Shoulder impingement syndrome

Authors:
Stephen M Simons, MD, FACSM
David Kruse, MD
J Bryan Dixon, MD
Section Editor:
Karl B Fields, MD
Deputy Editor:
Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jul 2017. | This topic last updated: Mar 07, 2016.

INTRODUCTION — Shoulder impingement syndrome (SIS) refers to a combination of

shoulder symptoms, examination findings, and radiologic signs attributable to the
compression of structures around the glenohumeral joint that occur with shoulder elevation.
Such compression causes persistent pain and dysfunction. Shoulder pain is a common
presenting complaint in primary care clinics, and SIS is likely the most common cause of
shoulder pain in this setting [1,2].

Much has changed in our understanding of shoulder function and dysfunction since Neer's
original classification of these disorders decades ago [3]. The diagnosis of SIS implies a
spectrum of clinical findings, not injury to a specific structure.

The pathophysiology, diagnosis, and management of SIS will be reviewed here. The
approach to patients with shoulder pain, the shoulder examination, and conditions that may
stem from SIS are discussed elsewhere. (See "Evaluation of the patient with shoulder
complaints" and "Physical examination of the shoulder" and "Rotator cuff
tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)

EPIDEMIOLOGY AND RISK FACTORS — Shoulder pain is highly prevalent within the
general population, second only to lower back pain. Studies suggest that shoulder
impingement syndrome (SIS) is the most common cause of shoulder pain [4-7]. However,
epidemiologic calculations can vary depending upon how SIS is defined.

Risk factors — Repetitive activity at or above the shoulder during work or sports represents
the main risk factor for SIS. As with many shoulder disorders, increasing age also
predisposes to SIS [7,8]. SIS is common among athletes who participate in overhead sports
[9-14]. These sports may include swimming, throwing, tennis, weightlifting, golf, volleyball,
and gymnastics [15]. Overhead work activities that can increase risk for developing SIS
include painting, stocking shelves, and mechanical repair [6,16]. (See "Throwing injuries:
Biomechanics and mechanism of injury".)

Instability of the glenohumeral joint can lead to impingement. Such instability allows
increased translation of the humeral head and predisposes patients to SIS, particularly if
they engage in repetitive overhead activity [9,14].

Scapular instability and dyskinesis, in addition to glenohumeral joint laxity, also predisposes
to impingement [17]. Other risk factors may include upper extremity inflexibility, particular
acromion anatomy, and acromioclavicular joint pathology [15].
(See 'Pathophysiology' below.)

CLINICAL ANATOMY — Understanding the pathophysiology of shoulder impingement

syndrome (SIS) depends upon knowledge of shoulder anatomy (figure 1A-C). The anatomy
of the shoulder is discussed in detail elsewhere, but aspects of particular importance to SIS
are reviewed here. (See "Evaluation of the patient with shoulder complaints", section on
'Anatomy and biomechanics'.)

Movement of the humeral head within the glenoid and of the scapulothoracic articulation
achieves motion in multiple planes (ie, flexion, extension, internal rotation, external rotation,
abduction, adduction). This impressive range of motion can entail compression of structures
within the shoulder, including the four rotator cuff muscles (ie, supraspinatus, infraspinatus,
teres minor, and subscapularis), subacromial bursa, labrum, and biceps tendon (long head).
(See 'Pathophysiology' below.)

Compression can occur against the acromion, osteoarthritic change on the undersurface of
the acromioclavicular joint, and the coracoacromial arch. The acromion is the lateral
projection of the posterior scapular spine, and its morphology may play a role in
impingement syndrome (figure 2). The acromion forms an articulation with the lateral
clavicle, and this articulation is stabilized by the acromioclavicular, coracoacromial, and
coracoclavicular ligaments. The coracoacromial arch is composed of the coracoid, anterior
acromion, and the coracoacromial ligament [18].

The small surface area of the glenoid fossa makes the glenohumeral joint relatively unstable.
Stability depends largely on surrounding ligamentous, capsular, tendinous, and muscular
structures. Any weakness or dysfunction of these stabilizing structures can increase
glenohumeral instability, allowing increased translation of the humeral head. This increased
motion makes surrounding structures susceptible to impingement [17].

PATHOPHYSIOLOGY

General — Shoulder impingement syndrome (SIS) consists of a spectrum of clinical

findings, NOT injury to a specific structure (ie, rotator cuff) [19]. This spectrum of disease
was first described by Charles Neer in 1972, and consists of the following stages [3,20]:

●Stage 1: Edema and hemorrhage (patient generally <25 years)

●Stage 2: Fibrosis and tendinitis (patient 25 to 40 years). Current term is tendinopathy.
(See "Rotator cuff tendinopathy".)
●Stage 3: Rotator cuff (RC) tear, biceps tendon rupture, bony change (patient generally
>40 years)

The underlying mechanism of injury occurs when the rotator cuff, subacromial bursa, and
other soft tissues (eg, long biceps tendon) are compressed between the humeral head and
the undersurface of the acromion, acromioclavicular joint, or the coracoacromial arch
[15,18,21]. A number of anatomic and mechanistic factors play a role in this mechanism,
including:
 ●Increased translation of the humeral head
●Acromion morphology that predisposes to impingement
●Decreased distance between undersurface of acromion and humeral head
●Osteophytic change of the acromioclavicular joint

Weakness or dysfunction of the structures that stabilize the glenohumeral joint (eg, rotator
cuff [RC] muscles) can lead to increased superior translation of the humeral head [17].
Increased translation can lead to compression of the subacromial bursa and RC tendons,
causing injury. This extrinsic compression is one of a number of injuries that contribute to the
development of SIS and RC tendinopathy. In addition, a decrease in the distance between
undersurface of acromion and humeral head appears to correlate with clinical symptoms in
patients with impingement syndrome [22]. (See "Rotator cuff tendinopathy".)

The relationship between the anterior third of the acromion and subacromial structures
accounts in part for compression and the development of SIS [3]. Three acromion types
have been described (figure 2):

●Type I – Flat
●Type II – Curved
●Type III – Hooked

These acromion morphologies were originally defined by their relationship to RC tear, with
type III acromions having the highest association [17]. (See "Presentation and diagnosis of
rotator cuff tears".)

Anatomic factors other than superior translation of the humeral head and acromion
morphology can also contribute to the development of SIS. Osteophytic change of the
acromioclavicular joint can cause compression and mechanical irritation of underlying soft
tissues [17,18]. The lateral band of the coracoacromial ligament has been implicated in
impingement of the rotator cuff [21,23,24]. Scapulothoracic dysfunction may play a role in
SIS, but it remains unclear if such dysfunction is causative or secondary [17,25].

Throwing athletes — Throwing athletes suffer from a unique form of SIS. Impingement of
the superior and posterior labrum and rotator cuff occurs with external rotation, extension,
and abduction of the shoulder (ie, the cocking phase of throwing). This motion together with
anterior translation of the humeral head causes impingement. Glenohumeral instability
accentuates the anterior translation and subsequent impingement [9,17]. Repetitive use of
the shoulder in extremes of rotation with throwing activities, combined with weakness of the
rotator cuff and laxity of the glenohumeral ligaments, places athletes at risk for this form of
SIS [9].

This form of impingement, sometimes referred to as posterior SIS, does not occur in all
overhead athletes, but specifically in throwing athletes whose motion involves a cocking
phase (figure 3). Such activities include baseball pitching primarily, but also tennis serves,
American football throws, and javelin throws. (See "Throwing injuries: Biomechanics and
mechanism of injury" and "Throwing injuries of the upper extremity: Clinical presentation and
diagnostic approach" and "Throwing injuries of the upper extremity: Treatment, follow-up
care, and prevention".)

DIFFERENTIAL DIAGNOSIS — Shoulder pain is very common in the general population,

and the differential diagnosis can be extensive (table 1). This differential diagnosis and a
discussion on how to approach the patient with undifferentiated shoulder pain are provided
separately. (See "Evaluation of the patient with shoulder complaints".)

Pain from shoulder impingement syndrome (SIS) may result from injury to a number of
involved structures, including: the rotator cuff, subacromial bursa, biceps tendon, and
labrum. The history and physical examination is used to identify the structures involved and
direct treatment.

It is important to distinguish SIS from rotator cuff tear and adhesive capsulitis, for which
management differs. Rotator cuff tears frequently cause weakness in addition to pain, occur
most often in older patients, and are associated with a positive drop arm sign and weakness
with external rotation. Patients with adhesive capsulitis generally give a history of shoulder
injury and manifest restricted active and passive glenohumeral motion. (See "Presentation
and diagnosis of rotator cuff tears" and "Rotator cuff tendinopathy" and "Biceps tendinopathy
and tendon rupture".)

Patients with shoulder impingement can concurrently develop cervical radiculopathy,

emphasizing the importance of a careful neurologic examination in patients with shoulder
complaints [26,27]. Both conditions should be treated [28].

CLINICAL PRESENTATION AND EXAMINATION

Clinical presentation — Symptoms of shoulder impingement syndrome (SIS) are similar to

those of rotator cuff (RC) tendinopathy. Patients complain of pain with overhead activity. The
pain may localize to the deltoid area or lateral arm and often occurs at night or when lying on
the affected shoulder. (See "Rotator cuff tendinopathy".)

Throwing athletes complain of shoulder stiffness and a difficult or prolonged warm-up period.
Pain occurs during the late cocking phase or the early acceleration phase of throwing.
Initially, the athlete may not be able to localize the pain, but with time may develop
discomfort at the posterior shoulder [9]. Serving athletes (eg, tennis and volleyball players)
may complain of pain at follow-through or terminal wrist snap before impingement becomes
severe. (See 'Throwing athletes' above.)

Physical examination — Several structures may be involved in SIS, including the

subacromial bursa, rotator cuff, biceps tendon, and labrum. Therefore, a number of shoulder
examination techniques are used to ensure adequate sensitivity for detecting injury to
susceptible structures. The overall approach to examination closely resembles that used to
detect rotator cuff tendinopathy, and is discussed separately. (See "Rotator cuff
tendinopathy".)

The Neer and Hawkins-Kennedy maneuvers are sensitive for SIS impingement (picture
1 and picture 2).
Performance of the shoulder examination, including special tests for impingement, is
reviewed elsewhere (see "Physical examination of the shoulder", section on 'Special tests
for shoulder impingement'). Examination for SIS includes the following:

●Complete neck examination

●Inspection for atrophy or disfigurement
●Evaluation of range of motion (including painful arc testing and a comparison of
passive versus active motion)
●Rotator cuff strength testing (including drop arm test and external rotation strength
testing)
●Specialty testing (including the Neer and Hawkins-Kennedy tests)
●Bedside musculoskeletal ultrasound (MSK US), if the technology is available and the
examiner proficient

Patients with SIS can manifest the following findings:

●Neck exam is within normal limits

●Tenderness present in the subacromial space or posterior shoulder
●Glenohumeral range of motion may be limited by pain (eg, positive painful arc)
●Reproduction of pain with specialty testing (eg, Neer, Hawkins-Kennedy, Yocum's)
●Atrophy of posterior shoulder musculature may be apparent with long-standing
impingement
●Shoulder strength is normal, except in some cases of long-standing impingement

In the throwing athlete, findings of SIS may include the following [9]:

●Asymmetric muscle development

●Tenderness over the region of the posterior rotator cuff and capsule
●Increase in external rotation and symmetrical decrease in internal rotation compared
with the unaffected (nondominant) shoulder (ie, glenohumeral internal rotation
deficiency)
●Possible increased laxity of the glenohumeral joint (anterior translation)
●Positive posterior impingement sign (see "Throwing injuries of the upper extremity:
Clinical presentation and diagnostic approach")

To perform the posterior impingement test, place the patient's shoulder in 90 degrees of
abduction, 110 degrees of extension, and maximal external rotation. The test is performed
with the patient supine and is positive if it recreates the athlete's shoulder pain (picture 3).

RADIOGRAPHIC FINDINGS

Plain radiographs — In general, radiographs are unnecessary for the initial evaluation of
shoulder impingement, and we do not routinely obtain them unless symptoms and function
fail to improve with physical therapy.

Plain radiographs may be useful in the following clinical situations:

 ●No improvement with conservative therapy
●Evaluation of acromion morphology (see 'Pathophysiology' above)
●Evaluation of the acromioclavicular joint (see 'Pathophysiology' above)
●Evaluation of distance between acromion and humeral head (see "Presentation and
diagnosis of rotator cuff tears", section on 'Plain radiographs')
●Evaluation for tendon calcification
●Anatomical evaluation prior to subacromial or glenohumeral joint injection (not
essential prior to injection)

Musculoskeletal ultrasound — Musculoskeletal ultrasound (MSK US) is an accurate tool

for the evaluation of superficial tendon and muscle lesions, as well as bursitis, of the
shoulder, and enables dynamic examination at the bedside. With experienced users,
dynamic MSK US can often show the site of impingement and tendons involved. Its role in
the evaluation of the rotator cuff is discussed in detail elsewhere. (See "Rotator cuff
tendinopathy" and "Musculoskeletal ultrasound of the shoulder".)

Additional ultrasound resources — Instructional videos demonstrating proper

performance of the ultrasound examination of the shoulder and related pathology can be
found at the website of the American Medical Society for Sports Medicine: sports US
shoulder pathology. Registration must be completed to access these videos, but no fee is
required.

Magnetic resonance imaging — Magnetic resonance imaging (MRI) is generally performed

in the following circumstances:

●Symptoms and function fail to improve despite appropriate conservative therapy.

●The diagnosis remains unclear after initial evaluation.
●A rotator cuff or labrum tear is suspected based upon clinical presentation
(see "Presentation and diagnosis of rotator cuff tears")

MRI can detect abnormalities associated with shoulder impingement syndrome (SIS),
including inflammation of subacromial structures, compression of the supraspinatus tendon
and subacromial bursa by bone spurs, acromioclavicular joint pathology, or a low-lying
acromion [8,22,29]. A low-lying acromion can be further defined by measuring the distance
between the acromion and the humeral head. For the athletic patient, MRI can be performed
if rapid confirmation of the diagnosis is needed to determine whether return to sport is
reasonable.

MRI arthrography with gadolinium intraarticular injection may be useful when the diagnosis
remains unclear following standard MRI. The study is generally obtained after consultation
with sports medicine or orthopedic surgery. MRI arthrography can detect pathology of the
labrum, undersurface rotator cuff irregularity, or small partial tears of the rotator cuff [9].

INDICATIONS FOR ORTHOPEDIC REFERRAL — We refer patients for orthopedic

evaluation if three months of conservative treatment, including appropriate physical therapy,
fails to improve symptoms and function, or if a diagnosis of rotator cuff tear, labrum tear, or
adhesive capsulitis is suspected.
Surgical intervention should be individualized by age, comorbidities, and level of physical
demand [17]. Surgical intervention may include debridement of the rotator cuff or labrum,
acromioplasty with debridement, or rotator cuff repair. If laxity is present in the throwing
athlete, a capsular repair may improve outcome [9,17]. (See "Presentation and diagnosis of
rotator cuff tears".)

MANAGEMENT — Initial management of shoulder impingement syndrome (SIS) is similar to

that for rotator cuff (RC) tendinopathy. Some aspects of management are supported by
evidence, but much is not. A description of the management approach and basic treatment
for SIS follows. Issues related to the specific management of SIS, as opposed to RC
tendinopathy, are discussed here; evidence for treatments used to manage both SIS and RC
tendinopathy is reviewed elsewhere. (See "Rotator cuff tendinopathy", section on
'Treatment'.)

General approach — We approach patients with suspected SIS in the manner described
here but recognize that evidence is limited and alternative approaches may be reasonable.
We begin with a focused history and physical examination. (See 'Clinical presentation and
examination' above.)

If based on the history and examination, we suspect a clinically significant rotator cuff tear, a
labral tear, adhesive capsulitis, or other significant pathology not amenable to conservative
therapy; we generally refer the patient to an orthopedic surgeon. We maintain a lower
threshold for referral in the case of high-functioning athletes. If we suspect a rotator cuff tear
or adhesive capsulitis, but the patient has minimal weakness and reasonable motion, we
generally embark on a course of conservative medical management, consisting primarily of
physical therapy. (See "Presentation and diagnosis of rotator cuff tears" and "Frozen
shoulder (adhesive capsulitis)" and "Rehabilitation principles and practice for shoulder
impingement and related problems".)

If we suspect acute SIS, we initiate conservative medical management, including the acute
treatments described below and an appropriate physical therapy program. (See 'Acute
treatment' below and 'Physical therapy' below.)

The duration and success of physical therapy depends upon many factors, including
underlying pathology, compliance with treatment, and the appropriateness of the program
prescribed. We believe that whenever possible, it is important for patients to begin
rehabilitation under the guidance of a knowledgeable professional (eg, athletic trainer or
physical therapist with experience managing shoulder disorders).

If function and symptoms improve over several weeks of physical therapy, we have the
patient continue therapy and begin a gradual, stepwise resumption of activities, including
sports. Should function fail to improve despite adequate rehabilitation, we obtain imaging
studies. Musculoskeletal ultrasound (MSK US), if not performed previously, may be obtained
first. We perform a plain radiograph for persistent symptoms to assess for anatomic variants,
such as a downsloping acromion or os acromiale, and acromioclavicular or glenohumeral
osteoarthritis. We obtain an MRI if the MSK US is nondiagnostic or not available, a rotator
cuff or labral tear is suspected, or the diagnosis is unclear. (See 'Radiographic
findings' above and "Musculoskeletal ultrasound of the shoulder".)

Subsequent management depends upon the results of imaging studies. Alternative

diagnoses are managed accordingly. We refer patients with rotator cuff tears, labral tears,
and adhesive capsulitis to an orthopedic surgeon. For rotator cuff tendinopathy or
subacromial bursitis, we continue conservative management. Some clinicians may choose to
incorporate adjunct treatments, such as glucocorticoid injection, at this point, or earlier if pain
is severe. Physical therapy may require several months before adequate shoulder function is
achieved. We refer the patient to an orthopedic surgeon if, after six to nine months of
conservative treatment, patient function and symptoms fail to improve significantly.
(See 'Indications for orthopedic referral' above.)

Acute treatment — Research to direct management of SIS is limited, but the following is a
generally accepted approach for acute symptoms:

●Cryotherapy – Ice may decrease acute swelling and inflammation and provide some
analgesia.
●Rest – This means avoiding activities that aggravate symptoms, including all overhead
activities.
●NSAIDs – For acute injuries, we give a short course (ie, 7 to 10 days) of scheduled
NSAID therapy. Thereafter, patients may use an NSAID for occasional analgesia if they
find the medication effective. (See "Rotator cuff tendinopathy".)

Physical therapy — Although studies of physical therapy regimens for SIS are limited,
available evidence and our clinical experience suggest that properly designed and
performed physical therapy programs effectively treat most patients with SIS and should be
implemented prior to surgical referral. Furthermore, several randomized trials have reported
no difference in outcome between patients treated with physical therapy alone and those
treated surgically with subacromial decompression [30-33]. (See 'Pathophysiology' above.)

The physical therapy programs used most often for SIS closely resemble those used for
rehabilitation of rotator cuff tendinopathy and these are discussed in detail separately. A
randomized trial of 97 patients with SIS reported that those treated with such an exercise
regimen had significant improvements in shoulder function and were less likely to undergo
surgery than patients treated with standard exercises (20 versus 63 percent; odds ratio [OR]
7.7, 95% CI 3.1-19.4) [34]. (See "Rehabilitation principles and practice for shoulder
impingement and related problems".)

A rehabilitation program for SIS should follow a progression from an initial focus on restoring
mobility, to stability and strength training, and finally to integration of shoulder rehabilitation
into overall functional training. A qualified therapist or trainer can help the physician to
design and implement an effective rehabilitation program for SIS, which generally includes:

●Range of motion exercises to improve motion in all planes (flexion, extension,

abduction, adduction, internal and external rotation).
●Glenohumeral joint mobilization, including specific maneuvers for capsular structures.
 ●Strengthening exercises, focusing on the rotator cuff, scapular stabilizers, and core
musculature. Eccentric exercises (application of a load during muscle lengthening) are
included in the program.
●Biomechanical training to improve the throwing motion or other repetitive activity that
led to injury.
●Exercises to improve the strength and stability of the core muscles and to integrate
shoulder rehabilitation into patient-specific functional activities.

Overhead athletes should generally refrain from all throwing activities for two to four weeks,
while performing physical therapy for the rotator cuff and scapular stabilizers. As symptoms
resolve, athletes begin a graded return to throwing [9]. Approximately 95 percent of throwing
athletes return to their previous level of function if started early on a well-designed
rehabilitation program [14]. (See "Throwing injuries of the upper extremity: Clinical
presentation and diagnostic approach" and "Throwing injuries: Biomechanics and
mechanism of injury" and "Throwing injuries of the upper extremity: Treatment, follow-up
care, and prevention".)

Inconsistent diagnostic criteria, disparate outcome measures, small numbers of participants,

and variable treatment protocols make studies of physical therapy for SIS difficult to interpret
[4,35,36]. Nevertheless, the available evidence suggests that stretching and strengthening
exercise programs consistent with the guidelines listed above provide effective treatment for
SIS [4,6,16,37,38]. The addition of glenohumeral mobilization exercises to rehabilitation
further improves outcomes. One small prospective study found that patients with less
acromion-humeral narrowing showed greater functional improvements following physical
rehabilitation [39].

Kinesio tape (ie, kinesiology tape) is a type of elastic tape that some clinicians apply to
specific injured regions to stimulate improved blood and lymph flow, and kinesthetic sense,
and to provide support to muscles and tendons. Adjuvant therapy with kinesio tape has
become quite popular despite a dearth of high-quality studies supporting its efficacy. A well-
designed randomized trial involving 100 patients diagnosed with subacromial impingement
found no added benefit from kinesio tape (or NSAID use) when performed in combination
with a short-term exercise program [40].

Subacromial injection — Although there is little evidence to support the use of subacromial
injection for the treatment of SIS [6,41,42], a few small, randomized trials found a short term
benefit from glucocorticoid injection [43-46]. Symptomatic relief gained from such injections
may improve a patient's effort and compliance with physical therapy.

Alternative treatment — No clear evidence exists to support the use of the modalities listed
here in the treatment of SIS, and we do not routinely use them in the care of our patients.
Alternative treatment modalities may include:

●Electrical stimulation, phonophoresis, and iontophoresis (see "Rotator cuff

tendinopathy").
●Therapeutic ultrasound – No evidence supports the use of ultrasound for SIS
[4,6,37,47,48].
 ●Laser – As a single intervention, laser may provide greater relief than placebo, but
studies suggest it provides no added benefit when used in combination with other
conservative treatments (eg, physical therapy) [4,37,48].
●Acupuncture – Some evidence suggests that acupuncture may provide some benefit
when combined with physical therapy [4,49].

FOLLOW-UP CARE — We have patients return to clinic within two weeks of the start of
their initial treatment. This allows us to reassess our original clinical impression and to
determine the effectiveness of interventions. Sometimes pain limits the initial physical
examination, and rehabilitation programs may need modification.

Monthly follow-up thereafter is appropriate. More frequent evaluation may be needed to

facilitate efficient return to sport or work activity. If nonoperative therapy does not provide
relief within three to six months, orthopedic referral is appropriate. (See 'Indications for
orthopedic referral' above.)

COMPLICATIONS — Untreated, chronic shoulder impingement syndrome (SIS) can result

in a significant loss of glenohumeral motion, possibly leading to adhesive capsulitis. This
complication can be difficult to treat and may require surgical intervention. For the athlete,
long-standing SIS can result in weakness, dysfunction, chronic pain, and the inability to
perform effectively.

RETURN TO SPORT OR WORK — Guidelines are the same as those for rotator cuff
tendinopathy. (See "Rotator cuff tendinopathy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five
key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12thgrade reading level and are best for patients who
want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Shoulder impingement (The Basics)")

●Beyond the Basics topic (see "Patient education: Shoulder impingement syndrome
(Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Shoulder impingement syndrome (SIS) refers to a combination of shoulder symptoms,

examination findings, and radiologic signs attributable to the compression of structures
around the glenohumeral joint that occur with shoulder elevation. Repetitive activity at
or above the shoulder during work or sports represents the main risk factor.
(See 'Epidemiology and risk factors' above.)
●SIS consists of a spectrum of clinical findings, NOT injury to a specific structure (ie,
rotator cuff). Increased translation of the humeral head, acromion morphology that
predisposes to impingement, and osteophytic change of the acromioclavicular joint all
may play a role. Throwing athletes may develop posterior SIS.
(See 'Pathophysiology' above.)
●It is important to distinguish SIS from rotator cuff tear and adhesive capsulitis (frozen
shoulder). Rotator cuff tears generally cause weakness, occur in older patients, and are
associated with a positive drop arm sign and weakness with external rotation. Adhesive
capsulitis is associated with a history of shoulder injury and restricted
active and passive glenohumeral motion. (See 'Differential diagnosis' above.)
●Patients with SIS complain of pain with overhead activity. Examination techniques for
the shoulder are sensitive for the presence of SIS, but cannot reliably distinguish
among specific causes of pain and dysfunction. In addition to general tests of shoulder
motion and strength, the Neer and Hawkins-Kennedy impingement tests are useful.
The neck and neurologic function must be carefully examined. (See 'Clinical
presentation and examination' above.)
●Plain radiographs are unnecessary for the initial evaluation of suspected SIS.
Ultrasound often reveals the site of impingement and tendons involved.
(See 'Radiographic findings' above.)
●Refer patients for orthopedic evaluation if three months of conservative treatment,
including appropriate physical therapy, fails to improve symptoms and function, or if a
rotator cuff tear, labrum tear, or adhesive capsulitis is suspected. (See 'Indications for
orthopedic referral' above.)
●Little evidence exists to guide management of SIS. Our approach is described above.
Properly designed and performed physical therapy programs effectively treat most
patients. (See 'Management' above and "Rehabilitation principles and practice for
shoulder impingement and related problems".)
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Topic 240 Version 19.0

GRAPHICS
Anterior view of shoulder anatomy

Graphic 81764 Version 2.0

Lateral view of shoulder anatomy

Graphic 54102 Version 4.0

Posterior view of shoulder anatomy

Graphic 69995 Version 7.0

Types of acromion morphology

The relationship between the anterior third of the acromion and subacromial structures accounts in

part for the development of SIS. Three acromion types have been described: flat, curved, and
hooked. The hooked acromion has the highest association with SIS.
Graphic 53837 Version 2.0
 Phases of throwing

The biomechanics of throwing are often separated into the following six phases: Windup; Stride

(sometimes called early cocking); Cocking (sometimes called late cocking); Acceleration;
Deceleration; and, Follow-through. A smooth transition from one phase to the next maximizes the

velocity of the object thrown, while reducing the risk of injury.

Reproduced from: DiGiovine NM, Jobe FW, Pink M, Perry J. An electromyographic analysis of the upper

extremity in pitching. J Shoulder Elbow Surg 1992 1:15. Illustration used with the permission of Elsevier

Inc. All rights reserved.

Graphic 98363 Version 3.0

Differential history and examination of the shoulder

History and epidemiology Examination findings Likely diagnosis

Generally age >40 Subacromial tenderness Rotator cuff tendinopathy

Pain increases with reaching Pain with Apley scratch tests (very common)

Frequent repetitive activity at or above Normal passive range of motion

shoulder Normal strength but pain with testing midarc

abduction and/or external rotation

Pain with impingement testing (Neer and

Hawkins tests)

Same as rotator cuff tendinopathy, but Same as rotator cuff tendinopathy but weakness Rotator cuff tear

weakness present often present with resisted abduction and/or

Midde aged and older external rotation

Past history of rotator cuff tendinopathy, Significant decrease in range of motion, both Adhesive capsulitis
diabetes, or immobility for any reason active and passive

Complaint of decreased motion +/- pain

Past history of shoulder trauma Decrease in range of motion - both active and Glenohumoral

passive osteoarthritis (uncommon)

Pain increases when carrying objects with Bicipital groove tenderness Biceps tendinopathy

elbows bent (eg, shopping bags) or lifting Pain with resisted elbow flexion or supination

overhead

Sudden increase in shoulder pain with Obvious biceps deformity Biceps tendon rupture

"Popeye" deformity (ie, prominent Pain with resisted elbow flexion or supination

ipsilateral distal bicep)

Recent fall onto adducted arm AC joint tenderness with possible stepoff Acromioclavicular injury

Focal AC joint pain Pain with adduction of injured arm

Clavicle elevation on x-ray with higher grade

sprain

Focal AC joint pain without recent trauma AC joint tenderness Acromioclavicular

Pain with adduction of injured arm osteoarthritis

Generally age <40 Sulcus test shows increased motion Multidirectional shoulder

Overhead athletes Apprehension, relocation, and release tests instability (may have

Nonspecific symptoms positive concomitant rotator cuff

tear)

Poor muscular development, frequent Superiomedial scapular border tender Subscapular bursitis

repetitive to-and-fro motion (eg, ironing), (performed with ipsilateral arm adducted)

and direct pressure (eg, backpack) are

common causes

Sedentary (eg, works at desk job); poor Abnormal, uncoordinated scapulothoracic and Scapular stabilizer muscle

posture with rounded upper back glenohumoral motion weakness

Wall push off may reveal mild scapular winging

Stabilization of scapula by examiner improves

shoulder strength
Graphic 53038 Version 3.0

Neer test for shoulder impingement

The "passive painful arc maneuver" shown above involves passively flexing the glenohumeral joint

while simultaneously preventing shoulder shrugging. The test is often referred to as the Neer test,

and is used to assess shoulder impingement.

Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD.
Graphic 76237 Version 5.0

Hawkins Kennedy test for shoulder impingement

The Hawkins Kennedy test is used to assess shoulder impingement. In this test the clinician
stabilizes the shoulder with one hand and, with the patient's elbow flexed at 90 degrees, internally

rotates the shoulder using the other hand. Shoulder pain elicited by internal rotation represents a

positive test.

Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD.
Graphic 60425 Version 4.0

Posterior impingement test

The posterior impingement test is performed by placing the affected shoulder in 90 degrees of

abduction, 110 degrees of extension, and maximal external rotation. The test is positive if it

recreates the athlete's shoulder pain.

Graphic 58355 Version 2.0

Contributor Disclosures
Stephen M Simons, MD, FACSMNothing to discloseDavid Kruse, MDNothing to discloseJ
Bryan Dixon, MDNothing to discloseKarl B Fields, MDNothing to discloseJonathan
Grayzel, MD, FAAEMNothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When
found, these are addressed by vetting through a multi-level review process, and through
requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.

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