Shoulder Impingement Part 1: Where is my pain coming from?

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The moment clients experience shoulder pain they tend to head to Dr. Google, type in their symptoms and BOOM, shoulder impingement pops up (or if you’re a hypochondriac like me, you’re convinced it’s cancer).

Impingement is like the physiotherapy equivalent of irritable bowel syndrome: a broad term that encapsulates a range of symptoms and tends to be over diagnosed. It’s a common referral I get from GPs. The problem is that similar symptoms can occur for a range of different shoulder issues, so it’s important not to jump to any conclusions before a thorough assessment.

No two cases of impingement are the same, and as a result there’s no “one size fits all” protocol or rehab process to follow. However, any good physiotherapist will have a toolbox of assessments, range of motion screenings, manual therapy techniques and exercises to call on once the underlying cause of pain is understood. The three main things I consider in my assessment of shoulder pain are:

1. Location
2. Structures involved
3. Cause

Asking questions about the clients’ daily activities, type of job, sports they play and gym exercises can all give clues as to why the pain has begun, the location of the structures affected and, more specifically, why it has occurred. Then I can tailor a treatment approach accordingly.

But before we dive into treatment, let’s take a closer look at the structure of the shoulder and locations where pain is commonly felt.

Here we have a structure of the shoulder. The most common structure to be affected by impingement is the supraspinatus muscle/tendon, which forms part of the rotator cuff and inserts onto the humerus (arm bone). Because of its placement there are two main sites where supraspinatus impingement can occur:

  • Bursal side impingement: this is impingement on the side closest to the bursa, which sits above the supraspinatus tendon. I believe the bursal side would be the standard subacromial impingement everyone refers to when diagnosis a shoulder impingement.
  • Articular side impingement: there is articular cartilage on the head of the humerus, which helps the shoulder joint move freely. The underneath part of the supraspinatus tendon comes into contact with this area and is often termed an ‘internal impingement’

Essentially the impingement is either occurring from above (bursal side) or below (articular side). The two are very different in terms of cause, assessment, and treatment so it’s important for your Physio to determine which one is affecting you.

If you are experiencing pain and reduced function in your shoulder, be sure to book in for an assessment instead of self-diagnosing with Dr. Google. Additionally, keep your eyes peeled for the next part in our Shoulder Impingement Series where we look at the causes of impingement, differentiating between primary and secondary impingement, and cover the keys to treatment and rehabilitation.

Nick Hunter

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