What is shoulder impingement, and how can you fix it without surgery?
Shoulder impingement is one of the most common shoulder problems that we treat with physical therapy at EVOLVE Flagstaff. But, this is a commonly misunderstood term, and we often see patients who have seen multiple providers without resolution of their pain.
Here’s a story that we hear almost every week with a hypothetical patient, Taylor.
Shoulder Pain: A Typical Story
Taylor’s shoulder started aching at some point in the past year or so. He can’t remember exactly why. But then things really flared up after a tough weekend that included a mountain bike fall, helping a friend move furniture, and jumping into an adult softball game. Come Monday morning, he could barely lift his arm. He does a quick google search and the terms sound scary: impingement syndrome, pinched nerve, bone spur, subacromial bursitis, rotator cuff tear, tendonitis. Google does little to reassure him.
It got slightly better after a few days, but reaching and lifting was extremely painful. He tried massage, which helped for a day or two, but then the pain returned. Taylor saw an orthopedic surgeon, who made the diagnosis of “shoulder impingement,” gave a corticosteroid injection, and provided a physical therapy referral.
Taylor goes to the closest PT clinic to his house that accepts his insurance. He gets some dry needling into the back of his shoulder (which hurts like crazy, but that’s part of getting better, right?), and is given a two page list of rotator cuff exercises and stretches. He goes a few times a week for a while, and will typically get needled by the PT before doing his exercises with a PT assistant.
After 6 weeks of PT, and almost 10 weeks since his initial injury, Taylor is still having pain. He can’t throw a softball or frisbee, and gets pain with climbing or mountain biking. He PT also seems frustrated, and suggested that maybe he “just needs to get stronger” and the pain will resolve. But, Taylor has actually stopped going to the gym as much because his shoulder hurts afterward. He’s not sure what to do next. Should he get an MRI, or return to the surgeon? Keep going with PT? Try something else, like acupuncture or chiropractic?
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What happened? Why didn’t Taylor get better?
It seems like he did all the right things: rest, massage, orthopedic consult, anti-inflammatory injection, and then physical therapy. Is surgery in his future?
Not so fast. Taylor’s experience is all too common, but can be avoided by a better understanding of shoulder impingement, and a specific shoulder treatment framework. Here’s how we approach the problem at EVOLVE Flagstaff.
First, what is shoulder impingement?
What is shoulder impingement?
Shoulder impingement is a general term that is not actually a specific diagnosis. Depending on the context, it can mean multiple different things, but is usually associated with pain reaching up, overhead, or out to the side. In the broadest sense, it is the result of the arm bone (the humerus) making contact with a part of the shoulder blade, called the acromion, either too early during a motion, or too forcefully. This causes pinching, or “impingement” of soft tissue structures between the two bones, resulting in pain. Tissues that can become painful include the rotator cuff tendons (specifically the supraspinatus or infraspinatus), the subacromial bursa, the biceps tendon or superior labrum, the shoulder joint capsule, or peripheral nerves in the region.
While this basic description is essentially accurate, it does not by itself lead to a shoulder impingement treatment framework. Providers try everything from stretching, or strengthening, to surgery, to injections in an attempt to treat what we just described, with mixed results.
What are the most common shoulder pain mistakes?
There are six common mistakes that we see providers make when treating shoulder pain. We’ll list them and then dive deeper into what each one is, and our solution.
Assuming all cases of shoulder impingement are the same
Misdiagnosis, or no diagnosis at all
Start with too many exercises
No consideration of pain triggers
Ignoring the thoracic spine, ribs, and shoulder blades
Narrow orthopedic focus
Short term mindset
How does the EVOLVE Flagstaff shoulder treatment framework address them?
We have helped many patients resolve their shoulder pain by following a framework that ensures we don’t get caught in these common mistakes. The framework ensures that we don’t miss anything, but can still individualize our plan of care to you and your specific injury. Here are the steps of Evolve’s Shoulder Pain Framework:
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Hear your story
Create a two-part diagnosis: pain generator and contributing factors
Desensitize the pain generator
Identify pain triggers
Address contributing factors in order of importance
Consider the whole person
Long term approach
Now, let’s dive into each one.
Problem: Assuming all cases of shoulder impingement are the same.
Many providers will simply ask if your shoulder hurts during various tasks, take an x-ray, and then quickly diagnose shoulder impingement. They fail to grasp the intricacies of your story that might make the difference in your recovery.
We want to hear your story - every detail.
EVOLVE’s Solution: Hear your story in detail
Everyone is unique, and your pain and injury is unique too. By just listening to your story in detail, we can make a more accurate diagnosis, identify possible triggers of pain, and get a feel for what the best treatment approach will be for you. There is no one-size-fits-all.
Problem: Misdiagnosis, or no diagnosis at all
“Shoulder impingement” is not actually a diagnosis, but a description of what happens when the humerus bumps into the acromion. It likely happens in everyone to some extent, and may or may not be painful. Calling something “shoulder impingement” does not tell us how to calm things down, what to modify or avoid, or which exercises might be most effective. Or, perhaps worse the problem might not even be due to shoulder impingement at all! Without a comprehensive exam and diagnosis, it is impossible to know.
EVOLVE’s Solution: Create a two-part diagnosis - pain generator and contributing factors
Shoulder impingement is an incomplete and vague diagnosis. We want to get much more specific and actionable. For all injuries seen at EVOLVE Flagstaff, we aim to give a practical two-part diagnosis using a comprehensive examination. Those two parts include:
What is your pain generator? Essentially, what is hurting? There is a long list of structures that can become painful in the shoulder. The pain that causes the symptoms of impingement can come from the neck or thoracic spine, nerves, muscles, tendons, bursae, ligaments, or joints. Each of these structures can be desensitized in different ways, and may have different triggers and a different prognosis
What are your contributing factors? The body is actually very good at healing itself. Most bruises, abrasions, and minor injuries heal on their own without treatment. When you have an injury that does not get better on it’s own, there is often a set of factors, which we call contributing factors, that are keeping it irritated. Once we identify a pain generator, we then do an in-depth assessment of your muscle strength and endurance, movement patterns and motor control, flexibility and mobility, and daily habits and behaviors. We look through a lens of “what is keeping the pain generator from healing?”
With these two categories identified, we now have a complete two-part diagnosis that allows us to develop a clear and straightforward treatment plan together. No more extensive lists of exercises, or just trying different treatments and hoping for the best.
Problem: Start with too many exercises
Is this what your shoulder rehab looks like? Exercises like these might be helpful, but they need to be part of a comprehensive framework, not given at random.
Many people will go to physical therapy with a shoulder impingement diagnosis and immediately be given a long list of exercises. This might include stretches, theraband exercises, or other drills. They probably don’t immediately make things feel better (and might even cause pain), but you are told that they will help in the long term. The problems with this approach are 1) It does not address your pain; 2) It is hard to gauge progress or confirm the diagnosis; 3) It may not be realistic to incorporate into your life.
EVOLVE’s Solution: Desensitize the pain generator
This should be obvious, but is often skipped… once we know the pain generator, let’s calm it down! By understanding which tissue is irritated, we can typically apply specific treatments to reduce pain of that specific structure.
This step is essential because, first and foremost, it makes you feel better! But it also helps confirm our pain generator diagnosis. If we are suspecting that your “impingement” is actually a subacromial bursitis, we would expect a bursal mobilization to reduce symptoms quickly. If this is not the case, we would immediately reassess to ensure we did not miss any differential diagnoses.
Problem: No consideration of pain triggers
Pain triggers are movements, positions, or activities that place force or load on a painful or injured body structure. Without an understanding of your triggers, you might inadvertently be putting excess force or load on the painful area throughout each day.
This is like giving yourself a bruise by bumping into something, and then continuing to bump the same area repeatedly throughout the day. That would make it harder for the bruise to heal, right? It’s the same with shoulder impingement, except that the movements of the shoulder are complex, and make triggers tricky to identify on your own.
EVOLVE’s Solution: Identify pain triggers
We aim to work with you to fully investigate what your pain triggers might be, and brainstorm how to temporarily modify them, so that you can heal as quickly as possible. Here is a full article on Pain Triggers.
Problem: Ignoring the thoracic spine, ribs, and shoulder blades
Too often, shoulder impingement rehab and exercises are just focused on the glenohumeral joint, which is interface between the arm bone (humerus) and shoulder blade (scapula). This is the joint that is controlled by the rotator cuff, and the joint that we typically think of as “the shoulder.” This is often where the pain occurs. However, only focusing on this area misses the forest for the trees.
We can’t talk about the shoulder without also talking about the scapula, ribs, and thoracic spine.
EVOLVE’s Solution: Address contributing factors in order of importance
Often, by simply getting a complete two-part diagnosis, desensitizing the pain generator, and identifying pain triggers, we can see rapid progress within a few days, or even one session. We accelerate this progress by now turning our attention to your contributing factors. Over the course of your treatment, we work to address them in order of what will make the biggest difference for you. These factors vary between patients, but typically include range of motion, muscle activation, movement control, and muscle capacity.
When it comes to shoulder impingement, we find that the contributing factors most often missed by other providers are related to the thoracic spine, rib cage, and shoulder blade.
Without getting too deep into biomechanics, these areas are absolutely essential, and in fact not separable from, function of the glenohumeral joint. Why is that?
Well, the arm bone connects to the shoulder blade. So, obviously how the arm moves is very important. However, we cannot forget that the shoulder blade moves as well! It can move up, down, forward, and backward. Where, how, and when it moves is going to significantly affect the position of the glenohumeral joint. We can’t even think about impingement without taking scapular movement into consideration.
Similarly, the shoulder blade sits and articulates upon the rib cage. We typically think of the ribs as coming from the sternum on the front of the torso (which they do), but forget they they actually have a joint with the mid- and upper-back, called the costovertebral joint. Movement occurs at this joint as well when the arm and scapula move. If this movement is not occurring properly, which is common after whiplash injuries, bike crashes, skiing falls, and other forceful impacts, then scapular and arm mechanics will be thrown off.
And let’s go one layer deeper: the rib joints connect to the thoracic spine, and, you guessed it, the thoracic spine also moves when the ribs, scapula, and arm all move. Stiffness here, which is common for anyone who uses a computer or smartphone (i.e., everyone) can in turn affect things all the way out at the arm and contribute to “impingement.”
While there are other contributing factors that we assess and address, a full understanding of how the upper body and torso all work together is essential. We can’t just think about the arm itself.
Problem: Narrow Orthopedic Focus
Orthopedic treatment often occurs in a silo. You go in for shoulder pain, get some exercises, and then head home. But what if there’s something else going on in your life that is affecting how you feel? Your provider should at least assess that, right?
EVOLVE’s Solution: Consider the whole person
With every patient at EVOLVE Flagstaff, we aim to consider the whole person. Pain is complex, and every individual is complex. We find that your nutrition, hydration, sleep, daily habits, movement throughout the day, and regular exercise routines can make a big difference in how you feel as a whole, and therefore by extension, how fast or slow you heal. We could have the most accurate diagnosis and best treatment plan in the world, but if you aren’t sleeping, eating only fast food, and not moving at all during the day, you might not get better, or at least won’t heal as quickly.
While our physical therapy treatment plans do not always include these elements, we do always screen to see if they are relevant to your situation.
Problem: Short term mindset
Most approaches to shoulder impingement or pain are inherently short term: rest, icing, a steroid injection, ibuprofen, or an endless list of exercises that you can’t do forever. How can we resolve your pain in the short term, and make sure it stays away, for good?
EVOLVE’s Solution: Long term philosophy
Reducing symptoms quickly is important, but we can’t stop there. We have to ask, “Why did this start? Why did this happen in the first place?” We want to eliminate symptoms, but we don’t just want to mask them, otherwise they will come right back. We take a long term approach by identifying and addressing contributing factors and triggers, and by teaching you as much as possible about how to take care of your shoulder and your body.
And beyond that, we want to end each plan of care with a strong strategy in place that helps you to continue to build capacity and resilience. We want you to become antifragile. This can look like a lot of different things, such as a solid strength and conditioning program or a clear action plan if symptoms ever do return.
Don’t wait! Let’s get started fixing your shoulder pain today.
If you are struggling with shoulder pain or have been diagnosed with shoulder impingement, don’t settle for a generic approach. We would love to help you get a better understanding of your pain, and get you on the rapid road to recovery. Book a free call with a Doctor of Physical Therapy to learn more and see if our approach is right for you.