Shoulder Impingement

Background
Shoulder impingement is a very common disorder seen in the clinical world. The most
common muscle involved in shoulder impingement disorders is the supraspinatus muscle of the
shoulder. This muscle is part of the collection of five other muscles that create the rotator cuff,
these include, subscapularis, infraspinatus, and teres minor. The supraspinatus muscle is
commonly involved due its location on the scapula. This muscle passes underneath the acromion
and the acromioclavicular ligament, therefore swelling of this muscle causes the space between
the muscle and bone to narrow and pinch against one another, leading to pain and discomfort
when the arm is in abduction. There are other subacromial space pathologies that result in similar
symptoms, these include, partial rotator cuff tears, rotator cuff tendinosis, calcific tendintis and
subacromial bursitis (Koester, George, & Kuhn, 2005). Shoulder impingement occurs most
commonly in individuals who overuse the overhead movement of the shoulder, examples
include, mail sorters, painters, swimmers, tennis players and many other overhead
movements/sports. It is also highly prevalent in older individuals that have weaker supporting
muscles and have overworked them. If untreated, this swelling can lead to poor blood supply to
the supraspinatus tendon which can ultimately lead to calcium deposits producing extreme pain
and discomfort.

Etiology
Although not fully understood, the cause of shoulder impingement is usually from over
use of the shoulder from repeatedly using it in the same movements. Individuals can cause this
impingement through improper mechanics of their movements, repeatedly lifting shoulder
overhead with the elbows out to the side causes compressive forces and can lead to the over use
and swelling of the joint. Lifting the arms overhead causes the pinching between the muscle and
bones. This disorder can also be posture related (Mackenzie, Herrington, Horlsey, & Cools,
2015). There are two classifications of major factors that increase risks, these are extrinsic
factors , those that compress structures within the space and intrinsic factors, those related to
degeneration of rotator cuff tendons, these factors are both associated with shoulder
impingement (Mackenzie et. al, 2015). Extrinsic factors include issues with alignment,
anatomical/osseous, kinematic, muscular extensibility as well as ergonomic and sport specific
factors (Mackenzie et. al, 2015). Intrinsic factors include those associated with degeneration
and/or alterations in mechanical properties, morphology, biology and vascularity within the
tendon (Mackenzie et. al, 2015). Commonly, there is a contribution from both extrinsic and
intrinsic factors that lead to shoulder impingement (Mackenzie et. al, 2015).

Diagnosis
Once patient comes in with shoulder pain, physiotherapists begin tests to correctly
identify the major muscle involved to create a plan of action for treatment and recovery. Patients
usually complain of discomfort at night, while lying on the injured shoulder, or during daily
activities such as reaching in a higher cupboard to grab items (Koester et. al, 2005). A proper
examination of the upper extremities should be assessed. There are tests that can be administered
to determine the diagnosis. The Lift-Off-Test involves isolating the subscapularis by placing one
hand behind the back, palm facing the examiner behind them, the patient then tries to push the
examiners hand away from theirs (Koester et. al, 2005). Another test is used to determine the
external rotation of the shoulder, the patient is instructed to hold arms out to the side with elbows
flexed, during this movement the examiner pushes their arms inwards while they try to restrict
(Koester et. al, 2005). When isolating the supraspinatus the patient abducts the arms at 90
degrees and then forward flexes them to 30 degrees while internally rotating them until the
thumbs face the floor, the examiner then pushes the forearms downwards while the patient
restricts (Koester et. al, 2005). Two commonly used tests are the NEERS and Hawkins-Kennedy
test (Koester et. al, 2005). The NEERS test is done by bringing the arm up overhead in internal
rotation while supporting the scapula (Koester et. al, 2005). The Hawkins-Kennedy test is done
by bending the elbow at 90 degrees with forward elevation and internal rotation (Koester et. al,
2005). Positive tests indicator there is an impingement (Koester et. al, 2005).

Treatment Techniques
The goal of treating patients with shoulder impingement is to increase the space in the
shoulder and diminish the pain associated with overhead movement. This is done by increasing
blood flow, decreasing scar tissue, teaching proper movement mechanics and strengthening the
supporting muscles. There are numerous methods that are incorporated into the treatment plan,
these include, heat, cold, shockwave and ultrasound therapy, electrotherapy, acupuncture as well
as education and exercise programs (Saltychev, Aarimaa, Virolainen, & Laimi, 2015). Therapists
first determine if treatment can assist in recovery of the shoulder, if it is too severe than surgery
may be necessary (Saltychev et. al, 2015). The use of manual therapy or manual mobilization has
been shown to be effective at improving shoulder function and decreasing pain and disability of
the shoulder (Braun, Bularczyk, Heintsch & Hanchard, 2013). Once the patient is diagnosed with
shoulder impingement they should be educated on proper movements and encouraged to rest the
injured shoulder. Once the patient is showing improvements and scar tissue has broken down,
they should be introduced to exercises that help stabilize and increase strength in the shoulder
(Braun et. al, 2013).

Patient Handout
Home Management

While at home, try to avoid overhead movements that will cause discomfort. When lifting
overhead ensure proper movement is completed, patient should have elbows in line with

the floor rather than pointing out to the side.

Avoid sleeping on injured shoulder
Work on proper posture
Patient should work on ROM stretches
Stretches and exercises could include:
o Lateral arm raises ensure elbows are pointed to the ground
o Lateral arm raises at 45 degree
o Anterior arm raises ensure elbows are pointed to the ground
o External rotation with resistance band
o Exercise ball counter and clockwise shoulder rotations
o Angel stretch ensure you always maintain two points of contact

Braun, C., Hanchard, N. C. A. (2010). Manual therapy and exercise for impingement-related
shoulder pain. Physical Therapy Reviews, 15(2) 62-83.
Koester, M. C., George, M. S., Kuhn, J. E. (2005). Shoulder impingement syndrome. The
American Journal of Medicine, 118(5), 452-455. doi: 10.1016/j.amjmed.2005.01.040

Mackenzie, T. A., Herrington, L., Horlsey, I., Cools, A. (2015). An evidence-based review of
current perceptions with regard to the subacromial space in shoulder impingement
syndromes: is it important and what influences it? Clinical Biomechanics, 30(7), 641648. doi: 10.1016/j.clinbiomech.2015.06.001
Saltychev, M., Aarimaa, V., Virolainen, P., Laimi, K. (2015). Conservative treatment or surgery
for shoulder impingement: systematic review and meta-analysis. Disability and
Rehabilitation, 37(1), 1-8. doi: 10.3109/09638288.2014.907364