Does it hurt to lift your shoulder over your head? If you go to a physician or consult Dr. Google, chances are you will be diagnosed with shoulder impingement. If you went to see a physician, they probably spent very little time explaining the condition to you. A study showed that the average primary care physician spends fewer than 17 minutes with a patient. This is usually not enough time for a thorough examination and explanation of your diagnosis. I often see clients who come to me saying, “I have shoulder impingement,” and when I ask what they think that means they say, “I have no idea.” This is a huge failure on our part as healthcare providers. It opens the door for confusion and fear among people. So let’s dive into what shoulder impingement really is!
First of all, shoulder impingement or any other shoulder injury is actually quite common. Research shows that anywhere from 16-30% of the population has shoulder pain in a month (1). It can be helpful to understand that you are not in the minority to experience shoulder pain. We often catastrophize our own injuries and assume the worst. However, 60% of people with shoulder impingement get better simply with conservative treatment.
Before we get further into impingement, it is important to understand the anatomy of the shoulder. Here is an image that shows many structures of the shoulder:
First of all, there are a lot of structures in and around the shoulder. It is a complicated joint. The shoulder is unique in that there is less bony support than any other joint in the body, and this allows for the immense range of motion. Think about the fact that you can move your shoulder in almost any direction. Now try to move your elbow in all directions. You cannot. It is only able to flex and extend. The freedom that allows shoulder mobility comes at a cost. Muscles and other structures have to be finely tuned because they are most of the support.
When things go wrong, we have irritation and that can be a cause of impingement. There are two categories of shoulder impingement: primary and secondary. Primary impingement is based on structural deviations that cause the space in your shoulder joint to be narrowed. Most impingement cases occur in the sub-acromial space, underneath your acromion bone.
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Sometimes your acromion bone can have a bony abnormality that decreases space in the joint.
shoulderdoc.co.uk
Secondary impingement is a result of functional issues such as tight or weak surrounding muscles. As I mentioned before, the shoulder has a lot of muscles and very little room for error in the joint.
So what can be done for shoulder impingement? It turns out there are multiple things to consider, but the first is the cause. Surgery is sometimes required particularly if there is primary impingement, but let’s think through the situation. Your bone has probably been shaped that way your entire life. It started causing pain and limiting your function for a reason. If you painted a room and your shoulder hurt, is the problem related to a bone that probably hasn’t changed for your entire life, or is it from a recent activity?
It can be easy to use imaging to find problems. We all have bumps and bruises from life, think of wear and tear as internal gray hair or wrinkles. A common cause of shoulder impingement or other issues is a rotator cuff tear. This can be seen on an MRI. However, did you know that almost 17% of non-symptomatic shoulders also had rotator cuff tears based on a study (2)? Another fun fact, a study was performed on 18 patients who had surgery to repair massive rotator cuff tears. When re-examined 1 year after surgery, 17 had re-torn their rotator cuff. Amazingly, 16 out of the 18 patients had a decrease in pain after the surgery and 12 had no pain at all (3).
All of this is to say that imaging is not the whole picture. A thorough physical evaluation along with a look into possible injury causes is crucial. If going overhead is painful, then modifying your activity to avoid this for the time being can be beneficial. However, you should try to do as much activity as you can tolerate. Often, people suffer an initial injury, become afraid to exercise, and the segment gets weaker and more painful. This downward spiral is all too common in healthcare.
My preferred methods of treatment for shoulder impingement involve a combination of manual therapy and exercise. Manual therapy typically involves dry needling or some type of soft tissue mobilization (cupping, scraping, massage, etc.) to decrease muscle guarding in the affected area. After experiencing pain, it is normal for your muscles to tighten up as a protective response. We need to help them relax and then reinforce their new mobility with exercises into comfortable ranges. The goal of physical therapy is to gently guide you back into full range of motion along with strengthening the surrounding muscles to hopefully prevent the injury from happening again.
While many injuries are flukes, there can be underlying factors that need to be addressed, and quality physical therapy should do so. The goal when you come into PT is to give you a picture of what happened, why it happened, and what we can do about it. Hopefully this gives you some idea of what goes into the diagnosis of shoulder impingement!
If you have any questions or are suffering from shoulder pain and want to figure out what is going on and how to fix it, reach out and come see me at our office in Sterling, VA.
1 Garving C, Jakob S, Bauer I, Nadjar R, Brunner UH. Impingement Syndrome of the Shoulder. Dtsch Arztebl Int. 2017;114(45):765-776. doi:10.3238/arztebl.2017.0765
2 Steuri R, Sattelmayer M, Elsig S, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. British Journal of Sports Medicine 2017;51:1340-1347.
3 Galatz, Leesa M. MD1; Ball, Craig M. FRACS2; Teefey, Sharlene A. MD3; Middleton, William D. MD3; Yamaguchi, Ken MD1 The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears, The Journal of Bone & Joint Surgery: February 2004 - Volume 86 - Issue 2 - p 219-224