Symptoms
- ■ Pain and weakness when raising the arm to the side or forward, especially between 60-120 degrees (painful arc)
- ■ Pain that is worse at night when lying on the affected shoulder
- ■ Tenderness directly over the front of the shoulder and subacromial region
- ■ Weakness when attempting overhead activities or reaching behind the back
- ■ Gradual loss of shoulder range of motion and stiffness
Causes
- ■ Weak rotator cuff muscles failing to keep the humeral head properly depressed during arm elevation
- ■ Poor scapular muscle control causing the acromion to tilt toward the humeral head
- ■ Forward head posture and thoracic kyphosis narrowing the subacromial space
- ■ Repeated overhead activities compressing the subacromial structures over time
- ■ Structural variants: a hooked (Type III) acromion narrowing the subacromial outlet
Diagnosis
- ■ Neer and Hawkins-Kennedy impingement tests to provoke subacromial pinching
- ■ Empty Can test to assess supraspinatus tendon integrity
- ■ Shoulder range of motion goniometry and painful arc identification
- ■ Ultrasound or MRI to quantify rotator cuff tendinopathy, bursitis, or partial tear
* Evidence-Based Interventions
Clinical
Approaches
Rotator Cuff Strengthening
External rotation and depression exercises to control humeral head position during arm elevation.
Scapular Stabilization
Mid and lower trapezius, serratus anterior strengthening to restore proper scapular upward rotation.
Postural Correction
Thoracic extension and pectoral stretching to open the subacromial space.
Manual Therapy
Glenohumeral joint mobilization and posterior capsule stretching to restore full range of motion.
🏠 Home Exercises Guide
Strengthen your recovery. Perform these exercises strictly under pain-free limits:
📋 Execution Blueprint: Side-Lying External Rotation
- 1Lie on your unaffected side with the affected arm on top, elbow bent to 90 degrees.
- 2Place a folded towel between your elbow and body to position the arm correctly.
- 3Slowly rotate the forearm upward (externally) as far as comfortable without pain.
- 4Hold for 2 seconds, then lower slowly to the start position.
- 5Perform 3 sets of 15 repetitions to strengthen the infraspinatus and teres minor.
* FAQs
Common Questions
Yes, the vast majority (over 85%) of shoulder impingement cases resolve completely with dedicated physiotherapy over 8-12 weeks. Surgery (subacromial decompression) is rarely needed and should only be considered after a thorough physiotherapy trial.
Nighttime shoulder pain is very common in impingement because lying on the arm increases subacromial pressure, compressing the already irritated bursa and rotator cuff tendons. Sleeping on the back or unaffected side with a pillow support can help.
The painful arc is pain experienced specifically between 60-120 degrees of arm elevation — where the greater tuberosity of the humerus narrows the subacromial space and pinches the rotator cuff tendons.
Yes, forward head posture and thoracic kyphosis tilt the acromion downward and forward, physically narrowing the subacromial space. Postural correction is a fundamental part of shoulder impingement physiotherapy.
Clinical tests can differentiate: significant weakness on resisted shoulder abduction or empty can test suggests a tear, while impingement tests (Neer, Hawkins) are positive in both. MRI confirms the diagnosis when clinically uncertain.
Initially, painful overhead activities are modified or avoided. As rotator cuff strength and scapular control improve, overhead activities are progressively reintroduced in a graded, sport-specific manner.
Subacromial bursitis is inflammation of the fluid-filled bursa protecting the rotator cuff tendons. It frequently coexists with impingement and is treated with similar physiotherapy approaches plus anti-inflammatory modalities.
Corticosteroid injections can provide short-term pain relief that enables physiotherapy to proceed comfortably. However, repeated injections weaken tendon tissue, so they should not be used as a standalone treatment.
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Verified Author Protocol
Dr. Karolin Rockson, PT (BPT), Ex. CMC - Vellore
Board: Indian Association of Physiotherapists (IAP)
Reg No: PT-84729