Shoulder impingement is a very common diagnosis and can be extremely painful and physically limiting. Many patients can feel a bit bewildered when the sharp pain that has been dropping them to their knees, waking them up at night, and hurting enough to bring them in to see a doctor, is then given such a simple diagnosis and instruction to do physical therapy. It can leave them feeling like not enough is being done for the amount of pain they are having, like an MRI should have been performed, and that physical therapy will not “fix” them.
While shoulder impingement is a very common injury and has good outcomes with physical therapy, it can take a lot of time and education to get clients on board with the impingement rehab plan. The following are common questions asked by those being treated with shoulder impingement and how Austin Sports Medicine approaches shoulder impingement rehab.
What exactly is shoulder impingement?
While the shoulder is considered a complex joint, it is actually pretty simple. It is made of 2 bones that form the ball and socket joint: the humerus (ball) and the scapula (socket). This is referred to as the glenohumeral joint.
Arm bone + shoulder blade = ball and socket
Unfortunately, there are other parts of the shoulder blade the stick out and take up space around the ball and socket: the acromion at the top and coracoid process in the front (not labeled in the picture). Plus, there is some important stuff that sits between the top and front of the humerus and these bony prominences: rotator cuff tendons, biceps tendon, and a bursa!
In a normally functioning shoulder, the humerus bone should be able to move around on the socket while maintaining space between those important structures and the bony prominences. An impingement occurs when space between them is not maintained and either the rotator cuff tendons, biceps tendon, bursa, or any combination of them get pinched between the humerus and acromion or coracoid. This can cause the tendons and/or bursa to become inflamed and very painful. And this is why when you reach overhead, out to the side, or behind your back, that you will get that sudden sharp pain; you’re pinching something in there!
How is physical therapy going to fix it?
Shoulder impingement is only sometimes a structural issue, meaning the shape of the acromion hooks down, or a bone spur is present, making impingement inevitable. Since those anatomical factors are less common in an active population, most of the time, impingement is a movement issue. This means that because of a muscle imbalance and/or mobility restriction, the humerus and scapula move in a way that causes the impingement to happen.
Addressing muscle imbalance and mobility restrictions are the bread and butter of physical therapy! By ensuring proper strength of the muscles that stabilize the humerus and give it the proper downward glide it require when you reach overhead, along with improving the flexibility of the shoulder and upper back, we are able to get your shoulder out of an impingement movement pattern.
This process can take time. When tissue is acutely inflamed, it can take about 6 weeks for it to calm down. Also, tissue change and adaption for improved flexibility/strength can take 6-8 weeks for just initial changes. So “fixing” impingement takes time and can’t be given up on in a matter of a week or two. Also, so much education goes into treating shoulder impingement, like lifting technique, chest to back ratios, and flexibility routines to keep someone from developing an impingement again. So the bottom line is shoulder impingement rehab takes time, patience, and diligence!
Should I get an MRI?
Not at first.
If your symptoms are mainly pain with movement, an MRI is most likely not necessary. Evidence has shown that even when there are small bone spurs and small rotator cuff tears, physical therapy has the ability to eliminate shoulder pain by addressing the above stated muscle imbalances and mobility impairments.
So, if you can get better without it, wouldn’t you want to start with the less expensive, less invasive route first?
If after being diligent with a PT program the shoulder continues to be painful or worsens, an MRI may be warranted to check for large tears or anatomical factors contributing to the injury.
If I keep impinging my shoulder, can it get worse or turn into a tear?
Yes! Tissues do not like repetitive compression. And when this goes on for a long time, degenerative rotator cuff tears and tears to the biceps tendon can occur. So, this is one condition where you do not want to push through the pain and repeat a painful movement over and over again. Rest is imperative and modifying the activities or movements that cause the pain is necessary to allow the tissues to heal.
Should I get an injection?
Shoulder impingement can be a tough cycle to break: you impinge the tissue, it gets inflamed, inflammation causes weakness and further muscle imbalance, muscle imbalance and pain lead to compensation, which all further lead to movement dysfunction and more impingement. It can be a rough one.
A lot of the time, rest and activity modification can be enough to allow the pain to resolve. However, in some cases, the cycle can be really hard to break. In those cases, a corticosteroid injection into the shoulder joint can help reduce inflammation and pain and help break the cycle.
But once the pain is better, keep doing your physical therapy! Even though the pain is gone, the movement dysfunction must be addressed to prevent it from coming back once the injection wears off.
Would it be easier to just have surgery and get it over with?
Surgery should be a last resort. Sticking with a physical therapy plan is much easier than recovering from a surgery. Plus, long term studies have shown that physical therapy and surgery both had similar long term outcomes for small rotator cuff tears and chronic impingement.
It is also important to note that surgery can help the anatomical reasons impingement occurs: hooked acromion and/or bone spurs. However, it does not fix the movement dysfunction. You can have surgery to make more space in the shoulder joint, but if you do not address the muscle imbalance and flexibility deficits, you could end up having shoulder pain again. Whether physical therapy “fixes” your shoulder or it doesn’t, it should be your first line of treatment for shoulder impingement.