Shoulder Impingement: Part 1 – What It Is and Why It’s Important

I recently had the opportunity to speak with one of my professors Mark Butler, a physical therapist I have a lot of respect for.  I asked him what he...

I recently had the opportunity to speak with one of my professors Mark Butler, a physical therapist I have a lot of respect for.  I asked him what he thought was the most common shoulder problem in the world of fitness.   His response:

Shoulder Impingement

From my own experience and speaking with other crossfit trainers and therapists, the most common problem area for people in crossfit is the shoulder.  Just take a look at the major exercises in crossfit; overhead press, push press, push jerk, pushups, kipping pullups, snatches, dips, muscle-ups and handstand pushups.  All awesome exercises, all tough on the shoulder.  No wonder we have impingement.

Unfortunately, the term shoulder impingement is thrown around quite a bit to describe every type of shoulder pain.  In reality there are several different types of impingement, each with unique aspects.  This is why its important to consult a professional if you are concerned you may have an impingement situation.  The problem can be very complex and impingement can be coupled with other issues as well.

In understanding shoulder impingement first we’ll learn the anatomy.

In this picture we have the shoulder joint.  Here are the key structures:

  1. The humeral head – This is the top portion of the bone in your upper arm.  Normally it should stay snugly fit centered into its socket, the glenoid fossa
  2. Acromion, Coracoid and Coracoacromial ligament – These structures sit above the humeral head and provide a small space aptly named the subacromial space.
  3. Supraspinatus Tendon (part of the rotator cuff), long head of the biceps tendon and a bursa.  These structures sit between the humerus and the structures labeled above in #2 in the subacromial space.  These are the structures that get impinged upon with this syndrome.

In an impingement scenario, the rotator cuff and scapular musculature is not holding the humeral head firmly into the socket.  Commonly the humeral head translates superiorly (goes up) and the contents of the subacromial space gets pinched (impinged) against either the acromion, coracoid or a combination of the two.

This can occur with all different movements of the shoulder.

Dr. Kietrys has an excellent saying about impingement.  He says, “All roads lead to shoulder impingement”   What he meant by this is that most types of shoulder pain end up causing some type of impingement.  So regardless of how you hurt your shoulder (overuse, technical breakdown, overstretch, muscular imbalance, poor posture, dyskinesis) it will most likely end up causing a shoulder impingement.  This is why its so important to avoid situations that may damage the shoulder.  In a lot of cases shoulder pain can lead to a cascade of additional problems.  Now you’ve got a complex rehabilitation situation on your hands or in some cases, surgery.

As discussed earlier, the impingement can be occurring in multiple places:

  1. Coracoid Impingement
  2. Acromial Impingement
  3. Internal Impingement (Thrower’s Impingement)

Impingement by the coracoacromial arch (a fancy term for the acromion, the coracoid and the ligament that connects the two)  is what we discussed earlier.   It’s also commonly referred to as subacromial impingement.  The most important thing to remember about this condition is that the humeral head is not being held tightly into the glenoid fossa (ball into socket) in the correct position during exercise.  This happens for a variety of reasons we’ll discuss in the next articles.  Because of this we get excessive impingement, pain and eventually damage to the structures within the subacromial space.

In subacromial impingement of the shoulder there is typically a painful arc of motion while raising your arms overhead, usually in the 70-120 degree range.

These patients usually have pain when reaching across the body, internal rotation of the shoulder and elevation of the arm into the painful arc of motion as described earlier.  These are a few provocative diagnostic tests to rule in  subacromial impingement syndrome.

Coracoid Impingement – This guy looks especially happy to be having shoulder problems

Hawkins Impingement Test

Internal impingement is a different beast.  This is an impingement common in throwing athletes and occurs with excessive external rotation of the shoulder seen in pitching and in the tennis and volleyball serve.  Although this impingement is specific to overhead throwers, the motion that causes internal impingement is very close to crossfit exercises that require external rotation of the shoulder in an overhead position (kipping pullups, muscle-ups).  Crossfit athletes are also put at risk in other exercises that require a lot of external rotation of the shoulder such as with back squats, the rack position of front squats and the bottom position assumed before overhead pressing with a barbell.  Because of this its important to take precaution to avoid this type of impingement as well.  We’ll discuss prevention strategies later.

Extreme Range of motion?  Yes? Internal Impingement?  Maybe.

Again, please don’t try and diagnose and treat yourself, consult a professional if you’ve got pain.  This isn’t a problem to take lightly.  In the next installments we’ll talk about common causes of impingement and how to specifically prevent these issues in the crossfit population.

Part 2 HERE:

Want to learn more about how to assess your own and your athlete’s shoulder motion during common exercises and find the best exercises to optimize it so you don’t get back in pain again?  Check out Dr. Dave Tilley and my product:

Monkey Method – Movement Essentials

The Ultimate Guide to Understanding and Fixing Technical Flaws in the Handstand, Muscle-up and Olympic Lifts

Here’s to healthy shoulders,

Dan Pope

References:

Behnke, R. S. (2006). Kinetic anatomy. (2 ed., pp. 35-56). Champaigne, IL: Human Kinetics.

Page, P., Frank, C. C., & Lardner, R. (2010). Assessment and treatment of muscle imbalances the janda approach. (pp. 195-207). Champaigne, IL: Human Kinetics.

Wilk, K. E., Reinold, M. M., & Andrews, J. R. (2009). The Athlete’s Shoulder . (2 ed.). Philadelphia, PA: Churchhill Livingstone.

Categories
Injury PreventionShoulderUncategorized
45 Comments on this post.
  • 9 Most Popular Posts of 2012 | FITNESS PAIN FREE
    31 December 2012 at 10:26
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    […] Shoulder Impingement Series: Part 1, Part 2, Part […]

    • Talia
      4 September 2015 at 10:26
      Leave a Reply

      Hi Dan,
      Thank you for the informative graphic and article. I am having a problem figuring out where my injury is. I tried the tests but I seem to be able to move painless. Basically, I cannot do pullups. Hurts my left shoulder at the bottom of the movement as I am trying to pull up. I feel it a little bit when doing toes to bar or when Im rowing but I can still workout but pullups are impossible. I can do everything else.. Lifts, push press, etc. its been like this since mid August. Think I injured when holding the bar down after cleaning. Would you have any suggestions? Im getting desperate 🙁

      • djpope
        28 September 2015 at 10:26
        Leave a Reply

        Best case scenario is to go see a medical professional in person. Have you been to the doc?

  • Rob
    26 February 2013 at 10:26
    Leave a Reply

    Ahh, Finally! I had been wondering exactly what kind of impingement I had, because it didn’t seem to fit the standard complaints and tests that some people had mentioned. I used to play tennis, and serving almost always ended up causing pain. Fast forward 15 years later and I try crossfit movements and especially kipping pull-ups (it’s like a guarantee), but also other movements like push press, all caused the same exact type of pain. Yeah, so now I know what I have. What do I do about it is more the problem now. Can I strengthen anything to compensate?

    Thanks so much for your articles- Very helpful!

    • djpope
      26 February 2013 at 10:26
      Leave a Reply

      Thanks for the question Rob! If you don’t mind I’m going to try and speak about this on the next podcast. Keep an eye out for the next episode!

  • Shoulder Impingement: Part 4 – The Thoracic Spine and Ribcage’s Role in Impingement | FITNESS PAIN FREE
    24 March 2013 at 10:26
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    […] Part 1  Part 2  Part 3   […]

  • Hygo
    2 April 2013 at 10:26
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    Great info Dan!!
    My situation is very similar to Rob’s.
    I was wondering if you have done the podcast you just mentioned above. If so (and if available), could post a link to your podcast so I could listen to it.

    You do such a great job with all those articles buddy…

    Thank you very much

  • Shoulder Impingement: Part 5 – How Posture and Breathing Effects Shoulder Impingement | FITNESS PAIN FREE
    7 April 2013 at 10:26
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    […] Part 1  Part 2  Part 3 Part 4 […]

  • Rob
    11 April 2013 at 10:26
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    I still need to get all the way though the pod cast. In the interim I completed a lot of pull ups- and surprise my shoulder is bothering me. I’m having a hard time making it go away, so, I’m resting it entirely, and missing a lot of WODs. However, I noticed today that using a lacross ball, laying on top of it with the ball just on the inside of the shoulder and rotating so that the ball travels around the front of the shoulder, to the outside of the arm (and generally grinding it around on there)- it’s tender, but, I can immediately lessen/eliminate the pain when I move the arm after doing this. How this helps I cannot begin to understand. Any idea’s here what I might be dealing with?

    • djpope
      12 April 2013 at 10:26
      Leave a Reply

      Are there specific exercises that bother your shoulder? Was a specific incident that caused the pain or a gradual thing?

  • Shoulder Impingement Part 6: Do You Have Shoulder Impingement? | FITNESS PAIN FREE
    15 April 2013 at 10:26
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    24 April 2013 at 10:26
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  • Shoulder Impingement: Part 3 – The Shoulder Blade’s Role in Impingement | FITNESS PAIN FREE
    1 August 2013 at 10:26
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    […] joint is a very important part of understanding impingement.  If you haven’t checked out part 1 and part 2 I’d recommend starting there before reading about the shoulder blade. To make […]

  • Shoulder Impingement: Part 2 – What Happens at the Shoulder Joint During Impingement | FITNESS PAIN FREE
    1 August 2013 at 10:26
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    […] narrowing of the subacromial space, impinging on the structures contained within the space.  If you missed part 1, find it HERE.  Impingement can […]

  • 3 Reasons Kipping Pullups Cause Injuries | FITNESS PAIN FREE
    4 August 2013 at 10:26
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    […] Another unfortunate side effect of lacking dynamic stability of the shoulder is the humeral head misbehaving when we perform shoulder exercises.  When we lack solid stability to control the humeral head, the humeral head is more free to move into positions that can promote both subacromial and internal impingement.  For more information on the shoulder anatomy, why this might happen and probably way more informatio… […]

  • The Best Mobility and Stability Exercises to Improve the Front Rack: Part 1 – Addressing the Thoracic Spine | FITNESS PAIN FREE
    9 December 2013 at 10:26
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    […] and like I mentioned earlier, I actually ended up with some pretty nasty internal impingement (internal impingement explained HERE) symptoms in the winter of 2012 I attribute to a poor front rack.  Healing was slow and it took […]

  • 10 Most Popular Posts of 2013 | FITNESS PAIN FREE
    1 January 2014 at 10:26
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    […] 4. Understanding Shoulder Impingement Series: […]

  • Weekly Resources January 13th Shoulder focus. | David Carter
    14 January 2014 at 10:26
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    […] This series of four posts is a nice overview over of shoulder impingement its potential causes. From my experience […]

  • Weekly Resources January 10th Shoulder focus. | David Carter
    14 January 2014 at 10:26
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    […] This series of four posts is a nice overview over of shoulder impingement its potential causes. From my experience […]

  • Chris
    20 September 2014 at 10:26
    Leave a Reply

    Nice read. I have been struggling with a shoulder issue that is currently undiagnosed as of right now. It came on out of nowhere one day well working out I noticed a clicking and grinding sound in the shoulder joint. The next morning I woke up with a terrible link in my neck (about 5 months ago now) the kink in my neck furthered on to my right rhomboid and the popping in the shoulder joint started to worsen. I have had x rays done and was told the joint is fine. I’ve seen chiropractors and rmt and they say the muscles are extremely tense in the neck and back. It’s really frustrating now knowing what it is an being I’m a gym rat so to say it’s difficult to adjust. Any advice or additional help would be greatly appreciated. I can do shoulder press with my max weights and feel no pain in the shoulder only at the joint , it’s as if it feels loose. When I raise my arm just before in line with my shoulder the pop comes in. It sounds like cracking nuckles. The pain brought on to the rhomboid has made me feel as if my left side is forward and my right side is being pulled back by the left side. I can not activate the muscles in my upper back to the muscle spasm I’m guessing through the neck, rhomboid and shoulder. Very frustrating injury. My right side lateral also feels as if it’s out of place and being pulled back.

    • djpope
      4 January 2015 at 10:26
      Leave a Reply

      Have you ever tried therapy?

  • Lance
    20 November 2014 at 10:26
    Leave a Reply

    Thanks for the article! I woke up after a day of attempting countless hand stands on an inner tube in a river, unable to move my arm. I went to an ortho who diagnosed shoulder impingement/inflammation of subcromial bursae. I backed off crossfit for a couple weeks but cant seem to shake the pain. The minute it feels better, I do something to agitate it. For me, regular pushups, burpees (because of the push off the ground) and kettlebell swings bother me during the movement. Hanging from a pullup bar disengaged hurts, but if I’m engaged I’m fine. However I will be quite sore the following day if I do bar work. Same with movements like HSPU. Doesnt hurt during, but sore the next day.

    I went to physical therapy for one day per week for 5 weeks and they expected me to be out just a couple of weeks then back to doing everything I want. Well 5 weeks later and I’m easily put in pain just by doing a few pushups. Going for MRI tomorrow mostly for my own curiosity, but I think I’m just to anxious to get back to how I was and doing anything I wanted, and I’m not giving the shoulder the healing time it needs.

    • djpope
      7 December 2014 at 10:26
      Leave a Reply

      Hey Lance, unfortunately a few weeks of therapy may be enough to get you out of pain with every day activities but not enough to get you back to pain free crossfit. I’d work closely with your box owner and therapist to develop a plan to return back to crossfit that is slow and progressive in nature.

  • Roland
    7 January 2015 at 10:26
    Leave a Reply

    The information is really great Dan! I’m sure that I have some sort of impingement because I’m having problems with my whole left arm. Most of my pain is in the side of shoulder and ALWAYS when I try to do over head press but not so much with Lat pulldowns. I couldn’t even do an over head press at first but now I can do low weight a little bit.
    There is also a pain with internal rotation of the shoulder while elevating the arm. I don’t have as much pain with the arc of motion raising my arm up over my head except when I move the arm past the north point above my head.
    I’ve been dealing with this pain for about 8 months now. After the first few months I gave it a rest for 8 weeks. I’ve also been through 8 weeks of physical therapy and the pain seems to have had about a 65-70% improvement but I am still worried about weight training. The pain is NOT unbearable. As long as I don’t work shoulders hard the pain is not so bad during a work out but after the ache goes all the way down the bicep to the inside joint. I stretch a lot and that seems to help. I’m still waiting for the MRI appt.
    Any more advice? Do you think I should stop exercising it or just continue nursing it?

    Thanks!

    • djpope
      8 January 2015 at 10:26
      Leave a Reply

      Sounds like you’re on the right track. What are you trying to get back to? It definitely takes time to return to full function, especially if you want to be lifting overhead heavy again. It’s theorized that impingements leads to tendinopathy which is a common condition that can take somewhere between 6 weeks to 6 months to feel better and have the tendon remodel.

  • Diario di un atleta indeciso (che prova a fare weightlifting) – Pagina 87
    6 March 2015 at 10:26
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    […] sinistro. Ieri ho trovato un articolo interessante sulla sindrome di conflitto subacromiale ( Shoulder Impingement: Part 1 – What it is and Why its Important | FITNESS PAIN FREE ) che mi ha fatto riflettere sul coinvolgimento della scapola nel mio problema. La mia scapola […]

  • Shoulder Impingement: Part 3 – The Shoulder Blade’s Role in Impingement | FITNESS PAIN FREE
    21 June 2015 at 10:26
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    […] joint is a very important part of understanding impingement.  If you haven’t checked out part 1 and part 2 I’d recommend starting there before reading about the shoulder blade. To make […]

  • Greg
    4 August 2015 at 10:26
    Leave a Reply

    Thanks for the post Dan. Pretty much the same as the other fellas – massively frustrating – glad I found this very succinct but informational article.

  • Jesse
    25 August 2015 at 10:26
    Leave a Reply

    I was doing a standard bench press may have put to much weight on. I put up the weight once felt fine until next day. Nursed it ice and heat two times a day for two weeks the severe pain had let up now it seems to linger throughout the day. The pain seems to start at top of shoulder and sometimes feel discomfort at the bottom of scapula. The Dr. Did X-ray said it was fine. Did not have Mri. It feels like a rubber band at times when I reach up or across my body it feels like its actually pulling itself back. I read this article and my symptoms seem like sub acromial impingement what do you think and what is the best way to get better it’s been going on months of pain.

    • djpope
      28 September 2015 at 10:26
      Leave a Reply

      Best case scenario is to go see a medical professional in person. How has the pain been?

  • WM
    10 May 2016 at 10:26
    Leave a Reply

    Hi,

    Just went for MRI for my AC joint pain and will be seeing a specialist on that. Was wondering what sort of exercises should I be avoiding like push ups etc? I have my own weights at home and do regular exercises on different muscle groups like deltoids, biceps, triceps, back and pecs. Should I be stopping these completely and for how long?

    Many thanks

    • djpope
      29 May 2016 at 10:26
      Leave a Reply

      Hey WM, best case scenario is to see a therapist and get a good evaluation. Very hard to tell without an eval. Usually deep dips and heavy bench variations bug the AC joint but again it depends on the individual. best of luck!

  • How Tight Lats and Kipping May Cause Shoulder Pain (Subacromial Shoulder Impingement) | FITNESS PAIN FREE
    5 June 2016 at 10:26
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    […] To learn more I’ve beaten subacromial impingement to death in an article series you can find H… […]

  • Shoulder Impingement Part 7: Stages of Rehabilitation | FITNESS PAIN FREE
    5 June 2016 at 10:26
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    […] Part 1  Part 2  Part 3 Part 4 Part 5 Part 6 […]

  • Karen
    26 June 2016 at 10:26
    Leave a Reply

    Hi,
    I believe back squatting has caused my shoulder pain, specifically when I’m pulling down on the bar while coming up/out of the squat. Which kind of impingement or issue is caused while back squatting again?

    • djpope
      29 June 2016 at 10:26
      Leave a Reply

      My best guess is a posterior / internal impingement. This occurs at end range external rotation of the shoulder (in a back squat position). Tough to tell without being in person though to see.

  • Dean
    10 October 2016 at 10:26
    Leave a Reply

    Hi
    I am hoping you can help with the shoulder pain I have. Originally started 15yrs+ ago with lower back pain, finally diagnosed 2yrs ago with spondylilothesis and had 2 level spinal fusion at L4/L5 L5/S1 Nov14. 6mths prior to this operation starting having shoulder pain which didnt ease post surgery. Shoulder pain has progressively worsened over the past 2yrs. I have seen my GP, several spine specialists, shoulder specialist, Had MRI on thorasic spine, Ultrasound scan of shoulder, electrical nerve testing on arm, countless physiotherapy, chiropractor and acupuncture sessions, all with no success or diagnosis. I read your article on ‘shoulder impingement part 4 – the thorasic spine and ribcages role in impingement’ and my pain is at the scapula, but I dont have increased pain when carrying out any arm movements, instead I have the pain when I sit leaning against the back of a chair or when lying on my back or side. I am having to take medication from my GP to sleep through the pain (not ideal at all)I sometimes have the pain when walking or standing, It can feel like carrying a heavy weight on my arm, a type of pulling sensation. I am getting no relief with painkillers and have no idea which other medical professional to see, have you any idea what the problem could be and what I could do??
    Many thanks

    • djpope
      21 October 2016 at 10:26
      Leave a Reply

      What did physiotherapy look like for you?

  • David
    14 October 2016 at 10:26
    Leave a Reply

    Everyone asking for help, and every reply is “Go see a doctor” haha. Even good shoulder doctors can’t tell (or don’t really care to put in the work to analyze) what a shoulder problem is. I’ve had both of my shoulders operated on at age 20 due to torn labrums and shoulder instability. They would subluxate/dislocate all the time with any sport and likely caused the tears in my labrum. The surgeries didn’t really help at all. My shoulders are still just as loose and torn labrums likely still/again only 5 years later. One of the best orthopedic shoulder doctors supposedly did mine as well. It’s hopeless everyone.

    • djpope
      21 October 2016 at 10:26
      Leave a Reply

      Definitely not hopeless, do you have a history of looseness? Ever been diagnosed with ehler’s Danlos? Have you seen an experienced therapist who can help you? Have you or do you currently follow a solid training program?

  • Dean
    1 November 2016 at 10:26
    Leave a Reply

    Sorry only just noticed your reply… My physio involved resistance band exercisers (trapping one end in top of doorway and pulling downwards across body)
    also rolling a tennisball up around shoulder blade leaning against door
    massage by physiotherapist
    core strength exercises and using one of the gym balls . None of this has really helped, but I was just wondering if you knew why it would hurt more when I am lying or sitting down leaning against the back of a chair than it does during movement?

    • djpope
      1 November 2016 at 10:26
      Leave a Reply

      It probably means your shoulder likes movement. We just need to find the right movements. Has the band work made any change in your daily pain levels? Did your physio ever progress you to more challenging movements that are more specific to what you want to get back to?

  • Dean
    1 November 2016 at 10:26
    Leave a Reply

    The band work didnt worsen or improve the daily pain level, not progressed , not currently receiving physio as it wasnt helping after nearly a year of treatment , just want to get back to pain free

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