectiveness depends on dosage, wavelength and the site and duration of treatment.

  • Pulsed electromagnetic field therapy (PEMF)

In PEMF therapy, a series of on/off pulses of low-frequency magnetic fields is sent through the body.

It is believed it can cause temporary pain relief by influencing tissue regeneration and cell proliferation.

  • Interferential current therapy (IFT)

In interferential therapy, two medium frequency currents are transmitted into the body.

The currents generate a low-frequency beating in deep tissues.

The beat frequencies are believed to reduce pain, increase circulation and block nerves electrical conduction.

  • Microcurrent electrical neuromuscular stimulation (MENS)

In microcurrent electrical nerve stimulation, small electrical signals (in microampere range) are delivered across the skin.

It is believed it can provide beneficial effects such as pain relief and facilitation of tissue repair.²²

► Shoulder mobilization and exercise

Once acute pain is treated, the emphasis of conservative treatment will be on physical therapy and exercise to further reduce pain and improve mobility.¹

Stretching and swinging exercises and passive movements are usually utilized at the beginning.
Later on, when the pain is reduced, shoulder blade mobilization may be added to the exercise program.¹

Also, the individual is usually given a simple exercise program to do independently.¹

shoulder_physical_therapy

Shoulder Impingement Surgery

Shoulder operation is often considered when conservative treatment fails to deliver results, or the individual is a candidate for early surgery.

Generally, to consider surgery, symptoms, physical examination, and imaging tests should all indicate structural abnormalities that require correction.¹

surgical_procedures

Surgical procedures

There are several surgical procedures to correct shoulder abnormalities.
Below are some examples:

  • Subacromial decompression (acromioplasty)
  • Bursectomy
  • Coracoacromial ligament release
  • Rotator cuff reconstruction
► Subacromial decompression (acromioplasty)

Shoulder pain in subacromial impingement is attributed to the narrowing of subacromial space.
This narrowing can be due to bone spurs or soft tissue projecting from the acromion.
If the undersurface of the acromion is smoothened, then the subacromial space becomes wider.
This smoothening procedure is called subacromial decompression or acromioplasty.²·¹⁴

Subacromial decompression is one of the most common orthopedic procedures.²

  • Arthroscopic subacromial decompression

In arthroscopic acromioplasty, decompression is done arthroscopically.¹⁴

In this surgical technique, a small incision is made in the skin around the shoulder to insert a narrow instrument called arthroscope.

The arthroscope is a tube with a fiber-optic video camera attached to it. It allows the surgeon to view the inside of the shoulder joint and examine it without the need for a large cut.

To perform the operation, the surgeon makes additional small incisions to insert specially designed pencil-thin surgical instruments.

Arthroscopic surgery is a minimally invasive procedure. It is believed it can shorten the recovery time and allow earlier postoperative rehabilitation.²³

  • Open subacromial decompression

Open subacromial decompression is a surgical technique in which the acromial portion of the deltoid muscle is detached to perform the surgery.¹

Open surgery is usually the treatment of choice for chronic impingement syndrome¹ or for arthroscopic failures.²⁴

► Bursectomy

An inflamed and thickened bursa can cause pain.
Bursectomy is a procedure in which the surgeon removes the damaged bursa.¹

A medical study compared the outcomes of bursectomy with and without additional acromioplasty. The findings of the study show no significant difference in the clinical outcomes.¹⁴

However, it seems the acromion shape and the nature of symptoms can affect the surgical outcome.¹

► Coracoacromial ligament release

In this procedure, the coracoacromial ligament is gently detached.

A small cut or removal of pieces of the coracoacromial ligament can decompress the subacromial space.¹

This procedure is believed to relieve the impingement and its symptoms.²⁵

► Rotator cuff reconstruction

There are several surgical procedures available to treat rotator cuff defects.
Examples are:

  • Rotator cuff tendon debridement
  • Rotator cuff tendon repair
  • Tendon transfer


EXTRA: Rotator Cuff Defects and Tears

Learn more about treatment options for rotator cuff defects and tears.

Prognosis

Shoulder impingement can result in loss of function and disability of the shoulder.

If rotator cuff impingement left untreated, it might lead to partial or complete rotator cuff tears.⁸


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Shoulder Impingement: Home Treatment & Remedies

home_treatment_remedy​​-chapter6

What you learn in this chapter:

  • Educate yourself​
  • Shoulder pain management
    • Tens treatment
    • Trigger point release
    • Heat and ice therapy
    • Acupuncture
    • Shoulder massage
      • Deep tissue massage
      • Shiatsu massage
    • OTC topical pain relievers
  • Shoulder exercises
  • Nutrition and diet

Always consult with your doctor before trying any home treatments.

Health needs and risk factors are different for everyone. This means not every home treatment and remedy mentioned below is appropriate for you. Ask your doctor or health care provider to see which one is safe and effective for you.

Educate Yourself​

In addition to getting professional treatments and following your doctor’s instructions, there are several things you can do at home to manage the symptoms and accelerate your recovery.

The most important one is to educate yourself about shoulder impingement and its healing process.

FREE eBook: Shoulder Impingement Syndrome

The more you know about your shoulder condition, the better prepared you are to improve it.

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Knowing more enables you to make better decisions in your daily activities and the treatments you pursue.

“Many people, myself among them, feel better at the mere sight of a book.”

Jane Smiley, American novelist and Pulitzer Prize winner

read_books-websites

Such knowledge helps you in two main ways:

  • You can ask better questions from your doctor
  • You can explore new ways to restore your health

There are many good books and online resources out there you can use.
Many of them have pictorial instructions about prevention, treatment and symptom management.

Get a couple of books or subscribe to reliable websites and educate yourself.

The more you know, the better you understand how you can overcome this condition.

Shoulder Pain Management

There are several things you can do at home to manage your pain.
Even though the effectiveness and safety of some of the methods mentioned below are not medically proven, many people find them helpful.

► Tens treatment

TENS stands for transcutaneous electrical nerve stimulation.

In this therapy, a device called TENS unit is used to send electrical pulses through the skin to ease pain.

shoulder_tens_therapy

EXTRA: TENS Treatment

Learn more about TENS therapy and how you can do it at home for pain relief.

TENS unit

You can get a TENS unit and do this therapy yourself at home.
Since TENS units are portable, you can also use them at work or on the go.

Buy one of the below best-selling units and relieve your shoulder pain.

healthmateforever_YK15AB_tens_unit
HealthmateForever YK15AB
tens_7000
TENS 7000 2nd Edition
nursal_tens_unit
NURSAL TENS Unit

► Trigger point release

In trigger point therapy, pain is managed by pressing or rubbing trigger points on the body.

shoulder_trigger_point_release

Trigger points, also called myofascial trigger points, are a controversial topic in the medical field.

This could be because there is no clear understanding as to what they are or why they behave the way they do.

Regardless of lack of medical evidence, it seems some people find relief from this type of therapy.

trigger_point_taut_band_nodule

EXTRA: Trigger Point Release

Learn more about trigger point therapy and how you can do it at home for trigger point release.

Myofascial release tools

You can do this therapy by yourself at home using the below myofascial release tools.

These tools allow you to reach and stimulate the trigger points all over your body.

Buy one of them and start the therapy to ease your pain:

trigger_point_self_massage_tool
Self-massage tool
massage_stick
Massage stick
lacrosse_balls
Lacrosse balls
foam_roller
Foam roller

► Heat and ice therapy

Heat and ice therapy is a common practice in managing injuries, swelling, stiffness, and pain.
heat_ice_therapy

The heat treatment can help relax sore muscles of your shoulder while applying ice on your shoulder can help reduce inflammation and pain.

Heat and ice impact the blood flow in the below ways:

  • Heat increases the blood flow
  • Ice reduces the blood flow
Shoulder heating pad and ice pack

To do heat and ice therapy for pain relief, you can use an ice pack and a heating pad.

Use a towel during the therapy, so these products don’t touch your skin directly. That’s because extreme heat or cold can damage your shoulder tissues.

Also, keep in mind that both heat and ice impact the blood flow. So don’t apply them for too long. Application of heat or ice for too long can result in tissue damages such as frostbite or skin dehydration and burn.

Buy one of the below products to manage your shoulder pain:

shoulder_heating_pad
Heating Pad
shoulder_dual_hot_cold_therapy
Dual Hot Cold Wrap
shoulder_ice_pack
Gel Ice Pack

► Acupuncture for shoulder impingement

Acupuncture is a non‐drug therapy that can treat shoulder pain. Its effectiveness or safety is not yet proven by medical research.²⁶

In this therapy, acupuncture needles are inserted into the body to reduce pain.

This treatment seems to work by ²⁶

  • stimulating the body to release chemicals that ease the pain
  • suppressing pain signals in the nerves
  • allowing energy or blood to better flow in the body

During the treatment, the acupuncturist inserts the needles around the shoulder and upper arm.

You can get an appointment and try this therapy to ease your shoulder pain.

► Shoulder massage

Who doesn’t like a good massage?
A good massage by a massage therapist can increase circulation and relieve pain and tension.

However, always consult with your doctor before doing any massage therapy to make sure it is safe for you and your body can tolerate it without causing any complications.

shoulder_pain_massage_therapy

Massage styles

There are several styles of massage therapy, and each uses a different technique to manipulate the body.
Below are the two most common ones:

  • Deep tissue shoulder massage

As the name suggests, deep tissue massage allows deep penetration into muscle tissue to relieve pain and tension.

This massage style is more of an aggressive type since it targets deeper layers of the muscles.

Some people might find it painful if they are used to gentle massages.

deep_tissue_shoulder_massage

  • Shiatsu shoulder massage

Shiatsu is a type of Japanese massage performed by hands.

In this style, body manipulation is done by applying pressure with thumbs, fingers, and palms.

shiatsu_shoulder_massage

Shoulder self-massage

To get a good massage you not only can go to a therapist but you can get a body massager and do it yourself.

Here are some benefits of a self-massage:

  • You decide where, when and how much massage you want to receive.
  • You are in control of its intensity and pressure level.
  • You don’t need to get an appointment, take time off from work or pay each time you get a massage.
Self-massage tools

There are body massagers in the market that incorporate deep tissue massage and Shiatsu techniques and mimic a therapist’s massage strokes.

Buy one of the below massagers and enjoy a self-massage in the comfort of your home.

deep_tissue_massager
Deep Tissue Percussion Massager
deep_tissue_percussion_massager
Facial & Deep Tissue Percussion Massager
deep_kneading_shiatsu_massager
Deep-kneading Shiatsu Massager

► OTC topical pain relievers

Over-the-counter topical pain relievers can also alleviate your muscle pain and soreness.

These products come in different shapes and forms:

  • Pain relief cream and gel
  • Pain relief spray
  • Pain relief roll-on
  • Pain relief patch

shoulder_topical_pain_relief

Shoulder Impingement Exercises

Stretching and exercise can help you increase your shoulder strength, flexibility, and mobility.

They can also help you with reducing pain over time.

crossover_arm_stretch_shoulder_exercise

Your doctor or therapist will give you a set of exercises to do at home as part of your treatment.

There are also plenty of books and online resources that provide step by step exercise instructions to address shoulder impingement syndrome.

But make sure to consult with your doctor beforehand to see if they are appropriate for you.

Shoulder physical therapy equipment

Many shoulder rehabilitation exercises require accessories to engage the right muscles and joints.

Below tools are the most common shoulder rehab equipment that you can buy and use during your workout at home:

shoulder_finger_ladder_exercise
Shoulder finger ladder
shoulder_resistance_band_exercise
Resistance Bands
shoulder_pulley_exercise
Overhead Shoulder Pulley


EXTRA: Shoulder Finger Ladder Exercise

Learn more about shoulder ladder exercise and how you can do it at home.

Nutrition and Diet

Your overall health and fitness can influence your symptoms and recovery.

A proper diet along with nutritional supplements can help you improve your health and wellness.
But always check with your doctor before taking any supplements.

  • Anti-inflammatory diet

Foods that fight inflammation like Mediterranean diet can help reduce pain and inflammation associated with shoulder impingement.

  • Dietary and herbal supplements

Supplements can help the body to reduce pain and inflammation.
They can also enhance joints overall health and prevent re-injuries.
Examples are supplements that contain omega-3 (fish oil), Glucosamine and Chondroitin with MSM, turmeric, and ginger.


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Considerations

Please note that the information compiled in this article is from a variety of sources and it may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. Always seek the advice of a doctor or other qualified health providers with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. Learn more

REFERENCES

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[5] Chester, R., Smith, T. O., Hooper, L., & Dixon, J. (2010). The impact of subacromial impingement syndrome on muscle activity patterns of the shoulder complex: A systematic review of electromyographic studies. BMC Musculoskeletal Disorders, 11,45. doi:10.1186/1471-2474-11-45

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[11] Kirchhoff, C., & Imhoff, A. B. (2010). Posterosuperior and anterosuperior impingement of the shoulder in overhead athletes—evolving concepts. International Orthopaedics, 34(7), 1049-1058. doi:10.1007/s00264-010-1038-0

[12] Manske, R. C., Grant‐Nierman, M., & Lucas, B. (2013). Shoulder posterior internal impingement in the overhead athlete. International Journal of Sports Physical Therapy, 8(2), 194–204. PMCID: PMC3625798, PMID: 23593557

[13] Neer, C. S. (1983). Impingement Lesions. Clinical Orthopaedics and Related Research, 173, 70–77.

[14] Beard, D. J., Rees, J. L., Cook, J. A., Rombach, I., Cooper, C., Merritt, N., . . . Woods, D. (2018). Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): A multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet, 391(10118), 329-338. doi:10.1016/s0140-6736(17)32457-1

[15] Singh, B., Bakti, N., & Gulihar, A. (2017). Current concepts in the diagnosis and treatment of shoulder impingement. Indian Journal of Orthopaedics, 51(5), 516. doi:10.4103/ortho.ijortho_187_17

[16] Carli, A. D., Pulcinelli, F., Rose, G. D., Pitino, D., & Ferretti, A. (2014). Calcific tendinitis of the shoulder. Joints, 2(3), 130–136. PMCID: PMC4295680, PMID: 25606556

[17] Rogerson, J. S. (2008). Role of Arthroscopic Decompression and Partial Clavicle Resection. Arthroscopic Rotator Cuff Surgery, 83-104. doi:10.1007/978-0-387-39343-8_7

[18] Umer, M., Qadir, I., & Azam, M. (2012). Subacromial impingement syndrome. Orthopedic Reviews, 4(2), 18. doi:10.4081/or.2012.e18

[19] Dong, W., Goost, H., Lin, X., Burger, C., Paul, C., Wang, Z., . . . Kabir, K. (2015). Treatments for Shoulder Impingement Syndrome. Medicine, 94(10), e510. doi:10.1097/md.0000000000000510

[20] Bannuru, R. R., Flavin, N. E., Vaysbrot, E., Harvey, W., & Mcalindon, T. (2014). High-Energy Extracorporeal Shock-Wave Therapy for Treating Chronic Calcific Tendinitis of the Shoulder [Abstract]. Annals of Internal Medicine, 160(8), 542. doi:10.7326/m13-1982

[21] Page, M. J., Green, S., Mrocki, M. A., Surace, S. J., Deitch, J., Mcbain, B., . . . Buchbinder, R. (2016). Electrotherapy modalities for rotator cuff disease. Cochrane Database of Systematic Reviews, (6), CD012225. doi:10.1002/14651858.cd012225

[22] Fujiya, H., Ogura, Y., Ohno, Y., Goto, A., Nakamura, A., Ohashi, K., . . . Goto, K. (2015) Microcurrent Electrical Neuromuscular Stimulation Facilitates Regeneration of Injured Skeletal Muscle in Mice. Journal of Sports Science and Medicine (14), 297-303.

[23] Pillai, A., Eranki, V., Malal, J., & Nimon, G. (2012). Outcomes of Open Subacromial Decompression after Failed. ISRN Surgery, 2012, 806843. doi:10.5402/2012/806843

[24] Bhattacharyya, R., Edwards, K., & Wallace, A. W. (2014). Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: A cohort study. BMC Musculoskeletal Disorders, 15, 324. doi:10.1186/1471-2474-15-324

[25] Okutsu, I., Ninomiya, S., Takatori, Y., Hamanaka, I., Schonholtz, G. J. (1992). Coracoacromial ligament release for shoulder impingement syndrome using the Universal Subcutaneous Endoscope system [Abstract]. Arthroscopy, 8(1), 2-9.

[26] Green, S., Buchbinder, R., & Hetrick, S. E. (2005). Acupuncture for shoulder pain. Cochrane Database of Systematic Reviews, (2), CD005319. doi:10.1002/14651858.cd005319