İhsan ErenShoulder blade squeeze
Stand or sit up straight. Without lifting your shoulders towards your ears, squeeze your shoulder blades back and slightly down. Hold for 5 seconds, then relax.
10 reps, 2–3 times a day%44–65Share of shoulder pain complaints due to subacromial pain
%22People with a full-thickness tendon tear in a community screening; two-thirds of these tears were painless
2 yearsAt follow-up, surgery added no benefit over an exercise programme
Strongrecommendation against decompression surgery from an international expert panel
What is it?
The narrow space between the bony roof on top of the shoulder (the acromion) and the upper arm bone is called the subacromial space. It contains the tendons of the muscles that rotate the shoulder (the rotator cuff) and a small sac (the bursa). Putting too much load, or a load they are not used to, on these structures leads to pain.
It used to be thought that the tendon was "pinched" against the bone. We now know that the problem is usually overload of the tendon itself, which is why the name "rotator cuff related shoulder pain" is also used.
Symptoms and risk factors
- Pain that increases at a certain angle as you lift your arm out to the side or forwards
- Pain on the outside of the shoulder, sometimes spreading down as far as the elbow
- Pain that gets worse when you lie on the painful side and at night
- Difficulty with tasks such as brushing your hair, reaching up to a high shelf or putting on a jacket
- Risk factors: age over 40, and jobs and sports that involve repeatedly using the arm above head height
Is a tear on an MRI always the cause of the pain?
In a study that screened 664 people in a village in Japan, one in five (22.1%) had a full-thickness rotator cuff tear, and two-thirds of these tears caused no pain at all. Tears become more common with age: from 10.7% of people in their 50s to 36.6% of those in their 80s.
So seeing tendon wear or a small tear on an MRI does not mean it is the only cause of your pain, or that you need surgery. Decisions are made by taking your symptoms and examination findings into account as well.
Treatment
Guidelines put exercise at the centre of treatment. Other methods are used as support, to make exercise possible.
- ExerciseThis is the foundation of treatment. A programme that strengthens the shoulder and shoulder blade muscles, with the load increased gradually, reduces pain and improves function. To get results, you need to keep the programme up regularly for weeks.
- Manual therapy and supporting treatmentsManual therapy, taping, shockwave therapy and laser therapy can be added to exercise; although the evidence is limited, they may help reduce pain.
- Cortisone injectionIt works better than a placebo and can make it easier to start exercising; however, it has not been shown to be better than exercise.
- Adjusting your daily loadTemporarily cutting back on overhead tasks that clearly increase your pain gives the shoulder time to recover without resting it completely.
- SurgeryDecompression surgery, which shaves down the bony projection, was found to be no better than sham surgery or diagnostic-only surgery in the CSAW trial in the UK and the FIMPACT trial in Finland. An international expert panel strongly recommends against this operation. Surgical assessment of large tendon tears caused by an injury is a separate matter.
Exercises at home
Six exercises for the shoulder
You may feel some mild, bearable pain during exercise; if the pain is back to its starting level by the next day, it is safe to carry on. The first two exercises are also suitable during the painful phase. If pain increases in exercises where you lift your arm, make the movement smaller.
Door frame external rotation
Stand with your painful side next to a door frame. Bend your elbow to 90 degrees and keep your arm against your side; you can put a small folded towel in between. Press the back of your hand against the door frame without letting your arm move. Hold for 30–45 seconds, pressing only as hard as you can without increasing the pain.
5 reps, 1–2 times a daySide-lying external rotation
Lie on your pain-free side. Bend the elbow of your top arm to 90 degrees and rest it against your waist. Holding a light weight (a full water bottle will do), lift your hand towards the ceiling while keeping your elbow still, then lower it slowly.
10–15 reps, 2–3 setsResistance band row
Tie a resistance band to a door handle or another sturdy anchor at chest height. Holding the ends of the band and keeping your elbows close to your body, pull back and squeeze your shoulder blades together. Slowly return to the start.
10–15 reps, 2–3 setsScaption (angled arm raise)
Stand with your arms by your sides and your thumbs pointing up. Raise your arms forwards and slightly out to the sides, at an angle of about 30 degrees, up to shoulder height; you can hold a light weight in each hand. Lower them slowly, without lifting your shoulders towards your ears.
10 reps, 2–3 setsWall slides
Stand facing a wall and rest your forearms against it at shoulder height. Slide your arms up the wall as far as you can without pain, feeling your shoulder blades glide forwards and upwards. Slowly return to the start.
10 reps, 1–2 times a dayLooking after your shoulder in daily life
The aim is not to keep the shoulder still, but to adjust its load to what the pain allows and to build the muscles back up.
- Move things you use often from high shelves down to chest height.
- If you cannot lie on the painful side, lie on the other side and rest your arm on a pillow in front of you.
- At a desk, support your elbows and keep the keyboard and mouse close to your body.
- Keep up your everyday movements within the pain-free range; do not put your arm in a sling.
- When you return to sport, increase the load of overhead movements gradually.
Video
Videos for shoulder impingement
From the YouTube channel of US physical therapists Bob Schrupp and Brad Heineck.
Ten exercises for shoulder pain
Exercises used for impingement, bursitis and rotator cuff problems.
Three exercises for the rotator cuff
Basic movements to strengthen the muscles that rotate the shoulder.
Frequently asked questions
Does shoulder impingement get better without surgery?
For most people, yes. With physiotherapy, medication, an injection when needed and adjusting daily load, about 60% of patients get a satisfactory result within 2 years. An exercise programme with gradually increasing load is the foundation of recovery.
Do I need surgery?
Usually not. Decompression surgery, which shaves down the bony projection, was found to be no better than sham surgery or diagnostic-only surgery in two large studies, and an international expert panel recommends against it. If you cannot lift your arm after an injury such as a fall, a separate surgical assessment is needed.
My MRI shows a tendon tear. What should I do?
Try not to worry. In a community screening in Japan, one in five people had a full-thickness rotator cuff tear, and two-thirds of these tears caused no pain at all. Treatment decisions are based on your symptoms and examination findings, not on the MRI image; for tears not caused by an injury, exercise is also the first treatment.
Should I have a cortisone injection?
A cortisone injection can reduce pain and make it easier to start exercising; however, it has not been shown to be better than exercise, and on its own it is not a lasting solution. Make the decision together with your doctor.
Can I play sport while my shoulder hurts?
Yes, you can carry on with sports that do not clearly increase your pain. Cut back on sports that use the arm overhead, such as swimming, tennis and volleyball, until the pain eases, and increase the load gradually when you go back.
How is it different from frozen shoulder?
In shoulder impingement, the arm usually moves freely when someone else lifts it, and the pain appears at a certain angle. In frozen shoulder, the shoulder is equally restricted whether you lift your arm yourself or someone else lifts it. Read the frozen shoulder guide →
When to seek help right away
Shoulder pain is not always shoulder impingement. See a doctor without delay if you have any of the following:
- Being unable to lift your arm, or a visible change in the shape of the shoulder, after a fall or a blow
- Redness, swelling and warmth in the shoulder, with a fever
- Pain spreading from the neck into the arm, or numbness, tingling or sudden weakness in the arm
- Especially if left shoulder pain comes with chest pain, shortness of breath or sweating (it may be your heart; call 112)
- Unexplained weight loss, severe night pain that does not ease with rest, or a history of cancer
Sources
- Beard AJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-338.
- Ketola S, Lehtinen J, Arnala I, et al. Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome? A two-year randomised controlled trial. J Bone Joint Surg Br. 2009;91(10):1326-1334.
- Lewis J. Rotator cuff related shoulder pain: assessment, management and uncertainties. Man Ther. 2016;23:57-68.
- Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: from mass-screening in one village. J Orthop. 2013;10(1):8-12.
- Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ. 2018;362:k2860.
- Physiopedia. Shoulder Impingement.
- StatPearls. Shoulder Impingement Syndrome. Treasure Island (FL): StatPearls Publishing.
- Steuri R, Sattelmayer M, Elsig S, et al. 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. 2017;51(18):1340-1347.
- Vandvik PO, Lähdeoja T, Ardern C, et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ. 2019;364:l294.