Shoulder Impingement: The 7 steps to fix it!

shoulder impingement
Image courtesy of stockimages at FreeDigitalPhotos.net


Here’s what to expect in this post:


// What is Shoulder Impingement?

Shoulder Impingement is a condition where certain structures in the shoulder (… namely the Subacromial bursa and Supraspinatus tendon) get squashed by the surrounding bones.

As a result, shoulder pain can arise from 2 main issues:

  • a) Subacromial bursitis
  • b) Supraspinatus tendonopathy.

a) Subacromial bursitis:

subacromial-bursitis

What does this mean?… Let’s break it down into simpler terms:

  • Subacromial = “underneath the acromion”. (The acromion is a bony part of your shoulder blade.)
  • Bursitis “inflammation of the bursa”. (A bursa is a fluid-filled sac within the shoulder complex.)

Translation: It is the inflammation of the fluid-filled sac structure in the area of your shoulder that is underneath the acromion.

… Still confused?… You see that red thing in the above picture? … It’s getting squashed …and it’s causing your pain!

b) Supraspinatus tendonopathy:

supraspinatusimpingement

The Supraspinatus muscle is part of a group of shoulder muscles which has the important role of stabilising the shoulder joint.

As the tendon of the Supraspinatus is subject to getting squashed in Shoulder impingement, it can lead to inflammation, strains and tears.

 

// Area of pain

supraspinatus-2

With Shoulder impingement, the area of pain is usually felt deep within the shoulder joint.

In many cases, pain can also refer down the side of your upper arm. (see above)

// What are the causes?


Video from Smart PT Pro.

Since the area where your Subacromial bursa and Suprasinatus tendon is located is already very narrow, it is subject to being squashed and irritated. (see video)

There is further narrowing of the area when you move your shoulder (eg. lifting/throwing/pulling/pushing/carrying). And even more so if the shoulder is not moving properly.

… But here’s the real issue:

Your posture.

If you have bad posture… your shoulder will be in a position which will amplify the impingement of the bursa and tendon!

By fixing your posture, you will be addressing the root cause of your Shoulder impingement issue.

 

// The posture of someone with Shoulder Impingement

kyphosis

This type of posture is very common in people with Shoulder Impingement. (.. although I must admit I may be exaggerating it just a tad bit).

It places the shoulder in a very ineffective position which predisposes the bursa and tendon to being impinged.

… How does your posture compare?

// Do you have Shoulder Impingement?

Here are 3 quick tests that you can do to find out!

a) Painful arc

painful-arc

Instructions:

  • Raise your arm out to the side and over your head.
    • (Also known as Shoulder abduction)
  • You may have Shoulder Impingement… if you have pain between ~60-120 degrees of abduction, but nil/reduced pain at early and late movements.

b) Hawkins Kennedy test

crank-test

Instructions:

  • Bring your bent arm bent to 90 degrees of shoulder flexion in front of you. (see above)
  • Crank your hand down with the help of your other hand. (Internal rotation)
  • You may have Shoulder Impingement if this movement reproduces your symptoms.

c) Neer’s test

neer-test

Instructions:

  • Raise your arm in front of you with your thumb pointing downwards.
  • You may have Shoulder Impingement if this movement reproduces your symptoms.

Note: These tests for Shoulder Impingement give a general guide line in diagnosing your shoulder problem. Many other structures in your shoulder can also make these tests reproduce pain as well.

 

 


The 7 steps to fix your Shoulder Impingement

shoulder-hurts
Image courtesy of stockimages at FreeDigitalPhotos.net

  1. Stop all activities that cause pain
  2. Reduce inflammation
  3. Reduce pressure on squashed structures 
  4. Release tight muscles
  5. Start with these exercises
  6. Scapula position
  7. Strengthening exercises

Note: Each exercise must be comfortable and performed gently. Listen to  your body!


Step 1: Stop all activities that cause pain

How can you expect your shoulder to get better if you keep exposing it the activities that make it worse?

stop

It may sound really straightforward, but I’ve seen so many people get this first simple step wrong.

… STOP aggravating your pain!

The body can not (…and will not) heal itself if you don’t allow enough time for it to do so.

“… If it hurts, don’t do it!”

Avoid over head movements, lifting and sleeping on the painful shoulder!

reachingover-head-liftingside-sleeping-no

Step 2: Reduce inflammation

If there is excessive inflammation in the area, everything will be painful! Once the inflammation levels have subsided, we can then start to do some exercises without aggravating the shoulder again.

a) Anti-inflammatory gel

voltaren

Apply the anti-inflammatory gel to the whole shoulder.

Do this 2-3/day.

I prefer products with natural active ingredients like arnica, calendula or hypericum.

 

b) Non-steroidal anti-inflammatory drugs (NSAIDs)

It is recommended that you take the anti-inflammatory medication for at least 7-10 days.

(**  Please consult your general practitioner before taking any new medication)

 

c) Ice/Cold therapy

coldpack

Apply an ice pack to your shoulder for at least 10-15 minutes.

Do this 4-5/day.

 

d) Shoulder sling

shoulder-sling

If all else fails, you can temporarily immobilise your shoulder for a short period of time. (… but I wouldn’t go past 2 days!)

Step 3: Reduce pressure on painful structures

a) Shoulder traction (with a resistance band)

traction-shoulder

Instructions:

  • Anchor a strong resistance band underneath your foot.
  • Whilst holding onto the end of the resistance band, start to lean away from the band.
  • Aim to feel a downward pulling sensation in your shoulder.
  • It is important that you keep your shoulder as relaxed as possible.
  • Apply more tension to the band if you would like to increase the stretch.
  • Hold for 30 seconds.
  • Repeat 3-5 times.

Step 4: Release tight muscles:

If your posture is not ideal, then your shoulder will be in an sub-optimal position. This leads to a higher risk of Shoulder Impingement!

Tight muscles are pulling you shoulder girdle out of the ideal alignment. We need to release those muscles first!


Instructions:

  • Place target area on to a massage ball (or foam roller).
  • Apply a firm pressure in a small circular motion.
  • Aim to do 1 minute on each area.
    • (… or as long as you require)

Images from TriggerPoint.

a) Pec minor

pec-minor-trp

 

b) Upper trapezius

upper-trap-trp

 

c) Latissimus Dorsi

lats-trp

 

d) Serratus anterior

serratus-trp

f) Posterior capsule

A tight posterior capsule can push the humeral head forward in the shoulder socket. This may increase the chance of shoulder impingement.

posterior-capsule-trp

 

Note: Following these releases, I strongly recommend that you also stretch the muscles for best results.

 

Step 5: Initial exercises

The goal here is to keep the shoulder as mobile as possible.

Do what you can. Don’t do more than you can do…

Depending on the severity of your pain, these exercise may be quite challenging (… or not difficult at all). If there is nil issue, move on to Step 6.

a) Pendulum

pendulum

Instructions:

  • Lean over to allow your arm to dangle underneath you.
  • Using the momentum of your arm, gently sway your arm side ways/forwards/backwards/circles.
  • Allow the shoulder to move as much as you can without reproducing any pain.
  • Repeat each movement for 10 repetitions each.

 

b) Forward leans

shoulder-flexion

Instructions:

  • Place your hand on the back of a chair.
  • Lean forward as to bring your arm in an upwards direction.
    • Do this as much as you can without reproducing any pain.
  • Repeat 20 times.

c) Rotations

extrotn-movement

Instructions:

  • Bend your elbows to 90 degrees.
  • Keep your elbows in contact with the side of your body.
  • Proceed to rotated your arm outwards/inwards.
  • Allow the shoulder to move as much as you can without reproducing any pain.
  • Repeat 20 times.

Step 6: Scapula position

Many dysfunctional positions of the scapula will increase the chance of Shoulder Impingement from occurring.

By optimising posture (… and with it the scapula position), the subacromial area where it is subject to narrowing will be adequately maintained.

Note: There is no one perfect position of the scapula. The scapula is designed to move and be adaptive to whatever function it needs to perform.


Video from Daily Bandha.

Main points:

  • The scapula should glide smoothly and be well controlled on the rib cage.
  • As the arm is raised, the scapula should laterally rotate so that the inferior angle reaches the side of your ribs.
  • Over head arm movement is highly reliant on optimal scapula positioning.
  • It can help if you visualise how the scapula should be moving as you use your arm.
  • The scapula should sit flat on the rib cage throughout movement.

Step 7: Strengthening

You must ensure optimal scapula positioning throughout all of these exercises. This is CRUCIAL!

1. Isometric training:

This involves strengthening your shoulder muscles without moving.

This is to make sure that you do not aggravate the inflammation in  your shoulder.

External rotation

isometric-external-rotation

Instructions:

  • Keep you elbows tucked to the side of your body.
  • Pull the resistance band away from each other.
  • Bring your arms forward by 10cm.
  • Hold this position for 30 seconds.
  • Repeat 3 times.

 

 

2. Anti-impingement training:

rotatorcuffstability

If the shoulder bone (… also known as the humeral head) is not centrated in the shoulder joint, it can often move in an upwards position. This can lead to the impingement of the structures in the subacromial space.

Humeral head depression:

You need to get familiar with the sensation of depressing your humeral head in your shoulder socket.

Imagine your shoulder bone is constantly being sucked in a downwards/inwards direction into the socket whilst you move your arm. (see picture above)

(This may take some time to understand and perform correctly… and that’s fine. Keep at it!)

a) Extension:

extension

Instructions:

  • Anchor resistance band on top of the door.
  • Face the door.
  • Starting at shoulder height, pull the resistance band down towards your body.
  • Keep constant tension through resistance band throughout movement.
  • Hold for 3-5 seconds.
  • Slowly return the hand back to shoulder height
    • If this hurts, you may want to start at a lower height
  • Repeat 10-30 times. 3 sets.
  • Progression:
    • Start from a higher position.
    • Apply more tension to the band

b) Adduction:

adduction

Instructions

  • Anchor resistance band on top of the door.
  • Stand side on to the door. The affected shoulder should be closer to the door.
  • Starting at shoulder height, pull the resistance band down towards your body.
  • Make sure your palms are facing forward.
  • Keep constant tension through resistance band throughout movement.
  • Hold for 3-5 seconds.
  • Slowly return the hand back to shoulder height
    • If this hurts, you may want to start at a lower height
  • Repeat 10-30 times.
  • Perform 3 sets.
  • Progression:
    • Start from a higher position.
    • Apply more tension to the band

c) Internal rotation:

ir

Instructions:

  • Anchor the resistance band at elbow height.
  • Stand sideways with the affected arm closer to the door.
  • Pull the band towards your body.
  • Aim to keep your elbow in contact with the side of your body.
    • Think about squeezing a piece of paper between your elbow and the side of your body
  • Repeat 10-30 times
  • Perform 3 sets
  • Progression:
    • Apply more tension to the band

3. Against gravity

Progress to these exercises only if you are able to conduct the previous Shoulder Extension, Adduction and Internal rotation exercises easily.

Ensure that you are depressing your humeral head throughout movement. (see above exercises)

a) Flexion:

flexion

Instructions

  • Stand on the end of a resistance band.
  • Aim to pull the resistance band upwards to shoulder height.
    • Consider lifting as high as possible with NO pain.
  • Keep constant tension on the resistance band throughout movement.
  • Hold for 3-5 seconds.
  • Slowly return the hand back to the body.
  • Repeat 10-30 times.
  • Perform 3 sets.

b) Abduction:

abduction

Instructions:

  • Stand on the end of a resistance band.
  • Pull the resistance band side ways to shoulder height.
    • Consider lifting as high as possible with NO pain.
  • Keep constant tension on the resistance band throughout movement.
  • Hold for 3-5 seconds at end range.
  • Slowly return the hand back to the body.
  • Repeat 10-30 times.
  • Perform 3 sets.

c) External rotation:

ext-rotn

Instructions:

  • Anchor the resistance band at elbow height.
  • Stand sideways with the affected arm further from the door
  • Pull the band away from your body.
  • Aim to keep your elbow in contact with the side of your body at all times.
    • Think about squeezing a piece of paper between your elbow and the side of your body
  • Repeat 10-30 times
  • Perform 3 sets

 

4. Get strong at your meaningful task

Ask yourself:

What exact activity can’t you do because of your painful shoulder?

You need to find an exercise that will mimic the motion of doing this SPECIFIC movement/activity.

For example: If you have difficulty hanging out the clothes on the clothes line… you can do the following exercise:

meaningful-task

Instructions

  • Stand on the end of a resistance band.
  • Aim to pull the resistance band upwards to above shoulder height.
    • Make sure there is NO pain.
  • Keep constant tension on the resistance band throughout movement.
  • Hold for 3-5 seconds.
  • Slowly return the hand back to the body.
  • Repeat 10-30 times.
  • Perform 3 sets.

(… Have no idea what to do? Send me an email and I will help you out!)

 

Step 8: Fix your posture!

Remember… if your bad posture is placing your shoulder is an ineffective position, it is going to be susceptible to injury. (… and that includes getting shoulder impingement!)

Oh no… 🙁

… But you’re in luck! I’ve dedicated this WHOLE website to offering the exact strategies to fix your posture.

Bad posture is the root cause of your pain!

Have a look at these posts to get your started:

 

// What about the Cortisone injection?

cortisone-needle

If you have already been to your doctor, then the chances are that they have already suggested that you get the cortisone injection.

“Huh? What’s that?…”

This particular injection consists of a steroid (cortisone) and an analgesic substance.

The aim of the injection is to:

  • a) reduce the inflammation and
  • b) reduce the pain by numbing the area.

Sounds great in theory… right?

Yes.

BUT – The problem is that it does absolutely nothing to address the underlying cause of the shoulder impingement.

More often than not – the injection may provide some short term relief, but only to have the pain come back at a later date (… and usually with a vengeance!).

“Mark! … But what do YOU suggest?”

I say, see how you go with these 7 steps for about 4-6 weeks. If there is absolutely no improvement (… or if it’s getting worse), you then can consider getting one.

It should NEVER be the first thing that you do.


Any questions?…

Leave a comment down below and I will get back to you!

About

I am a physiotherapist who has personally experienced the pain as a result of bad posture. I would like to offer you some of the solutions that I and my patients have greatly benefited from.

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31 thoughts on “Shoulder Impingement: The 7 steps to fix it!

  1. Can a shoulder impingement cause a winged scapula? What about the reverse?

    I had labrum repair on my right shoulder. Once it healed, I realized that I had a severe (3 to 4 inches) winged scapula. I can’t support the weight of my arm when it is above my head. It has been months and the doctor/PT has told me that they think it is LTN damage but that it will regenerate and be ok. We have had no MRIs or any other images taken of this area post surgery.

    I have been through two months of physical therapy and I am not seeing any progress. My doctor has suggested a shot but I don’t know if that will really help me.

    I have winged scapula, shoulder pain, my trap is overworked so I have a sharp pain going from my trap into my shoulder on top (hurts to touch), pain while lifting my hand over head (and during other shoulder impingement tests). One thing is that I don’t have too much pain in my right shoulder until I start reaching the top of my range (head is almost directly over head). I am lifting my hand with my trap mostly.

    I have tried different serratus anterior exercises but I can’t tell if I am working that muscle or if my lat and pec minor are doing all of the work. I can see my pec minor contract when doing all of the serratus anterior exercises.

    What should I do? I think I need to get some imaging to help determine what is wrong!

    1. Hi Ryan,

      Yes – a Winged scapula can result from impingement of the shoulder. (And conversely, winging can also predispose you to impingement.)

      Your winging may be due to the body compensating a) for weak muscles +/- nerve damage, b) tight structures and/or c) to avoid pain.

      It sounds like you are shrugging your shoulders to elevate your arm. This may be indicative that you have weak shoulder stabilising muscles (namely the rotator cuff and serratus anterior) and/or tight inferior capsule/lats/triceps.

      Ideally with arm elevation – you would like the serratus anterior and trapezius muscle to laterally rotate your shoulder blade so that you do not have to shrug your upper traps.

      Do you have full shoulder External and Internal rotation? I would check this first. (see link)

      You can get a MRI if you would like to double check everything.

      Mark

  2. I’ve been in physical therapy for 3 months for my impingement. I’ve gained some strength and mobility but I still have pain. I’ve tried 2 weeks of Advil but I can’t keep taking them due to gastritis from the anti inflammatories. Is it time for a cortisone shot? I’m getting frustrated

    1. Hi Ilene,

      I am not really a huge fan of the cortisone shot as I feel that most inflammation can settle once you remove the aggravating factor… but if you have tried everything with physical therapy and still not getting anywhere, it may be worth a shot.

      Mark

  3. Thanks Mark best advice I’ve come across for my shoulder. I’ve had impingement and subacromonial bursitis and these exercises made a massive improvement so much so I happily refused the steroid injection. My weakest area is external rotation but it’s much improved. The issue I have still with no resolve is tightness in the infraspinatus. When it’s really tight I can feel the humeral head off centre. If I abduct my arm and push the infraspinatus with a ball against the wall I get clicking and the tightness releases and humerus gets centred. Sometimes doing a chair lean stretch also resolves it. Is there an exercise I should be doing to prevent the tightness or is the tightness caused by weak external rotation? Thanks S

    1. Hey S,

      If the infraspinatus is tight, you can do stretches for it:

      Also make sure you have full INTERNAL ROTATION:

      70 degrees is what you want.

      If it is weak, continue with the strengthening exercises.

      Mark

      1. Brill thanks! I’ve added in the stretch as that one helps a lot. Just checked my internal rotation and very tight there too – probably at 60. It’s much less than it used to be before injury. Will stretch internal rotators as well. Thanks!

      2. Hello,

        I can’t understand what to do to mimic the above as dropping you arm down to 70 degree’s seems easy – What am I missing- to get better internal rotation is my issue as well.

        Please elaborate when you can

        1. Hi Raymond,

          If you can do 70 degrees easy:
          a) You have very good shoulder mobility
          b) You compensated your way to 70 degrees.

          I am going to assume you are b) as if you are a), then all is good!

          If you compensated your way to 70 degrees, you likely did not keep you shoulder back and down in a neutral position. Many people “cheat” this movement by letting their shoulder girdle rise up and forward.

          Let me know if that made sense.

          Mark

          1. Hi Mark,

            I finally got this I do not have close to 70 internal rotation since I had PT check it-more like 40 degrees- no wonder its hard to raise that shoulder

            Now i need to focus on the External Stretch’s she said the range can be improved by doing these frequently. You have provide some and are much appreciated i hope this can get back to at least 60? What is the best one i can do daily?

          2. Hey Raymond,

            The best stretches for Internal rotation of the shoulder joint
            – Sleeper stretch
            – Arm across body stretch

            Aim to get a specific stretch in the back of your shoulder joint.

            Mark

  4. Hi Mark
    49 yr old male . love cricket still but have knocking sound in between 90 and 180 degree
    and have zero external rotation. upon acceleration and at point of release my arm goes into extreme pain zone recovery is about 2-3 minutes before the pain goes away.
    When i heavily tape shoulder so that i kinda push it inwards the pain is not as bad. My feeling is im pushing over tissue that provides some cushioning to affected area. Mri did show some laberal tears but this seems common pathology with 49 yr old male. Im getting desperate for the inpingement to be fixed. Ive seen 7 different dr or physios and im just paying their holiday house off. Any advice

    1. Hey Chris,

      If you have no external rotation, that would be a good place to start.

      Without External rotation in your shoulder joint, there is no way you can safely raise your hand over 90 degrees (let alone throw a ball).

      You can work on it doing this simple exercise.

      Listen to your body. Do not push into pain (esp. if you have known labral tears).

      Mark

      1. Hi Mark,

        I was diagnosed with rotator cuff tendenitis and worked with PT and she said things were fine and I could resume my fav sport BB

        I find that I still baby that arm do not have pain just stiffness. I would think its important to keep it mobile. I use thera bands daily to do some of your shoulder inpingement stuff , external rotations, releases etc

        Any good warm ups for BB you would advise and if moving this daily going to make it worse.

        1. Hey Raymond,

          I like do start off with controlled shoulder articulations: Here is a video.

          From here you should try to do sport specific warm ups. Try to mimic the same positions you will be in during your sport.

          Sorry – Is BB basketball or baseball?

          Mark

          1. Thanks Mark-Basketball sorry about that

            I have a ? my right shoulder is stiff but have zero pain-

            Is this RC ( cuff)tendinitis?

            Can this be from poor posture as well?

            Doing a lot of band pull backs to help improve my external rotation.

            Don’t want to make it worse but it seems mobiliy is better than not

            You are great much appreciated

  5. Hi Mark, great website. I was diagnosed with a frozen shoulder, is that the same? Only got one exercise to practice, but seem to have all the symptoms described here.

    1. Hi Ishbel,

      Frozen shoulder (also known as adhesive capsulitis) is where the capsule around the shoulder joint becomes very tight +/- painful. It usually can take >12 months to heal !

      Whereas Shoulder impingement is where the structures in the shoulder joint get squashed when your lift your arm up.

      Although different, shoulder impingement may lead to adhesive capsulitis if not addressed properly !

      Mark

  6. Hi Mark, I have been diagnosed with a frozen shoulder, is that what we are talking about here? I will try the exercises, and hopefully improve overall posture as well

  7. Thank you so much for this. Your explanations and the visual aids have helped me get a better “feel” for what’s happening when I move, and how to go about the exercises. I am a violinist, and experience pain in my bowing arm when lifting the bow – it hurts more to hit the lowest string (G), since it is the one farthest away from my hand, than playing the E string which can be reached with my elbow closer to the ribs.

  8. Thank you for your the great pictures and explanations it’s extremely helpful for myself and my clients.
    It is terrific to have such helpful professionals sharing their knowledge with people like myself.

    Thank you
    Peter

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