Shoulder impingement has become a somewhat loaded term. I’ll explain why but first we need to unpack the shoulder anatomy and the origins of the term ‘shoulder impingement’ to help you better understand how the thinking and understanding has evolved as research has progressed.
Next we’ll look at how you might treat the discomfort or pain you can feel on top of your shoulder when going into overhead positions.
If you were hoping for a quick top 3 exercises, we apologise in advance. We feel it is important for our clients and our readers to understand the why as well as the how.
This is especially important with regards to the conversation about shoulder impingement which is not a simple one. With so much conflicting information out there and the latest research and conversations happening within the practitioner fields like rehabilitation and physiotherapy and not necessarily being shared with you as fitness enthusiasts and sports people, we wanted to make it accessible to you too.
So, let’s dive in.
The Shoulder Anatomy Overview
When we are talking about the shoulder, we are talking about four joints: the sternoclavicular, acromioclavicular, scapular thoracic and glenohumeral joints.
The shoulder’s job is to position the hand in space, and we need to be able to transfer forces through the shoulder to the hand to help us with functional activities. This is especially important for sport-based conversations.
To move your hand into an overhead position, these four joints need to move. the scapula needs to upwardly rotate and protract. The collar bone is going to need to elevate and rotate and we need to keep the ball of the humerus on the socket. It’s this articulation that is super important when we talk about ‘shoulder impingement’.
It’s important to note that the humeral head is four times bigger than the socket it sits on. This allows us the move the shoulder in all the different ways that we need it to move but the cost of this mobility means that we have a relatively less stable joint.
The sub-acromial space
Now we can zone in on the sub-acromial space which is the area of consideration when we’re talking about ‘shoulder impingement’.
We have the acromion process which is a bit like the roof of the shoulder, the humeral head, and the sub-acromial space is the small space between the two. In this space, you have the long headed bicep tendon, the supraspinatus (which is one of the rotator cuff muscles) and we have the sub-acromial bursa (which is basically a fluid filled sack, like a cushion).
The Origins of ‘Shoulder Impingement’
The term impingement originates from around 1972 by orthopaedic surgeon, Charles Near. The understanding at this time was that people were getting ‘shoulder impingement’ because there was an attrition of the supraspinatus tendon and the sub-acromial bursa. So essentially there was friction between the acromion process and the structures sitting underneath it.
To help remedy this, Charles Near invented the subacromial decompression surgery, where they essentially shave off the lateral aspects of the acromion process, thereby in theory, creating less friction or more space for the shoulder to be able to move.
During 2000 and 2010, relatively up to date considering we started this journey in 1972, we saw a 75% increase in subacromial decompression surgery. We don’t have the data of what has happened since, but it is due to be published soon.
In 2010 (the latest figures we have at this stage), 21,000 procedures were performed in NHS hospitals which cost around £50 million.
“If the only tool you have is a hammer, it is tempting to treat everything as if it were a nail.”
We all have our biases, us included. If you’re a surgeon and you think you have a solution which is going to require surgery, your hammer is to go and do a surgery.
The shoulder is complex
We can’t just look at the one to half a centimetre space between the acromion and the humeral head and say that is the source of all the issues we’re having. There are many muscles acting on your shoulder based on how many movement options your brain needs your shoulder to have to position your hand in space.
For the shoulder to move well, all the muscles acting on the shoulder needs to be coordinated, able to move through the appropriate range of motion and produce the appropriate amount of force accordingly.
It gets more complex.
The shoulder needs to be looked at as part of the kinetic chain because it is attached to the wider movement system. This is particularly important for our athletic population because we must be able to create, generate and transfer forces through the chain and potentially, if we’re in overhead sports or lifting, be able to express those forces through the shoulder and the hand.
Old habits die hard
Even though the research and understanding has now evolved, shoulder impingement terminology and thinking has stuck around for a long time. To illustrate…
The British Medical Journal in 2019 came out and strongly urged against subacromial decompression procedures. “Their strong recommendation against surgery is based on new evidence that it does not sufficiently improve pain, movement or quality of life compared with other treatment options.”
Yet…
According to BUPA (reviewed January 2024), shoulder impingement is usually treated with rest, physiotherapy and steroid injections first to see if your symptoms ease. But if these non-surgical treatments don’t work, you may need sub-acromial decompression surgery.
In our webinar, you can dive a little deeper into the current research evidence. You can sign up here for FREE to watch on demand.
If you are being diagnosed or told that you have a shoulder impingement and been indicated towards a sub-acromial decompression surgery, you may want to consider your options. You are welcome to book a FREE consultation call if you’d like to talk this through with us.
Your Next Best Steps
If you are feeling discomfort at the top of your shoulder, we need to take a more holistic approach. We now know that we can’t nail down pain to one factor. Pain is complicated and multi-faceted.
Yes, there can be some physical contribution to it, and we also need to consider other areas such as lifestyle, stress levels, sleep, recovery etc. All of these can contribute to the feeling of pain.
For this article, we’ll focus on movement and strength training. At Dynamic Shoulders, we talk about shoulder reconditioning: the integration of physiotherapy and strength and conditioning. Essentially, start looking at movement and strength across the spectrum from post-surgery rehabilitation and the return to play phase through to performance.
If you are in significant pain, we’d recommend you book a call or speak to your physiotherapist or medical practitioner. However, if you’re still training regular, we’ve put together a few simple things for you to try.
Try the windmill rotation with a focus on breathing
Try the windmill rotation with a focus on your breathing to build your thoracic mobility and improve your ribcage kinematics.
Try the single arm wall slide
The single arm wall slide is a great exercise to help us restore shoulder range of motion patterns particularly focussed on the scapula.
Have a go at the high hip bear crawl (it's not as easy as it looks)
Introducing the bear crawl with a high hip position because it's a great way to get more serratus anterior activation. Ground-based movements like the bear crawl are brilliant additions to your training repertoire for many reasons, one of which is that they connect the shoulder and the pelvis together, creating that stability and kinetic chain integration.
Last but not least, the inverted kettlebell shoulder press
The inverted kettlebell shoulder press is a favourite when it comes to shoulder stability. Really simple, by taking the kettlebell upside down the shoulder has to think about delivering the hand and the elbow through a good movement pattern to maintain stability.
We'd love to hear your thoughts on the article and the exercises. Comment here or share on Instagram @dynamicshoulders.
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