Shoulder Impingement Syndrome

Upper Limb

Overview

Shoulder impingement syndrome occurs when the rotator cuff tendons and subacromial bursa become compressed beneath the acromion process during overhead activities. This is one of the most common causes of shoulder pain, particularly in middle-aged individuals and overhead athletes. The condition results from a combination of structural narrowing and functional movement dysfunction.

Pathophysiology

Impingement occurs when the subacromial space is reduced, causing compression of the supraspinatus tendon, infraspinatus tendon, and subacromial bursa during arm elevation. This may result from anatomical factors (hooked acromion, osteophytes, thickened bursa), postural dysfunction (forward shoulder posture, thoracic kyphosis), scapular dyskinesis (abnormal scapular kinematics), or rotator cuff weakness. Repetitive compression leads to inflammation, microtrauma, and potential tendon degeneration. Secondary impingement involves dynamic compression from muscular imbalance and instability rather than structural narrowing.

Patient Education

Most impingement syndrome can be effectively managed with activity modification, postural correction, and strengthening exercises; avoiding forceful overhead activities during the acute phase allows inflammation to settle and prevents progression to rotator cuff tears.

Typical Presentation

Site

Anterolateral shoulder, particularly over the greater tuberosity and subacromial region; pain may radiate to lateral arm

Quality

Dull, aching pain; may be sharp with specific movements; sensation of catching or grinding

Intensity

Mild to moderate (3-7/10); often worsens with overhead activities and may disturb sleep when lying on affected side

Aggravating

Overhead reaching and lifting, throwing activities, cross-body adduction, repetitive activities, lying on affected shoulder, pushing movements (e.g., push-ups), carrying heavy objects

Relieving

Rest, immobilization or sling support, ice application, anti-inflammatory medication, gentle pendulum exercises, postural correction, specific rotator cuff strengthening

Associated

Scapular dyskinesis (winging or prominence of medial border), weakness in external rotation and abduction, restricted internal rotation, postural dysfunction (forward head, rounded shoulders), possible referred pain to neck or upper back, clicking or catching sensation with movement

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade B
Moderate evidence: supported by at least one good study

Painful Arc Sign

Procedure

Ask the patient to raise the arm slowly out to the side as far as possible and lower it again. Note where pain appears and disappears.

Positive Finding

Pain in the middle of the range (roughly 60–120° of elevation) that eases above and below it.

Interpretation

A mid-range painful arc supports a subacromial source. Pain only at the top of the range points more to the acromioclavicular joint. A 2013 JAMA review of the examination for rotator cuff disease (Hermans et al.; 28 studies, all in patients seen by specialists) found the painful arc the most useful pain-provocation test: a positive arc made rotator cuff disease more likely (likelihood ratio 3.7) and a normal arc made it less likely (0.36). The review reports likelihood ratios rather than one sensitivity and specificity pair, so no figure is shown.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Neer Impingement Sign

Procedure

Patient seated or standing. Stabilise the scapula with one hand and, with the arm internally rotated (thumb down), passively raise it forwards to full flexion.

Positive Finding

Reproduction of the familiar anterior or lateral shoulder pain near the end of range.

Sensitivity / Specificity

72%/60%

Reference: Hegedus EJ et al., Br J Sports Med 2012; PMID 22773322

Interpretation

Supports a subacromial source of pain (cuff or bursa). It is positive in many shoulder problems, so it should not be used alone. Neer's original test also included an injection of local anaesthetic into the subacromial space to see whether the pain is relieved. Neer sign pooled figures (72%/60%) are from Hegedus (2012) meta-analysis; original description Neer 1972.

Sources

Grade C
Limited evidence: indirect or low-quality support only

Hawkins-Kennedy Impingement Sign

Procedure

Patient seated or standing. Raise the arm to 90° of forward flexion with the elbow bent to 90°, support the elbow, then turn the forearm down to internally rotate the shoulder.

Positive Finding

Reproduction of the familiar anterolateral shoulder pain.

Interpretation

Supports a subacromial pain source but does not identify the structure. 'Impingement' describes a pain pattern; most such pain is now managed as rotator cuff-related shoulder pain with loading exercise. Pooled sensitivity/specificity for the Hawkins–Kennedy test vary widely across studies (Hegedus 2012); no single confirmed pair is shown. Original description: Hawkins & Kennedy 1980 (Am J Sports Med, not JBJS).

Sources

Grade C
Limited evidence: indirect or low-quality support only

Empty Can Test (Jobe's Test)

Procedure

Patient standing. Arms elevated to 90° in the scapular plane, elbows straight, thumbs pointing down. Apply a downward force at the forearms while the patient resists; compare sides.

Positive Finding

Weakness compared with the other side, or reproduction of the familiar shoulder pain.

Interpretation

Loads supraspinatus. Pain supports rotator cuff involvement; clear weakness should raise concern for a tear. Itoi (1999, Am J Sports Med — not JSES) compared the empty-can and full-can tests by diagnostic accuracy (~70–75%), not a sensitivity/specificity pair.

Sources

Grade C
Limited evidence: indirect or low-quality support only

Scapular Dyskinesis Assessment

Procedure

Observe from behind as the patient raises both arms slowly overhead and lowers them five times, holding a light weight if needed.

Positive Finding

Winging of the medial border or inferior angle, early shrugging, or jerky, asymmetrical scapular movement.

Interpretation

Describes movement quality to guide exercise. Scapular dyskinesis is also common in people without shoulder pain, so it is not a diagnosis. The scapular assistance and retraction tests can show whether correcting it changes the pain. Kibler (2013, Br J Sports Med — not JOSPT as previously cited) provides a reliable observational method for scapular dyskinesis, not a diagnostic sensitivity/specificity pair.

Sources

No accuracy study

Infraspinatus Strength Test (Resisted External Rotation)

Procedure

Patient seated, arm at the side, elbow bent to 90°. Ask the patient to push outwards against your hand; compare sides.

Positive Finding

Weakness or pain on resisted external rotation compared with the other side.

Interpretation

Tests infraspinatus. Weakness suggests posterior cuff involvement or a larger tear. The hornblower's sign is a different test (inability to externally rotate with the arm abducted to 90°), mainly for teres minor. Park (2005) reported the infraspinatus strength test as highly specific (~90%) for rotator cuff disease; sensitivity is lower and a single confirmed pair is not shown.

Sources

⚠ Red Flags

  • •Acute trauma or fall on shoulder with severe pain and loss of function
  • •Signs of complete rotator cuff tear (inability to initiate or maintain abduction, positive drop arm test)
  • •Severe progressive neurological symptoms suggesting nerve compression
  • •Systemic symptoms (fever, malaise, unexplained weight loss) suggesting infection or malignancy
  • •History of cancer with shoulder pain
  • •Chest pain or cardiopulmonary symptoms coinciding with shoulder pain
  • •Radiating pain with dermatomal distribution suggesting cervical radiculopathy

⚡ Yellow Flags

  • •Symptom duration exceeding 3 months despite conservative management
  • •Catastrophizing beliefs about shoulder pain or fear-avoidance behavior
  • •High levels of psychological distress or depression
  • •Work or sport demands incompatible with current function
  • •Poor compliance with rehabilitation exercises
  • •Expectation of quick resolution without participation in therapy
  • •Multiple failed treatments suggesting possible chronicity

Osteopathic Techniques

Exercise is the first-line treatment, and most add-ons may not beat exercise alone. Manual therapy can be added for a small, mostly short-term drop in pain; the evidence is low quality.

Region

Upper and mid thoracic spine

Technique

Articulation, thoracic
Grade B
Moderate evidence: supported by at least one good study
Reviews found thoracic mobilisation reduced pain and disability in shoulder impingement. Thrust manipulation (HVLA) did not show the same effect.

Rationale

Gentle, rhythmic mobilisation of a stiff upper back. Reviews found it reduced shoulder pain and disability in impingement.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of restricted thoracic segments within their passive range, with no thrust. The patient is seated, side-lying or prone. For neck problems the upper thoracic segments (T1–T6) are the usual focus.

Evidence in Shoulder Impingement Syndrome

A 2026 meta-analysis of 12 studies found thoracic Maitland mobilisation improved pain and disability in subacromial impingement more than control, while thrust (HVLA) techniques showed no significant effect. A 2025 meta-analysis of 10 trials found thoracic manual therapy reduced pain and disability, including versus placebo. An earlier 2018 review found a single session was no better than placebo straight after treatment.

Region

Glenohumeral joint (Spencer sequence)

Technique

Articulation, shoulder (Spencer technique)
Grade C
Limited evidence: indirect or low-quality support only
Manual therapy eased pain a little more than placebo or exercise alone, with low-quality evidence. The best placebo-controlled trial found no clinically important difference.

Rationale

Graded mobilisation of the shoulder through its range. Adds a small, short-term pain benefit to exercise.

How it's done, cautions & evidence

How it's done

Patient side-lying, affected shoulder up. Stabilise the shoulder girdle with one hand and support the arm at the forearm and wrist with the other. Work through seven stages: extension, flexion, circumduction with compression, circumduction with traction, abduction (then adduction with external rotation), internal rotation, and traction in abduction. At each barrier use slow rhythmic oscillations, then a gentle isometric contraction to reach the new barrier.

Cautions

Its isometric step is a muscle energy technique, so do not use it with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in Shoulder Impingement Syndrome

A 2015 meta-analysis of 21 trials found manual therapy cut pain by about 1 point out of 10 versus placebo or when added to exercise; its effect on function was unclear. A 2017 meta-analysis found it beat placebo and, added to exercise, helped only at the shortest follow-up (very low quality). A 2016 Cochrane review found the one high-quality trial of manual therapy plus exercise versus placebo showed no clinically important difference. These trials tested shoulder mobilisation in general, not the Spencer sequence.

Region

Upper and mid thoracic spine

Technique

Muscle energy, thoracic
Grade C
Limited evidence: indirect or low-quality support only
Thoracic MET beat placebo for pain and disability in shoulder impingement, up to 1 year. This is one trial of 75 patients.

Rationale

Low-force, patient-powered upper-back technique. Beat placebo for pain and disability in one impingement trial.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Shoulder Impingement Syndrome

A 2022 placebo-controlled trial of 75 patients aged 40 or over with shoulder impingement, run in an osteopathic practice, found 4 weekly sessions of MET to the thoracic spine improved pain and disability more than placebo at discharge, 6 and 12 months. MET plus soft tissue massage improved disability but not pain.

Region

Rotator cuff, deltoid and periscapular muscles

Technique

Soft tissue, shoulder and periscapular muscles
Grade C
Limited evidence: indirect or low-quality support only
Massage helped pain, function and range in the short term versus no treatment (low-quality evidence). Added to exercise, it gave no extra benefit in a trial.

Rationale

Eases tension in the rotator cuff and shoulder blade muscles. Short-term help; it adds little to exercise.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the muscles around the shoulder: the rotator cuff, deltoid and the muscles around the shoulder blade. In trials it was given alongside shoulder exercise.

Evidence in Shoulder Impingement Syndrome

A 2014 meta-analysis found low-quality evidence that soft tissue massage improved pain, function and range of motion in non-specific shoulder pain in the short term, versus no treatment. A 2015 trial of 80 patients found adding massage to exercise gave no extra benefit; at 12 weeks exercise alone did slightly better for pain. A 2025 review found trigger point manual therapy matched other passive treatments for pain in rotator cuff related shoulder pain, with slightly better function.

Rehabilitation Exercises

Pendulum Exercises

Range of MotionBeginner

Cross-Body Shoulder Stretch

StretchingBeginner

Doorway Pectoralis Stretch

StretchingBeginner

Sleeper Stretch for Internal Rotation

Range of MotionBeginner

Resisted External Rotation at 0 Degrees Abduction

StrengtheningBeginner

Prone Y-T-W Raises

StrengtheningIntermediate

Side-Lying External Rotation

StrengtheningBeginner

Quadruped Shoulder Taps (Scapular Stabilization)

StrengtheningIntermediate

Prone Horizontal Abduction (T-Position)

StrengtheningIntermediate

Prone Cobra with Scapular Retraction

PosturalIntermediate

Resistance Band External Rotation in 90/90 Position

StrengtheningIntermediate

Standing Single-Arm Overhead Stability (with Light Weight)

BalanceAdvanced

Referral Criteria

  • •Persistent impingement symptoms unresponsive to conservative treatment after 8-12 weeks
  • •Clinical signs suggesting full-thickness rotator cuff tear (positive drop arm test, severe weakness disproportionate to pain)
  • •Suspicion of labral pathology with instability symptoms
  • •Neurological deficits or cervical radiculopathy not responding to conservative care
  • •Imaging findings indicating surgical candidates (severe osteophyte burden, significant subacromial narrowing)
  • •Systemic disease presentation requiring investigation (rheumatoid arthritis, inflammatory conditions)
  • •Acute traumatic injury requiring orthopedic assessment
  • •Patient preference for surgical consultation after trial of conservative management