Shoulder Impingement (Subacromial Pain Syndrome).
What is shoulder impingement?
Shoulder impingement is a condition in which the rotator cuff tendons and bursa of the shoulder become compressed or irritated as they pass through the subacromial space — the narrow gap between the top of the humeral head and the underside of the acromion. This compression produces pain, typically with overhead movements, reaching across the body, or lying on the affected shoulder at night.
It is worth acknowledging that the terminology and understanding of this condition has evolved considerably in recent years. The term "subacromial pain syndrome" has largely replaced "impingement" in the clinical literature, reflecting a shift in thinking about the mechanisms involved. Research — including the landmark CSAW trial — has shown that structural impingement of the acromion on the rotator cuff is not the sole or even primary driver of symptoms in most cases. Neuromuscular dysfunction, rotator cuff tendinopathy, bursitis and altered shoulder mechanics all contribute, and the traditional focus on the bony anatomy has been revised in favour of a more comprehensive rehabilitation approach targeting these contributors. The practical implication: physiotherapy addressing the muscular and movement causes of subacromial pain is more effective than previously appreciated, and surgery is less indicated than was once believed.
What causes shoulder impingement?
Shoulder impingement can occur due to repetitive overhead movements, poor posture, or aging. People who participate in sports that require repetitive overhead movements, such as baseball, tennis, and swimming, are at a higher risk of developing shoulder impingement.
The most consistent contributing factors in the current evidence base are poor scapular control — where inadequate lower trapezius and serratus anterior function fails to upwardly rotate the scapula sufficiently during arm elevation, reducing the functional subacromial space — and rotator cuff weakness or dyscoordination that allows superior migration of the humeral head under load. Thoracic kyphosis and forward head posture reduce the available subacromial space by altering the resting position of the scapula, and are common postural contributors particularly in desk workers.
Age-related rotator cuff tendinopathy and partial tears, calcific tendinitis, and subacromial bursitis are structural contributors that coexist with the functional factors above.
What are the symptoms?
Pain on the outer or front of the shoulder with overhead movements — particularly between 60 and 120 degrees of arm elevation — is the classic presentation, sometimes called the "painful arc." Night pain — particularly when lying on the affected shoulder — is a characteristic and often debilitating feature. Weakness and difficulty with reaching overhead, behind the back, and across the body are common functional complaints. The pain is typically dull and aching at rest, sharp with provocative movements.
How is it diagnosed?
A physiotherapist can diagnose shoulder impingement by taking a detailed medical history and performing a physical examination. They may also use imaging tests such as X-rays, MRI, or ultrasound to confirm the diagnosis and rule out other conditions that can cause shoulder pain.
Clinical tests including the Hawkins-Kennedy test, Neer's sign, and the empty can test have moderate sensitivity and specificity for subacromial pathology. Ultrasound is the most accessible imaging — it directly visualises the rotator cuff tendons and bursa, identifying tendinopathy, partial tears, calcific deposits and bursitis. MRI provides more comprehensive information where the diagnosis is uncertain or full-thickness rotator cuff tearing is suspected.
How can physiotherapy help?
Physiotherapy is an effective treatment option for shoulder impingement. The goals are to reduce pain, improve mobility, and strengthen the muscles of the shoulder and scapula.
The evidence base for physiotherapy in subacromial pain syndrome is strong — structured physiotherapy produces outcomes equivalent to subacromial decompression surgery for the majority of presentations, which is the primary finding of the CSAW trial. This makes physiotherapy both the first-line and, for many patients, the definitive treatment.
The rehabilitation approach addresses both the structural contributors and the movement pattern dysfunction that perpetuates symptoms. Rotator cuff strengthening — particularly the infraspinatus and teres minor for external rotation, and the subscapularis — restores the compressive force couple that keeps the humeral head centred in the glenoid during movement. Scapular strengthening — lower trapezius, serratus anterior and middle trapezius — restores the upward rotation that creates functional subacromial space during arm elevation.
Manual therapy to the glenohumeral joint and thoracic spine improves joint mobility and allows the shoulder to move through full elevation without the compensatory patterns that provoke symptoms. Thoracic extension and scapular mobility work directly addresses the postural contributors to subacromial compression.
Clinical Pilates is an excellent environment for this rehabilitation — combining thoracic extension work, scapular control exercises and progressive rotator cuff loading in positions that can be precisely modified to stay within the pain-free range as strength builds. Real time ultrasound assists in retraining the deep rotator cuff and lower trapezius activation where pain-related inhibition is affecting muscle recruitment. Dry needling of the periscapular musculature assists with pain management and muscle guarding reduction.
For patients whose subacromial pain has not responded to adequate conservative management and for whom subacromial decompression surgery is being considered, we can also provide post-surgical rehabilitation.
For patients whose shoulder pain arose from a workplace or motor vehicle incident, WorkCover and CTP funded physiotherapy is available.
Our physiotherapists Yulia Khasyanova and Emma Cameron both have experience in shoulder conditions and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Shoulder impingement is a condition in which the rotator cuff tendons and bursa of the shoulder become compressed or irritated as they pass through the subacromial space — the narrow gap between the top of the humeral head and the underside of the acromion. This compression produces pain, typically with overhead movements, reaching across the body, or lying on the affected shoulder at night.
It is worth acknowledging that the terminology and understanding of this condition has evolved considerably in recent years. The term "subacromial pain syndrome" has largely replaced "impingement" in the clinical literature, reflecting a shift in thinking about the mechanisms involved. Research — including the landmark CSAW trial — has shown that structural impingement of the acromion on the rotator cuff is not the sole or even primary driver of symptoms in most cases. Neuromuscular dysfunction, rotator cuff tendinopathy, bursitis and altered shoulder mechanics all contribute, and the traditional focus on the bony anatomy has been revised in favour of a more comprehensive rehabilitation approach targeting these contributors. The practical implication: physiotherapy addressing the muscular and movement causes of subacromial pain is more effective than previously appreciated, and surgery is less indicated than was once believed.
What causes shoulder impingement?
Shoulder impingement can occur due to repetitive overhead movements, poor posture, or aging. People who participate in sports that require repetitive overhead movements, such as baseball, tennis, and swimming, are at a higher risk of developing shoulder impingement.
The most consistent contributing factors in the current evidence base are poor scapular control — where inadequate lower trapezius and serratus anterior function fails to upwardly rotate the scapula sufficiently during arm elevation, reducing the functional subacromial space — and rotator cuff weakness or dyscoordination that allows superior migration of the humeral head under load. Thoracic kyphosis and forward head posture reduce the available subacromial space by altering the resting position of the scapula, and are common postural contributors particularly in desk workers.
Age-related rotator cuff tendinopathy and partial tears, calcific tendinitis, and subacromial bursitis are structural contributors that coexist with the functional factors above.
What are the symptoms?
Pain on the outer or front of the shoulder with overhead movements — particularly between 60 and 120 degrees of arm elevation — is the classic presentation, sometimes called the "painful arc." Night pain — particularly when lying on the affected shoulder — is a characteristic and often debilitating feature. Weakness and difficulty with reaching overhead, behind the back, and across the body are common functional complaints. The pain is typically dull and aching at rest, sharp with provocative movements.
How is it diagnosed?
A physiotherapist can diagnose shoulder impingement by taking a detailed medical history and performing a physical examination. They may also use imaging tests such as X-rays, MRI, or ultrasound to confirm the diagnosis and rule out other conditions that can cause shoulder pain.
Clinical tests including the Hawkins-Kennedy test, Neer's sign, and the empty can test have moderate sensitivity and specificity for subacromial pathology. Ultrasound is the most accessible imaging — it directly visualises the rotator cuff tendons and bursa, identifying tendinopathy, partial tears, calcific deposits and bursitis. MRI provides more comprehensive information where the diagnosis is uncertain or full-thickness rotator cuff tearing is suspected.
How can physiotherapy help?
Physiotherapy is an effective treatment option for shoulder impingement. The goals are to reduce pain, improve mobility, and strengthen the muscles of the shoulder and scapula.
The evidence base for physiotherapy in subacromial pain syndrome is strong — structured physiotherapy produces outcomes equivalent to subacromial decompression surgery for the majority of presentations, which is the primary finding of the CSAW trial. This makes physiotherapy both the first-line and, for many patients, the definitive treatment.
The rehabilitation approach addresses both the structural contributors and the movement pattern dysfunction that perpetuates symptoms. Rotator cuff strengthening — particularly the infraspinatus and teres minor for external rotation, and the subscapularis — restores the compressive force couple that keeps the humeral head centred in the glenoid during movement. Scapular strengthening — lower trapezius, serratus anterior and middle trapezius — restores the upward rotation that creates functional subacromial space during arm elevation.
Manual therapy to the glenohumeral joint and thoracic spine improves joint mobility and allows the shoulder to move through full elevation without the compensatory patterns that provoke symptoms. Thoracic extension and scapular mobility work directly addresses the postural contributors to subacromial compression.
Clinical Pilates is an excellent environment for this rehabilitation — combining thoracic extension work, scapular control exercises and progressive rotator cuff loading in positions that can be precisely modified to stay within the pain-free range as strength builds. Real time ultrasound assists in retraining the deep rotator cuff and lower trapezius activation where pain-related inhibition is affecting muscle recruitment. Dry needling of the periscapular musculature assists with pain management and muscle guarding reduction.
For patients whose subacromial pain has not responded to adequate conservative management and for whom subacromial decompression surgery is being considered, we can also provide post-surgical rehabilitation.
For patients whose shoulder pain arose from a workplace or motor vehicle incident, WorkCover and CTP funded physiotherapy is available.
Our physiotherapists Yulia Khasyanova and Emma Cameron both have experience in shoulder conditions and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
