Shoulder impingement: How to treat and prevent it

The muscles in the shoulders work and move like vehicles in a bustling, tightly packed freeway with absolutely no room for error. Shoulder impingement is akin to a pesky traffic jam in this 3D joint, leading to discomfort and pain. One can prevent this by following an active strengthening and stretching routine, as long as the correct technique is followed in performing the exercise, say experts. Getting an exercise wrong is, in fact, one of the major causes of shoulder impingement.  

Weaknesses in the rotator cuff muscles can also lead to impingement. “We have four rotator cuff muscles — supraspinatus, infraspinatus, teres minor and subscapularis,” says Dr Bharath Kumar B, sports medicine specialist, founder and director of Ziathlon Sports Medicine Clinic, Bengaluru. “The supraspinatus is the topmost muscle. When one has shoulder impingement, the supraspinatus gets stuck between the head of the humerus and the undersurface of the acromion, a part of the scapula.” Dr Bharath adds, “A tear in the rotator cuff or muscular imbalance in the region results in the inability of the head of the humerus to rotate during shoulder movements. When there is a torque produced at the shoulder, the head of the humerus moves up instead of down, resulting in impingement of the supraspinatus.”  

Testing for shoulder impingement 

Diagnosing shoulder impingement involves a few examinations designed to bring out the pain caused by impingement by placing the shoulder in controlled impingement-prone positions. “We start with a physician examination to understand the underlying cause. Then, we try to ascertain whether someone has an injury, a rotator cuff tear or muscular imbalance. Then we suggest rehabilitation.” Common tests to diagnose shoulder impingement are:  

1. Hawkins-Kennedy test: The arm is flexed up to 90 degrees and then turned, forcing an internal rotation. This involves the arm being positioned in a way that elicits impingement. The doctor will then move the arm passively to assess for pain or discomfort. In case of pain, the test is positive.  
2. Neer test: While scapular rotation is prevented using one hand, the arm is elevated at an angle between flexion and abduction. If this causes pain or discomfort, it could indicate impingement. 
3. Horizontal abduction test: The arm is forced to adduct towards the other shoulder while the elbow is flexed. If pain occurs, this suggests the test is positive. 

Following the physical diagnostic examinations, doctors turn to medical imaging for confirmation. “An ultrasonography is the most common diagnostic investigation. In many other cases, an MRI of the shoulder is also done. In the rare instance of a traumatic shoulder impingement, an x-ray may be necessary,” says Dr Bharath. 

Caring for shoulder impingement  

If impingement strikes, here are some suggestions to help in healing: 

1. Rest: Stop performing activities that aggravate your shoulder pain. Instead, rest and allow the inflamed tissues to heal. 
2. Icing: Icing the affected area for about 15-20 minutes several times a day can help reduce pain and inflammation. 
3. Physical therapy: A structured physical therapy program can strengthen the muscles around the shoulder, improve flexibility and correct any imbalances that might contribute to impingement. “Physical therapy is the treatment of choice — we do pain management with electrotherapy and mobilize the rotator cuff and the shoulder to correct the tightness,” explains Dr Bharath. 
4. Modified routine: Temporarily modifying or completely avoiding activities that worsen your symptoms can aid in recovery. One can gradually reintroduce these activities as the shoulder heals. 
5. Posture correction: Focus on maintaining good posture to reduce strain on the shoulders. 

How to prevent shoulder impingement?

1. Maintain good posture: Sit and stand correctly and avoid slouching. This keeps your shoulders aligned and reduces strain. 
2. Strengthen the muscles: Focus on exercises that strengthen the muscles supporting your shoulders, especially the rotator cuff muscles. This can help stabilize the joint and reduce the risk of impingement. Whether you are at the gym or playing sports, ensure proper form and technique to avoid undue stress on your shoulders. 
3. Push-to-pull ratio: “To maintain shoulder health, the push-to-pull ratio should be 2:3, that is, if we push two times, we need to pull three times. Moreover, the weight should also be in the same ratio. For example, if you were to push 20 kg, you must be able to pull 30 kg. This maintains the optimal muscular strength ratios. This push-to-pull ratio applies both in the horizontal and vertical planes,” explains Dr Bharath. 
4. Gradual progression: When starting a new exercise routine or increasing intensity, do so gradually. Sudden and intense activities can strain your shoulders. 
5. Focus on rest and recovery: Give your shoulders time to rest and recover after intense activities. Adequate rest allows your muscles and joints to recuperate. 
6. Stretching: Incorporating shoulder stretches into your routine can help you maintain flexibility and prevent tightness that may lead to impingement. 

Takeaways

• Shoulder impingement occurs when the supraspinatus gets stuck between the head of the humerus and the undersurface of the acromion.  
• Tests like the Hawkins-Kennedy test and Neer test are used to diagnose it. 
• Rest, icing, modifying physical activities, posture correction and physical therapy can help heal the condition.  
• You can prevent shoulder impingement by maintaining good posture, strengthening your push and pull movements in a 2:3 ratio, resting adequately and stretching regularly.