The shoulder is a ball and socket joint. Most shoulder movement occurs where the ball at the top of your arm bone (the Humerus) fits into the socket (the Glenoid), which is part of the shoulder blade (the Scapula). The Rotator Cuff (RC) is a group of four muscles which work together to keep the joint in optimal position throughout movement. The 4 muscles are (pictured above):
The shoulder will not usually be stiff – this could suggest another diagnosis such as arthritis or frozen shoulder. Other terms that are used for shoulder impingement are impingement syndrome, painful arc syndrome, subacromial impingement and swimmer’s shoulder.
When you lift your arm, one of the Rotator Cuff tendons (Supraspinatus) passes through a space at the top of your shoulder known as the Subacromial space (see diagram – region inferior to the ‘Acromion’).
Shoulder impingement occurs when the tendon is challenged by a reduction in space on the sub-acromial space. This can occur when the tendon becomes irritated with subsequent swelling, thickened or torn which can be a result of injury, overuse (for example, from sports such as swimming or tennis) or “wear and repair”.
The fluid-filled sac (bursa) found between the tendon and Acromion becomes irritated and inflamed (bursitis) – this can also be caused by an injury or overuse of the shoulder. The Acromion – which is part of the shoulder blade (Scapula), has a curved or hooked appearance which tends be normal for the individual from birth. However, bony growths (spurs) can develop with time to cause irritation also. These changes can lead to shoulder instability, restricted movement of the joint, muscle imbalance and postural changes.
Shoulder impingement is a very common cause of shoulder pain up to 75% (Ostor et al 2005).
Our Physiotherapists at Pure are highly skilled in shoulder pain and by taking a history of your shoulder symptoms and through physical assessment, can provide you with an immediate, accurate diagnosis. This will allow the most effective treatment and management strategy to be implemented straight away so that the best possible outcomes are achieved.
Once you have been given your diagnosis, your Physio will explain the causes of the injury and will educate you on how you can help with your recovery at home. Pacing is important. Common activities which involve repeated overhead movements such as swimming, tennis, DIY and gardening, will require frequent, short rest periods to help you manage irritation levels. Whilst resting from certain activities, maintaining movement is essential for recovery and will help you carry on with normal daily activities as much as possible, reducing the risk of the shoulder becoming weak or stiff. It’s usually best to avoid using a sling.
Your Physiotherapist may recommend using an ice pack (or a bag of ice cubes or frozen vegetables) applied to the shoulder for around 20 minutes several times a day which can help reduce sensitivity and inflammation. Ice should not be placed directly on your skin – wrap it in a towel first.
You may also be given advice on ways in which you can reduce pain levels including taking painkillers – non-steroidal anti-inflammatory painkillers (such as ibuprofen) or paracetamol, which may help. Speak to a Pharmacist or GP if you have any questions. They may also recommended avoiding lying or leaning on the affected shoulder
There is evidence that Physiotherapist led exercises can improve pain, boost physical function and quality of life. Steuri et al. (2017) suggest that exercise may be considered as the ‘core conservative treatment for shoulder impingement’ and ‘furthermore, manual therapy and sports tape might provide additional benefit.’ – all of which we provide at Pure.
Research by Kromer et al (2009) found physiotherapist-led exercises as useful as surgery for Shoulder impingement syndrome in the short and long term.
Your Physiotherapist will be highly skilled at exercises prescription and will design a personalised home rehabilitation plan, based on your goals and what activities are important to you. As you progress and are re-assessed, your Physio will make adjustments to your exercises to ensure they remain highly effective and are helping you towards achieving the goals you have. You will be provided with ongoing advice and support so that you feel confident in managing independently and can prevent re-occurrence.
Steroid injections have been shown to help relieve pain if (relative) rest and exercises on their own do not help. But it remains vital to continue with your personalised shoulder exercises, as injections usually only have an effect for a few weeks and pain may return if you do not remain consistent with the exercises and self-management advice recommended. While the injection can be repeated if needed, having more than 2 is not usually recommended because it might damage the tendon in your shoulder in the long term.
An operation called a Subacromial decompression may be an option if other treatments have not worked. Click here to see Shoulder surgery in conditions section.
Ostor, A. J. K., Richards, C. A., Prevost, A. T., Speed, C. A., & Hazleman, B. L. (2005). Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology, 44(6), 800-805.
Kromer, T. O., Tautenhahn, U. G., de Bie, R. A., Staal, J. B., & Bastiaenen, C. H. (2009). Effects of physiotherapy in patients with shoulder impingement syndrome: a systematic review of the literature. Journal of Rehabilitation Medicine, 41(11), 870-880.
Steuri, R., Sattelmayer, M., Elsig, S., Kolly, C., Tal, A., Taeymans, J. & Hilfiker, R. (2017). Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med, 51(18), 1340-1347.