Shoulder Impingement — When the shoulder becomes too tight

Artistic depiction of a man's shoulder pain.

© BigBlueStudio | shutterstock.com

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Everything About the Development and Treatment of Shoulder Impingement Syndrome and Exercises for Immediate Help

It starts first with some slight pain in the shoulder, followed by discomfort and at some point pain when turning in bed at night. Raising your arms or overhead movements are a real torture. Does this sound familiar to you? Then it is possible that you suffer from shoulder impingement syndrome. In this case, tendons and bursa are trapped in the shoulder joint and thus cause the discomfort. In this article we explain to you

  • how your shoulder functions and which symptoms occur in shoulder impingement syndrome,
  • what different types of shoulder impingement there are,
  • how an impingement occurs and which factors influence its development,
  • which treatment options are available to you,
  • and which exercises can help immediately.
Roland Liebscher-Bracht

Roland Liebscher-Bracht

Germany's most trusted pain specialist and author of several bestselling self-help books on the treatment of pain conditions.

 
Read more

Roland Liebscher-Bracht is Germany's most trusted pain specialist and author of several bestselling books on pain treatment. Together with his wife, Dr. med. Petra Bracht, he has developed a revolutionary method to treat pain conditions. With the help of the so-called "osteopressure", where you press specific points on your body, and special stretching exercises, pain can be stopped entirely without medication or surgical intervention. This pain treatment allows you to alleviate pain by yourself. Find out how exactly this works in this article or our numerous YouTube videos.

Roland Liebscher-Bracht

Germany's best-known pain specialist and author of several bestselling books on self-help against pain.

 
Read more

Roland Liebscher-Bracht is Germany's best-known pain specialist and author of several bestselling books on pain treatment. Together with his wife, the physician Dr. Petra Bracht, he has developed a revolutionary new form of pain treatment: With the so-called "Osteopressur", in which certain points on your body are pressed, and special stretching exercises, pain can be stopped completely without medication or surgical intervention. It is particularly important that this pain treatment gives you the opportunity to help yourself against your pain in a self-determined way. You can find out exactly how this works in this article and in the numerous YouTube videos.

1. The Shoulder — Structure and Function


Your shoulder is a complex construction that allows you to move in many different ways. It consists of three joints, which are held, guided and stabilized by many muscles and tendons. This is also important because the shoulder or shoulder joints have no direct connection to the rest of the skeleton and the spine.

Illustration of the shoulder joint.

© Jana Mechmershausen

Your shoulder consists of the main joint, the acromioclavicular joint and the sternoclavicular joint:

  • The main joint is the center of your shoulder joint. It is a ball-and-socket joint that connects your humerus (upper shoulder bone ) with your scapula (shoulder blade). The head of the humerus sits in a small socket on the shoulder blade. In this joint, the humerus has a great deal of room to move, because the spherical head of the humerus is not very deeply embedded in the bony socket on the shoulder blade. This allows you great freedom of movement in your arms – but then again, the joint has little support.
  • Your acromioclavicular joint is the connection between your collarbone (clavicle) and the acromion (the bony process of the shoulder blade). If you have complaints in this area, doctors often speak of subacromial pain. This refers to pain below the acromion (subacromial).
  • For your shoulder not to float completely unattached, the sternoclavicular joint provides the connection to the skeleton. The sternoclavicular joint is formed by the clavicle and sternum.

These bones and joints of the shoulder are almost exclusively guided and stabilized by muscles. Some muscles are already attached to the main joint, such as the biceps muscle with the biceps tendon. Other muscles too end in tendons and thus almost completely enclose the spherical head of the humerus.

If problems in the shoulder area is not new to you, you may know the term “rotator cuff”. The rotator cuff is a kind of tendon cap that encloses the entire joint. It is partly responsible for a lot of pain in the shoulder. This is because the upper bone muscle (Musculus supraspinatus) runs along the inside of the cuff, ending in the supraspinatus tendon.

This tendon in turn runs through the very narrow space between the upper arm and acromion. To prevent the tendon from rubbing against the acromion (subacromial), there is a bursa as a buffer under the acromion.

In addition, the large pectoral muscle at the front and the deltoid muscle on the shoulder, the biceps on the upper arm and the trapezius muscle in the back provide the necessary support.

With so many “individual parts” moving, something can easily get out of balance and then cause pain. It is therefore not surprising that more than 25 percent of Germans suffer from shoulder complaints requiring treatment at least once in their lives.1) Shoulder operations, especially for the treatment of impingement syndrome, have increased significantly in recent years.2) ) Why subacromial pain in the shoulder and the impingement syndrome are becoming more and more frequent, you can find out in the chapter Causes.

📌 In short: What is Shoulder impingement Syndrome?

Shoulder impingement syndrome is also known as shoulder tightness. The upper arm is pulled too far into the shoulder joint and muscles, so the tendons and the bursa in the shoulder are pressed against the bony spur of the acromion. The resulting tightness causes irritation, inflammation and pain. Many movements are therefore only possible to a limited extent and in pain. Decompression, i.e. pressure relief, creates more space again and the pain can disappear.

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2. Symptoms of Different Types of Shoulder Impingement


The American surgeon Charles Neer first defined impingement as the main cause of shoulder pain in 1972, due to the narrow space between the humeral head (humerus) and acromion.3) The typical symptoms of shoulder impingement syndrome are

  • shoulder pain, especially after certain movements or loads,
  • restrictions on movement and mobility
  • loss of strength in the arms due to pain in the shoulder,
  • pain radiating into the upper arm, usually on the outside
  • and unnatural joint noises.

Most people suffering from impingement syndrome find certain movements of the arm painful due to the constriction of the tendon below the acromion (subacromial). Depending on the movement, the tendon is literally pinched in or out. And the more strain on the arm, the more discomfort.

Similar complaints in the shoulder

Calcific tendonitis has symptoms similar to the impingement syndrome: with calcific tendonitis calcified deposits form in the tissue of the shoulder tendons. About 80 percent of these are located in the supraspinatus tendon. Such deposits in the rotator cuff can lead to complaints such as shoulder pain when under stress. Depending on where the calcium has formed, the sliding ability of the tendon attachments can suffer. In addition, the bursa under the acromion is often inflamed.

Comparable symptoms occur with a frozen shoulder or shoulder stiffness. In a frozen shoulder, the joint capsule is thickened, hardened and partially inflamed. This inflammation leads to a severe restrictions of mobility in the affected shoulder, which is why patients often adopt a compensating and relieving posture.

You can find out more about the various complaints of the shoulder in our large article on shoulder pain.

2.1 Eccentric Shoulder Impingement

Eccentric impingement represents the “classic” form of shoulder impingement syndrome This causes tendons and the bursa under the acromion to become trapped. From a medical point of view, this is referred to as a subacromial space that is too narrow. Eccentric impingement can be divided even more precisely into primary and secondary eccentric impingement.

A so-called primary eccentric impingement of the shoulder is present when a painful arc is involved. This means that the acromion, which forms an arc over the entire shoulder, is in pain. You can feel the pain in the range of 60 and 120 degrees when you extend your arm and move it into the vertical. This effect is intensified by an inner rotation of the shoulder but reduced by an outer rotation.

Basically, the muscles, tendons and ligaments pull the humerus too much into the socket. This causes the excessive pull and pressure upwards against the acromion and acromioclavicular joint. As a result, tendons and bursae are irritated by the excessive pressure and limited space. Through specific exercises, the muscles, tendons and ligaments can be relaxed and the humerus can sink a little. This way the whole shoulder has a some ” wiggle room” again. You can find out which exercises can help you in our Exercise section.

Illustration of a frozen shoulder pain

© Jarva-Jar | shutterstock.com

Secondary eccentric impingement of the shoulder is a functional decentration when the joint is more mobile than normal (hyperlaxity). This increased mobility of the joint can lead to problems and, in the case of impingement, can trap soft tissue structures between the acromion and humerus.4)

2.2 Intrinsic Shoulder Impingement

The rotator cuff is involved in intrinsic impingement. To be more precise, this involves pinching within the rotator cuff. The rotator cuff encloses the entire humeral head and represents a complex muscle and tendon apparatus. As the name suggests, the rotator cuff primarily stabilizes rotational movements of the shoulder. Since it encloses the spherical head of the humerus, the rotator cuff is designed to center the humerus and hold it in the socket. However, the humerus can slip a little to the side and pinch the muscles and tendons of the rotator cuff – this leads to painful intrinsic impingement. We will explain what an effective treatment can look like in this case in the Treatment chapter.

📌 Rupture of the Rotator Cuff:

The rotator cuff consists of the rotator, which is responsible for the rotation, and the cuff, a wide tube. The supraspinatus tendon runs inside the rotator cuff and this can tear under extreme tension. This is known as a rupture of the tendon. The symptoms that occur range from shoulder pain and muscle weakness to neck pain because the surrounding muscles try to take over the tasks of the supraspinatus tendon. If a rupture is suspected, you should definitely go to the doctor and have it looked after.

2.3 Internal Shoulder Impingement

In an internal shoulder impingement syndrome, a distinction is made between posterosuperior impingement (PSI) and anterosuperior impingement (ASI). The internal impingement syndrome is actually a special form. It frequently occurs in athletes in overhead sports such as handball, basketball or swimming, as well as in professional groups working overhead, such as painters or mechanics. Here, due to the movements involved in overhead sports, overhead work or general overhead movements, bruising occurs in the shoulder joint or the supraspinatus tendon (SSP tendon) as well as the infraspinatus tendon through the posterior socket edge. In this case, it is mostly the joint socket that is involved in the pinching.

A man playing basketball.

Posterosuperior Impingement (PSI) occurs mainly during overhead sports such as handball, basketball or volleyball. If you repeatedly use your throwing arm to throw far, over time this leads to increased external rotation and reduced internal rotation. This uneven stress leads to instability and misalignment of the humeral head and thus causes the PSI pain.5) If the pinching is very severe, the so-called “dead-arm syndrome” can occur. In this case the athlete has barely any strength left in the arm and is no longer able to perform the throw with momentum. The same also occurs with non-athletes who do a lot of overhead work or movements.

Person swimming in an in-door pool.

Anterosuperior impingement (ASI) occurs much less frequently. In this case, pain occurs when the arm is pulled up (adduction) and rotated internally. It’s swimmers who mostly complain about these problems. If you swim a lot, you might know this. A swimmer’s shoulder is particularly susceptible to excessive strain, since in many swimming styles – in particular free style – arm movements provide the necessary propulsion.6) Here, too, tendons can become pinched during swimming and cause painful tearing in your shoulder.

In the chapter Exercises we will show you suitable stretching exercises that help you to relief your pain that comes with different types of shoulder impingement syndromes.

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3. Origin and Causes of Shoulder Impingement


Even if you are not a competitive athlete and your office chair is the only exercise machine you ever see, you might be faced with impingement syndrome in the shoulder. Especially the eccentric impingement syndrome is very common. Sitting for long periods of time, especially when working at your computer, often leads to a slouchy posture where mostly the shoulder-neck is overstressed. There is some research work on the connection between sitting postures and the onset of impingement syndrome.7) For example, it has been shown that a bent head posture or nerd neck created when sitting at a PC leads to an elevated humerus. Such a raised humerus, which presses too firmly into the glenoid cavity and against the acromion, is often the cause of shoulder impingement syndrome.

What Does This Mean Exactly?

In modern office life, you spend a lot of time at your desk. You usually stretch your arms forward towards the keyboard and support your elbows. Over time, this posture leads to immobile shoulders and neck pain and headaches are quite common too. In a sitting position with angled arms, your humerus is also pushed upwards. As a result, the muscles and fasciae around the shoulder joints are shortened. Without training, it is difficult for them to elomgate again – as would be necessary when standing up or making circular movements with the shoulder. This way, tension builds up in the muscles and fasciae and this pull the humerus up way too much against the acromion.

As a result, the tendons and the bursa become pinched and pain and inflammation develop.

Our aim is to relax and stretch the muscles and fascia in such a way that the humerus sinks a little and the tendons or bursa above it have more room again. Subsequently, irritation and inflammation can subside again. You can read more about our therapy in the next chapter.

A man clutching his shoulder, grimacing in pain.

© Africa-Studio | shutterstock.com

📌 How Is Shoulder Impingement Syndrome Diagnosed?

If impingement syndrome is suspected, doctors often first do a sonography, i.e. an ultrasound examination. This is inexpensive and provides a quick overview of soft tissue changes in the shoulder joint. X-rays of the shoulder are often taken for further clarification. If the diagnosis is still not conclusive, an additional MRI (magnetic resonance imaging) can be run.8) More and more frequently, arthroscopies of the shoulder joint are performed as well. During arthroscopy, a surgeon takes a close look at the shoulder joint in a minor operation to determine any possible damage or changes. An experienced manual therapist will find the reasons and locations for shoulder impingement – but without surgery.

4. Treatment of Shoulder Impingement


You have already learned how an impingement syndrome develops in the shoulder and what exactly the cause of your pain is. In this chapter, we would like to introduce you to our effective treatment approach – because our goal is for you to lead a pain-free life again.

One component of our therapy for lasting freedom from pain is our exercises. As you already know, it is important to keep the muscles and fascia in your shoulder nice and flexible.

Our exercises specifically target and expand the bottleneck, the narrowed passage, in your shoulder. This prevents the muscles and fasciae from contracting, cramping or shortening, thereby taking up space meant for the tendons in the shoulder.

If your complaints are not yet too bad, you are welcome to jump straight to our Exercise section and open your bottleneck. But the truth is your shoulder hurts so badly that you can’t even manage your daily life without problems and compromises?

Roland Liebscher-Bracht pointing at an osteopressure point on a skeleton.

No problem. Because then the other component of our pain therapy is just the right start for you: In Liebscher & Bracht’s pain therapy, we use the manual-therapeutic technique of osteopressure. This involves the targeted pressing of so-called alarm pain receptors in the periosteum. These receptors then transmit the message to your brain telling your muscles and fasciae in the corresponding area they should no longer tense up as much. As a result, the excessive muscular-fascial tensions normalize and the humerus is pressed less strongly into the socket. Your brain then registers that all structures have more space and freedom of movement again and finally stops the pain.

As already mentioned, manually reducing the excessive tension is a first and already extremely painless step. However, it is important for the lasting effectiveness to change the one-sided movement patterns and thus the bottleneck situations that have led to the pain. Roland Liebscher-Bracht has developed special stretching exercises to make this easier for you. They mobilize precisely your problem zones and help you to remain pain-free for good. You will find suitable exercises for the shoulder impingement syndrome in the next chapter.

How Is Shoulder Impingement treated in Classical Medicine?

  • As a rule, treatments start with medication that is supposed to have an anti-inflammatory effect. However, anti-inflammatory drugs only treat the symptom “inflammation” and not the cause. Therefore, the subacromial bottleneck syndrome lingers on and there is still not enough sliding space for the tendon under the acromion.
  • Physiotherapy also attempts to increase the subacromial space, i.e. the space between the acromion and the humeral head. However, physiotherapy sessions are limited and need a physician’s prescription first. You can also try our exercises without a prescription or referral.
  • For shoulder pain, some patients also try shock wave therapy. Shockwaves of different frequencies hit your shoulder. The goal of shock wave therapy is to stimulate the muscles to relax. However, shock waves are usually not very pleasant for the patient, the therapy is expensive, and the effect lasts only for a short time.
  • Acromioplasty is available as a surgical option. In acromioplasty, bone substance is removed from the shoulder to create more subacromial space.

5. Exercises for Shoulder Impingement


Here, we show you some emergency exercises for an impingement syndrome in the shoulder. If you are doing our exercises for the first time, it is best to watch the video first and read our exercise instructions in the exercise description – then you will be well prepared and can stretch without pain.

Here we go: the best exercises for shoulder impingement syndrome.

Woman kneeling on the ground with the arms stretched out on the floor and her face turned downwards.

Exercise #1:

  • For the first exercise go on all fours.
  • Stretch out your arms and place your hands well outside shoulder width. Find a position that allows you to “dive through” with your breastbone.
  • When you have found the angle where the stretch is most pronounced stay in it for two to two and a half minutes.
  • Try to keep increasing the stretch. Don’t worry, it may feel a little uncomfortable the first time. But even after this short stretching, you will feel a change in your body.
Woman using the exercise loop to do an exercise against shoulder pain.

Exercise #2:

  • For this exercise use a stretching sling or, for example, a kitchen towel.
  • Fix your hands with the sling slightly wider apart than shoulder width and place your feet on the floor.
  • Now it’s all about sliding very slowly forward with your buttocks by alternately swinging your legs to the left and right.
  • Make sure that your arms are fully extended and your chest remains completely open.
  • Move further and further into the stretch.
  • When you reach a point where you can’t go any further, just stop. This way you give your tissue time to slowly expand. After a short moment you can try to get a little bit more into the stretch of your troubled shoulder.
Woman performing a fascia roll massage on the floor, using a fascia ball to massage her shoulder joint.

Bonus Exercise:

  • A foam roller massage with a mini foam ball can also reduce the tension in your shoulder area.
  • Just lie on your back and place the ball exactly in the hollow under your collarbone.
  • Work your way deep into the tissue and look for the most painful area.
  • With slow, intensive and spiral movements you work on exactly that spot.

📌 Checklist for Liebscher & Bracht Exercises

To make sure nothing goes wrong with our exercises, we have put together seven important tips. They should help you to easily integrate the exercises into your daily life and achieve optimal results.

✅ Practice six days a week and do each exercise at least once a day.

✅ For each exercise you should invest two to two and a half minutes. If you are just starting to do the exercises or if the pain is still too much, you can also gradually increase the intensity. Remember, however, that stretching for only a few seconds has little or no effect.

✅ Always use your personal pain scale of one to ten as a guide. The best results are achieved if you work on a scale of eight or nine for each stretch. Nine means: You feel an intense pain but can still breathe calmly and do not have to muscled-guard.

✅ A pain that is still bearable is the most important point of reference for you. So, don’t be afraid of it: Your body will tell you that you are counteracting the muscular „contractions“ in exactly the right place.

✅ Be patient – even if it is difficult. It may take some time for your brain to store new movement programs. But if you stay on the ball and make the exercises your daily routine, you can regain your freedom from pain.

✅ Use professional aids and not cheap products to treat your pain. If you rely on a defective product here, this can have a negative effect. We have therefore taken great care in the development of our aids and developed them especially for pain treatment.

✅ If the pain increases due to the exercises, there is no reason to panic. That things get worse initially can be a normal reaction of your body. If your overall body statics change as a result of regular exercise, the musculoskeletal system will have to adapt to this gradually. If, however, you feel worse all the time instead of better after the exercises, your body signals that you may be overdoing it. Then simply take a break for a day or two and/or reduce the intensity a little bit during your next training sessions in order to increase it again in small steps. In this way, you gently guide your body to the eight or nine on the pain scale that is right for you.

Roland Liebscher-Bracht is performing a pain-free exercise.

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Roland Liebscher-Bracht is performing a pain-free exercise.

Sign up for our free weekly newsletter and get interactive exercise videos and articles about pain management and health delivered to your inbox.

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Roland Liebscher-Bracht is performing a pain-free exercise.

Sign up for our free weekly newsletter and get interactive exercise videos and articles about pain management and health delivered to your inbox.

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Sources & Studies [+]