Shoulder Impingement

Is it really a diagnosis ?

Approximately 20-25% of people are diagnosed with shoulder impingement. It is quite prevalent among athletes, particularly those in racquet sports, but it is also frequently seen in individuals with desk jobs and sedentary lifestyles. But is shoulder impingement really a diagnosis? In my opinion, it is an umbrella term for a cluster of symptoms rather than a pathology itself. Let’s understand shoulder impingement to get better clarity on diagnosis and treatment.

Impingement can be divided into two categories - Primary and Secondary shoulder impingement.

Primary shoulder impingement usually results from a structural abnormality that will reduce the sub-acromial space (space between two bones near the shoulder joint which serves as an outlet for various tendons) Structural abnormality can be:

1. The shape of the bone - it can create friction during the gliding of the tendons (Fig 1)

2. Bone spurs (small bone particles deposited on the ends of bone due to friction or bone inflammation)

Fig 1: Type II and III reduces the space for the tendons

Secondary shoulder impingement arises from an imbalance in muscular strength around the upper back and shoulder muscles, a condition scientifically referred to as mechanical dysfunction. The shoulder complex has four joints that must work together to facilitate arm movements. Of these, the most crucial is the coordinated action of the scapula (the bone in the upper back) and the ball-and-socket joint of the shoulder. The scapula has minimal bone-to-bone connection and relies on the upper back muscles for stability on the thoracic cage. This coordination then allows the shoulder muscles to raise the arm effectively. (Fig 2)

Fig 2 : Co-ordinated motion of these two bones will maintain the space

How to solve this problem ?

Medications can only offer short- term relief in symptoms, so a better way to address shoulder impingement is to consult a physiotherapist.

How will the Physiotherapist tackle the problem ?

1. Understanding the pain status

2. Assessment of movement pattern

3. Identifying dysfunctional movement pattern

4. Identifying weak muscles contributing to the dysfunctional movement patterns

Solutions to the Assessed Problems

1. Pain Management - There are several modalities available to alleviate pain, such as ice massage, ultrasound and TENS. The physiotherapist will prescribe the most appropriate modality as per the requirement.

2. Short Term Goals - Stiff muscles are lengthened and weak muscles are strengthened, through a range of physiotherapeutic techniques and exercise programs.

3. Long Term Goals - Managing any dysfunction effectively depends on preventing recurrence. Home exercise program along with ergonomic advice helps prevent symptom recurrence for individuals in desk jobs. Athletes typically undergo assessments of their sports specific functional movements to pinpoint any dysfunctional patterns.

In summary, because there are a cluster of symptoms to consider shoulder impingement cannot be a diagnosis. Medications can only be a solution to relieve pain temporarily but it is important to consult a physiotherapist for a sustainable solution. By addressing the root cause and implementing targeted exercises we can achieve long term improvement and prevent recurrence.