I think we all know that the term “shoulder impingement” is very nonspecific. It can mean a lot of things.
Many have argued that the term “impingement” tends to imply a biomechanical pathology. That isn’t always the case, but sometimes it is.
But it doesn’t need to be confusing. Here’s how we define “shoulder impingement,” think about it during our evaluations, and then use the info to build a treatment plan.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 241: What is Shoulder Impingement?
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Show Notes
Transcript
Student:
All right, we got Jackson from South Carolina. As a PT student, I’m currently finding it difficult to approach the broad phenomenon of shoulder impingement. How do you guys go about assessing this issue, and what are the most common findings you see in a patient or athlete?
Mike Reinold:
Awesome. Good job, Katie. All right. So Jackson says as a PT student, so I get this one, this is pretty good shoulder impingement’s gigantic, right? And I think that’s a big point. And what he says is how do you go about getting it started? He’s finding it difficult to even just start with shoulder impingement.
Mike Reinold:
And I think that makes sense. I think we have a lot of diagnoses that have these such broad terms that sometimes it’s not helpful. Why don’t we start with this? Why don’t I throw this at you guys, and we’ll see what we get for some answers. But why don’t we start with this? What is shoulder impingement to you guys? And this is like one of those personal questions, because I think the answer is not black and white.
Mike Reinold:
But if you have somebody that you would say has shoulder impingement, how would you even define that? And we could have a whole separate topic if shoulder impingement is even the right term to use, and if we’re even still using that. But why don’t we talk about definition first before we talk about treating a little bit, because maybe that will lead into that.
Mike Reinold:
So who wants to start with that? I’ll kind of throw that out there. How do you define it, and do you think shoulder impingement is the right choice of terminology for somebody with this? Dan Pope, what do you think buddy? [crosstalk 00:00:03:20].
Dan Pope:
I think this is a good opportunity to sound stupid, get thrown under the bus a little bit. Yeah, so I guess shoulder impingement is a little misleading just because we think that the rotator cuff can get irritated via some compressive mechanisms, that could be coming from the acromion, that could be coming from the glenoid, so we don’t really know where that’s coming from, and it’s different based on the person. And the compressive issues could be leading to pathology, or it could be maybe some of the tensile load the athlete’s going through. So when you say shoulder impingement, at least to me, it sounds like you think those compressive forces are the main problem, and you’re trying to address those specifically. Although they probably live together with other types of forces that, let’s say the tendons aren’t handling well, and then you end up with pain.
Mike Reinold:
So do you think Dan, you think it’s not always compressive forces. Because shoulder impingement is quite a biomechanical term. Impingement means like if you’re taking the ball and socket joint, and you have your rotator cuff, and your subacromial space, you’re impinging the rotator cuff, probably between the humeral head and the acromion, maybe the coracoid, maybe the coracoacromial ligament, whatever. But it’s implying impingement is the pathology. So are you saying compression might not be it? What else could it be Dan?
Dan Pope:
Yeah, I went down a pretty big rabbit hole at one point trying to figure this stuff out. Because the studies are all over the place. So you have some studies that are done in cadavers, you have some studies are done with MRI, you have some studies that are under arthroscope and surgical interventions, and they’re trying to see if impingement is incurring, and it changes from person to person. So a Neer’s test, for example, may show no impingement whatsoever in one person, and it will show a ton of impingement and the next person. So that’s actually pretty challenging, I think, to figure out if you’re getting impingement as a primary pathology. And I want to apologize, I lost my train of thought. What was your original question?
Mike Reinold:
So I guess the question is if it’s not always compressive, what else could it be?
Dan Pope:
Okay. So I think oftentimes your rotator cuff is just working a lot when you’re doing exercises. For my population they’re in the gym, so if you’re doing a bench press, your rotator cuff is working a lot. And people tend to overdo pressing exercises, which are generally working the infra and the supera bit more. And they end up with pain specifically with pressing, usually.
Dan Pope:
I think oftentimes that’s an overuse condition. So you’re using that tendon a ton, and if you overuse a tendon, let’s say a patellar tendon, or Achilles tendon, it becomes painful, and you can develop tendinopathy just because you’re using it so much. So I think that that’s probably one of the things occurring.
Dan Pope:
If they’re getting some increased compressive forces, let’s say someone’s snatching and their end range, and they’re getting more compressive forces, they may end up with pain simply because of the position, and they’re getting that compression. Whereas someone who’s just doing a ton of bench press might not be getting those compressive forces, but they end up with a similar type of pain, and just irritation, but of the same tissue, I guess.
Mike Reinold:
Right. And then if you look at your clinical examination, and you look at your special tests, the special tests are compressing, they’re compressive-based tests.
Mike Reinold:
But I like your point where sometimes it’s emulating the mechanism of injury, which might be compression, but sometimes you’re just compressing an irritable tendon that’s already irritable for some other reasons. So yes, compression could annoy it, but that doesn’t mean that’s what caused it. So I like that, I think that’s a good point.
Mike Reinold:
Let me ask another question to the group on impingement on this, so is compression and is impingement normal? And when I raise my arm up in the air right now, am I impinging normally? And does anybody know what the research shows on that a little bit?
Lenny Macrina:
I think so, I think so. I think the research does say that it does happen. I don’t know why exactly the tendon eventually breaks down. Because you’re going to see the tendon is breaking down in areas where it does kind of impinge on the acromion. You know what I mean? And it’s also a watershed zone, so there’s not a good blood supply to the area. So as we age, maybe it can’t handle the forces that are being put through it because it’s still compressing.
Lenny Macrina:
So the term impingement, I know social media wants to throw it out because it’s a scary term for people. But if you explain it correctly, it doesn’t have to be scary people. Like to come on, there is a pinching-type phenomenon that’s probably occurring over time that is the reason, along with an overuse thing. So it’s a combo of the two. So to just throw the term out, fine, we can call it, “Non-specific rotator cuff pathology.” Whoa, now we have pathology in our rotator cuff.
Mike Reinold:
What if it’s not the rotator cuff too? What if it’s-
Dave Tilley:
Right, it could be reversal, in the biceps, it could be so many different things. So right now I think the fancy term is non-specific rotator cuff pathology, just like non-specific low back pain is kind of the term. And again, we’re just playing word vomit right now with some of our terms, with some of our pathologies to not be so scary, but-
Mike Reinold:
I was in an online discussion about this too, but if we’re going to change terminology, it has to simplify and clarify. Right?
Dave Tilley:
Right.
Mike Reinold:
And I don’t think we achieved either of those with that one right there.
Dave Tilley:
No it definitely makes it more vague, more general, and now it’s up to us again, to explain it. So it still comes back to us to explain it correctly. Now, I completely, some people are going to explain it incorrectly and create this crazy scenario in somebody’s shoulder, where it’s just going to create more pain, and we know all that definitely contributes to somebody’s pain, is being anxious about their injury.
Dave Tilley:
But I think the normal therapist, the normal person that’s coming in for PT is doing a good job helping people with talking to them, and talking them through the pathology, and social media is going to pull out that 10% of the crazy stories that are out there and just true escalate it.
Mike Reinold:
Right. Right. Dan, what were you thinking there? Did you have some followup on that?
Dan Pope:
Yeah, I’m sorry, I don’t want to hijack. I just did like a-
Mike Reinold:
Hijack man.
Dave Tilley:
[inaudible 00:09:37].
Dan Pope:
… really deep dive into impingement because I’m trying to understand it. But yeah, it’s normal, and generally speaking, you’re getting impingement in what we consider the painful arc of motion. So when you raise your arms overhead, when you get around 90, there’s more impingement. A lot of the research I read is that the zone or the painful arc is much lower than we tend to think.
Dan Pope:
So, traditionally, I guess it’s somewhere between let’s say 80 and 110, or maybe a little bit higher or lower than that, it’s probably a bit lower than that, and it’s normal to get impingement; everyone’s going to have that. There’s more compressive force on that tendon. And that was the answer that I was trying to…
Mike Reinold:
And I appreciate that. I think in the normal arthrokinematics of the shoulder, it’s not like you have empty space in your body, and it’s just got all this room for the humeral head to move up and down, there’s not a lot of empty space. So yeah, when you move, yes you impinge. But this is where I think we run into some troubles with, especially some of the younger clinicians and students here, is where they assume like, “Well, if every time I lift my arm, I impinge, then that’s not bad, and we have to be careful saying that’s bad.”
Mike Reinold:
Well, let me throw this at you guys as a group. What if I have a tight inferior capsule? What if I have poor rotator cuff stability? What if I have excessive laxity in my joint and I can’t stabilize, and I get superior and humeral head migration?
Mike Reinold:
What if that normal compression, let’s make things up, please don’t annoy me on social media by responding to this. Let’s say every time I lift my arm, there’s 10 pounds of pressure on my rotator cuff, but my inferior capsule gets tightened, and now it’s 15 pounds of pressure. Please don’t comment on that. But if that happens, is that good? Is that bad? Are we building more resilience of the tissue? I don’t know, I think this is where we have to be careful saying that impingement’s normal because there’s other ways that can increase the compressive forces.
Dan Pope:
I don’t know. I’ll let [inaudible 00:11:34] talk.
Mike Reinold:
Dan’s going to get worked up. What do you think Tilley?
Lenny Macrina:
I’m learning to [crosstalk 00:11:37].
Lenny Macrina:
I think to go back to the original question, this person, I think it was a student wanted to know what we’re looking for. We’re looking for is pain making sense with the injury and their function?
Lenny Macrina:
First, I want to make sure, like in head, I’m thinking, “Is it a neck thing? Somehow is the pain, is there anything going down below the shoulder? Is it going down kind of below the deltoid insertion, going down to the elbow and the hand?” That’s a big red flag for neck issues.
Lenny Macrina:
Is it not like a thoracic allotype thing? Is it not a biceps issue? Or some kind of other tendonous issue? But all that stuff in the shoulder doesn’t matter, you can kind of treated the same way, right? Restore their mobility and work on their strengths. So I think we get so caught up with the diagnosis that we tend to treat it the same way anyway.
Lenny Macrina:
It’s going to be activity modification, slowly ramping up their volume, restoring their motion, if they have a lack of motion, like you said, an inferior capsule issue. So how can we do that? Self range of motion, mild fascia release, all those things, joint mobes, and then giving them a good program for their rotator cuff.
Lenny Macrina:
And I think it’s that simple. We don’t have to get too bogged down with crazy terminology. But people are going to PT because they want to know why they hurt. So as much as we don’t have to put a diagnosis on it, people want to diagnose; I go to the doctor, I don’t want to leave with a diagnosis of knee pain when I know I have knee pain, I just spent a ton of money to be told I have knee pain, but that’s what happens.
Lenny Macrina:
So up to us to try to do our best to get as tissue-specific as possible knowing, and that’s what I explain to my people, “It may not be, but it seems to be that way, and this is what we can do to help you.”
Mike Reinold:
What if you saw the doctor and he said you had nonspecific knee pain, would that help?
Lenny Macrina:
Exactly.
Mike Reinold:
Would that help, or irritate you more? You’re just like, “Well, no, it specifically hurts on my knee. I don’t what you’re…”
Lenny Macrina:
It would create more anxiety for me, my pain would go up, right?
Mike Reinold:
Piggybacking off of what Lenny said, I would say for me, I have not said, sometimes I’ll say I’ll use the phrase shoulder impingement, but I’ll just tell people right now it’s like, “Look, here’s what we know, your shoulder is irritable right now, the tissue in your shoulder is irritable.” And I say that quite a bit, and it’s hard to deny that, right?
Mike Reinold:
So, “It’s irritable. I showed you on a couple of these tests that I can do a couple of maneuvers that provoke it. So it’s irritable. We still need to figure out why. Is it just workload? Is it your capacity of your body wasn’t ready for it? Do you have some sub optimal things in your body that maybe increase the pressure like we talked about previously?” All those sorts of things kind of put together, but I agree, I just kind of say like, “Look, you have an irritable shoulder. I think that’s all that matters.” And you almost always blame it on workload, or your body’s ability to handle the workload more than to say, like, “Your problem is your bone or your acromion. Your problem is your workload and stuff like that.” So, Mike, what do you got?
Mike Scaduto:
I was just going to say as the youngest clinician in the crew, kind of helping a PT student, I think a big part of this is having a standardized assessment for the shoulder that you use in a very specific order. I think sometimes if you go and do a provocative special test early in the exam, it becomes a little bit more murky. So maybe saving those provocative Neer’s Hawkins–Kennedy impingement test towards the end of the exam, to kind of see if that is provocative and not trying to provoke pain, and then test other things where it becomes a little more murky, I think that’s where some PT students get in trouble with a shoulder exam.
Mike Reinold:
Right. I like that. Dave, what’s up? What do you think Dave?
Dave Tilley:
Mike said what I was kind of thinking already, is I think in the context of your order, your special tests and stuff like that, but also I think a lot of times students, there’s so much literature on there on what could be contributing to why the area is sensitive or overloaded. Thoracic spines, scapular mechanics, capsular stuff, soft tissue, strength, workloads. I think students unfortunately sometimes just kind of get overwhelmed, and they just start grasping at straws for random things they think could be part of the problem.
Dave Tilley:
And so something I’ve been trying to work with a lot of the students at Champion is like have three competitive diagnosis in your head, like labural, AC joint, and maybe something in the cuff. And how are you going to prove to yourself with a systematic exam which one of those is the most probable to start with?
Dave Tilley:
So obviously have your local shoulder exam, but then I go, “Okay, I got to check T spine mobility, I got to check the neck,” like Lenny said, “I got to check some strength.” You got to make sure you have a very standardized, like Mike said, reproducible the whole time, so you’re not just swimming in special tests and random things to do.
Mike Reinold:
Yeah, I like it. And then I’m going to make your life a lot easier Jackson, is I’m going to say kind of what Lenny said already here, but part of with me saying, “Hey, your shoulder is irritable,” means that the true specific diagnosis, if we’ve ruled out things that are problematic, labral tear, rotator cuff tear, the big things, if we ruled that out, and we now have, what was it, non-specific rotator cuff pathosis [crosstalk 00:16:24].
Lenny Macrina:
[crosstalk 00:16:29] pathology.
Mike Reinold:
Neural biomechemical. It has been a while since we pulled neural biomechemical out. If you have that, the reason why I’m comfortable with that diagnosis is because at that point in time, I’ve already made the decision on what my treatment approach is going to be, and dialing it down if it’s superspinatus, his biceps tendon, or his bursa, or whatever it may be, doesn’t change my treatment paradigm at that point. So I kind of just kind of move on.
Mike Reinold:
Now I hate to say it, Dave and Lenny kind of said a couple of things they’d start doing for treatments. It’s about getting the cuff strong, so that way you can center the humeral head. Dave talked about thoracic mobility and stuff like that. What are we doing? We’re decreasing the chances of compression, right? I hate to say it like, let’s just call a spade a spade sometimes. But again, what we’re trying to do is take some of the compressive forces off the cuff.
Mike Reinold:
So again, are there times where somebody has a complete just tendinopathy-type situation that’s not from compressive forces? Of course. But I think we all supraspinatus, let’s get over that, but there’s things that we can do that either increase the impingement or increase your body’s ability to handle the stresses that come from that impingement.
Mike Reinold:
And you kind of put that together. Like now you add that with some tensile stress, like Dan said, then now you’re kind of getting some double whammies, and that might be why we have some younger generation people with rotator cuff tendinopathy, is because they have the normal compressive stresses with tensile stresses from some of their aggressive things that they’re doing. And you put those two together, and maybe that’s like that whole analogy of the weed, right? Pulling the weed out of the ground, you don’t pull it straight up out of the ground, you kind of go side to side to pull that weed up. Maybe we’re getting compression, tension, compression tension, that sort of thing.
Mike Reinold:
So anyway, so good question, Jackson. I think we didn’t talk a ton about treatment. And I think that was intentional because I actually thought from your question that the guidance you actually needed was to take a step back and think it’s not that you’re necessarily missing anything on your exam, this is a big topic, but it may not necessarily change your treatment approach. So keep so kind of keep that in mind.
Mike Reinold:
So, great question, great answers from everybody. I appreciate this dialogue. I thought this was a good episode. So thanks so much. And if you have questions like that, head to mikereinold.com, click on that podcast link and ask away. And be sure, head to iTunes, Spotify, rate us, review us, subscribe to us, keep it coming so we’ll keep doing these episodes for you, and we’ll see you on the next episode.
