The TRUTH About Shoulder Impingement

in this video I'm going to tell you the truth about shoulder impingement so you better understand the research and arguments I'm going to present that challenge the long-held beliefs about shoulder impingement it's important for me to Define it and briefly describe the relevant shoulder Anatomy the shoulder consists of three bones the humerus or arm bone the clavicle or collarbone and the scapula or shoulder blade the scapula has two bony landmarks known as the coracoid process and the acromion the ligament that attaches from the coracoid process to the acromion is called the coracoacromial ligament the connection

between the acromion and the clavicle is referred to as the acromioclavicular joint the area between the humeral head and these structures is known as the subacromial space within this space is the supraspinatus tendon one of the rotator cuff muscles long head of the biceps brachii tendon subacromial Bursa and the capsule of the shoulder joint when most people discuss shoulder impingement they are referring to these tissues being compressed in this space the popularization of the shoulder impingement Theory can be attributed to Dr Charles near in 1972 who based his beliefs on dissections of cadavers and what

he observed during shoulder surgery in his 1983 paper he wrote that he believed 95 percent of Terrors of the rotator cuff are caused by impingement therefore he proposed and developed a surgery to treat shoulder impingement the acromioplasty now more commonly referred to as subacromial decompression involves removal of the subacromial Bursa cutting of the coracoacromial ligament and shaving of the acromion the intention of the surgery is to decrease the compression of tissues within the subacromial space such as the supraspinatus tendon during various shoulder movements to reduce symptoms although this sounds reasonable there is no concrete evidence

to substantiate the shoulder impingement Theory or the benefit of surgery however nears ideas have greatly influenced medical rehabilitative and resistance training practices over the past 50 years considering their rapid adoption and Rising incidence of the surgery with one paper by judge it all in 2014 finding a 746 percent increase in the surgery from 2000 in 2001 to 2009 and 2010 we'd expect subacromial decompression to be overwhelmingly successful there are five papers from the past five years that will shed light on this topic a study by kolk at all in 2017 compared bursectomy removal of the

Bursa only to bursectomy plus acromoplasty the authors found that the addition of the acromoplasty did not result in a clinically relevant Improvement in shoulder function or relief of pain at 12 years follow-up compared with bursectomy alone they also did not find a statistically significant difference in the prevalence of rotator cuff tears after 12 years beard it all in 2018 conducted a randomized placebo-controlled trial to determine whether decompression compared with Placebo arthroscopy only improved pain and function whether decompression differed in outcome to no treatment and whether Placebo differed to no treatment there were three big takeaways

from this study one there were no differences in outcomes between decompression surgery and Placebo surgery two surgery might not provide clinically significant benefit over no treatment three the mechanism of the treatment effect in the patients who received surgery might be the result of placebo post-operative physiotherapy or other factors a 2019 Cochran review which is the gold standard for the appraisal of research concluded that high certainty evidence shows that subacromial decompression does not provide clinically important benefits over Placebo and pain function or health-related quality of life based on the information up to this point the British

medical journal created a clinical practice guideline in 2019 that made a strong recommendation against surgery the panel concluded that almost all informed patients would choose to avoid surgery because there is no benefit but there are harms and it is burdensome a systematic review with meta-analysis in 2020 concluded that subacromial decompression surgery provided no important benefit compared with Placebo surgery or exercise therapy and probably carries a small risk of serious Harms finally pavola at all in 2021 conducted a randomized double-blind placebo surgery controlled trial to assess the long-term efficacy of subacromial decompression they also included an

exercise group for comparison the authors concluded that subacromial decompression provided no benefit over diagnostic arthroscopy Placebo or exercise therapy at five years for patients with shoulder impingement syndrome they go on to State as a current evidence indicates that the impingement theory has become Antiquated we would also recommend to abandon the term shoulder impingement as it refers to this mechanical Theory does that mean shoulder impingement doesn't exist shoulder impingement occurs but it's not the boogeyman it's been made out to be a study by Lawrence at all in 2019 examined participants with and without shoulder pain and

discovered three important findings one contact between the super speedus tendon and coraco are chromial Arch occurred in 45 percent of all participants two there was no difference between symptomatic and asymptomatic subjects three contact was most common at 60 degrees of elevation which means I might be impinging my shoulder all day long while typing eating drinking water and doing most other daily tasks for the next two papers it's helpful to know that the acromiohumeral distance the distance between the acromion and humeral head is just one way of measuring and describing the subacromial space a systematic review

by park it all in 2020 found no relationship between the acromiohumeral distance and pain in adults with shoulder pain a study by Hunter at all in 2021 concluded individuals with subacromial impingement syndrome had a larger acromial humeral distance and greater supraspinatus tendon thickness than controls tendon thickening is actually considered a beneficial adaptation and I'll describe what it potentially means toward the end of this video so up to this point what information have I presented one shoulder impingement refers to compression of soft tissue structures such as a supraspinatus between the humeral head and the overline acromion

coracoacromial ligament and acromioclavicular joints two the shoulder impingement theory was popularized by a surgeon in the 1970s before he proposed a surgery to treat the issue three if symptoms were solely caused by compression of these overlying structures we'd expect their removal to improve symptoms and function however research demonstrates that subacromial decompression is no better than Placebo surgery four subacromial decompression also doesn't seem to change the long-term prevalence of rotator cuff tears what I haven't mentioned is that rotator cuff tears are also present in asymptomatic individuals and are more common as we age like many other

Imaging findings in fact a study by Barreto at all in 2019 concluded that most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders people in our study had similar rates of partial tears in both shoulders despite only having symptoms on one side five compression of tissues in the subacromial space is common occurs equally and people with and without symptoms and it happens with normal day-to-day tasks six a smaller subacromial space is not correlated with symptoms or disability why does any of this matter not only is the diagnosis of shoulder impingement unhelpful

it can be harmful a study by zadros at all in 2021 found that participants labeled with subacromial impingement expressed feelings of psychological distress uncertainty and that the condition is serious and has a poor prognosis a paper by cuff and littlewood in 2018 explored the beliefs experiences and perspectives of patients diagnosed with shoulder impingement here's what one patient had to say it is the tendon being caught by this piece of bone and wearing it away how are we going to get this pain to go away by removing this piece of bone I can't imagine how any

amount of physio is going to shift this piece of bone which is in my shoulder another patient said I couldn't see how physiotherapy would help with the tear I'd be worried that I was doing even more damage as the author suggests the diagnosis can negatively influence expectations which are extremely important for recovery and may act as a barrier to rehab the so-called dangers of shoulder impingement have also heavily influenced the fitness Community most notably as it relates to exercise selection the upright row is probably the most well-known example of an exercise being labeled as bad

because it's supposedly harmful for your shoulders I'm going to provide counterpoints to some of the main arguments against the use of upright rows and other similar exercises one research by gipart at all in 2012 and Lawrence it all in 2017 2018 2019 and 2020 demonstrates that impingement most often happens at lower angles of arm elevation since this commonly occurs in asymptomatic individuals you'd have to keep your arms by your side at all times if you truly wanted to avoid impingement two you might suggest that upright rows are only dangerous when performed to 90 degrees or

higher based on an article from 2011. however the same research just mentioned discusses that the rotator cuff becomes positioned in such a way that it can no longer be compressed by 90 degrees of elevation three but it's actually the internal rotation that matters right well it's not so clear a review of the literature by Lawrence at all in 2020 discusses how internal rotation has been shown to increase or have no effect on the acromiohumeral distance while external rotation has been shown to increase decrease or have no significant effect this is why it's important to examine

the biomechanical literature instead of relying on skeletal models four why do doctors and physical therapists perform the Hawkins Kennedy test which mimics the upright row to assess for shoulder impingement then honestly they probably shouldn't a systematic review with meta-analysis by hejudice at all in 2012 informs us that it's not a valid test the test just tells us that people with shoulder pain sometimes experience shoulder pain when their arm is positioned in a way they're unaccustomed to you could just as easily crank their arm into external rotation five but what if you've had shoulder pain with

upright rows before that's totally fair but there's also people who report feeling better from doing upright rows six you might not have issues with upright rows now but just wait 20 years imagine replacing upright rows with any other exercise or activity you might not have issues with squats now but just wait 20 years you might not have issues with running now but just wait 20 years you might not have issues with playing sports now but just wait 20 years would you really be that surprised if someone who squats runs plays Sports bench presses Etc has

at least one episode of back hip knee shoulder or elbow pain I'd be more surprised if they didn't because that doesn't happen people experience pain from time to time it's normal we don't suddenly label every exercise that contributes to your pain at some point in your lifetime as bad and you can't compare upright rows something with zero research to support that they're harmful to smoking cigarettes which has Decades of unequivocal research to demonstrate their harm I've already said this in a previous video but I think it's worth reiterating you don't have to do any exercise

that you don't want to do your exercise choices don't personally affect me and I'm not getting paid by big upright row but part of my goal here is to reduce the fragility beliefs that have been created disseminated and instilled in society the human body is resilient and adaptable you might be thinking why does my shoulder hurt them when someone asks this question they're usually in search of a specific anatomical structure unfortunately despite popular belief it's incredibly difficult to pinpoint a specific cause of pain in most instances earlier I mentioned that supraspinatus tendon thickening is a

common finding in those with shoulder pain as opposed to a smaller subacromial space while often perceived as a negative finding tendon thickening may be considered a positive adaptive response during periods of excessive loading acutely or chronically therefore one component of the answer to the question why does my shoulder hurt then might be that you simply did a little more than your shoulder could currently tolerate think about the phrase too much too soon for example you might have started a new gym routine or increased the volume frequency or intensity of your current program and push beyond

your shoulder's current limits of recovery it happens for someone else perhaps you decided to repaint your house after years of not doing much overhead work either way you did too much too soon the other component of the answer relates to your overall well-being as much as we like to focus on load related factors and emphasize the strength range of motion and movement of the shoulder a person's General Health status can impact the onset or Persistence of symptoms such as sleep habits physical activity levels smoking status nutrition Etc this is truer for some people than others

in any case the goal is to address the possible contributing factors that are within your control which will be unique for each person generally this includes modifying aggravating activities gradually reintroducing those activities that are meaningful to you as your symptoms improve performing exercises with the intention of improving your function and trying to optimize certain aspects of your lifestyle to improve your overall health and well-being what should we call shoulder impingement instead different terminologies have been proposed such as subacromial pain syndrome and rotator cuff related shoulder pain the more important question is what's the purpose of

a diagnosis hopefully at least in part it's to inform management do these diagnoses do that they do it to some extent because as you know surgery isn't recommended however shoulder impingement and these other labels attempting to fill its void have become catch-all diagnoses for any non-traumatic shoulder pain that isn't related to instability frozen shoulder and some other diagnoses that may respond to specific medical management they are an attempt to simplify the complex and multi-factorial nature of pain while also easing our own uncertainty about the exact tissue structure that may be contributing to symptoms but as

a physical therapist as long as I know you're experiencing non-traumatic shoulder pain unrelated to some of the other diagnoses I just mentioned how we name your pain doesn't necessarily influence rehab what's more useful for me is knowing your age occupation lifestyle sleep habits exercise habits goals what makes your symptoms better what makes your symptoms worse Etc you might have the exact same diagnosis as someone else but your answers to these questions could be vastly different and those answers are what influence rehab this doesn't mean that the general rehab process needs to be significantly different from

what's already being used it's the explanation that changes and matters exercise is safe and encouraged you're not damaging your rotator cuff when you lift your arm and experience pain you don't have to worry about removing a piece of bone to get better compression of tissues is normal in the shoulder and elsewhere we compress nerves tendons ligaments and muscles all day long when we sit Bend lift twist walk Etc occasionally it's important to ask ourselves how do I know what I know I knew shoulder impingement was a valid and useful diagnosis because it was taught to

me by my professors in physical therapy school and my professors knew it was a valid and useful diagnosis because someone taught it to them and that goes back at least 50 years it's the same reason surgeons have been performing the subacromial decompression surgery or personal trainers advise against upright rows however bloodletting and leech therapy were used for thousands of years before someone finally questioned their validity and usefulness certain clinicians have actually been pushing back against the diagnosis of shoulder impingement for over a decade but it's hard to change 50 years of medical history that we

think we know to be true however enough research has surfaced since that time to question the usefulness of shoulder impingement as a diagnosis do you have to agree with everything that I've said in this video of course not but for the things that you disagree with ask yourself how do I know what I know thank you so much for watching if you enjoyed the video please hit that like button subscribe turn on notifications and leave any questions or comments down below peace