Disclaimer: This article is for general educational purposes only and does not constitute medical advice. Always consult a qualified health professional for advice specific to your condition. © 2026 Better Physiotherapy Bundoora.
Shoulder impingement syndrome is the most common shoulder presentation in physiotherapy practice. The good news: the vast majority of cases resolve completely with physiotherapy — without cortisone injections or surgery.
What Is Shoulder Impingement?
The shoulder's subacromial space — the gap between the humeral head and the overlying acromion — contains the rotator cuff tendons and subacromial bursa. When the arm is raised, this space narrows. In shoulder impingement, the tendons and bursa are compressed during arm elevation — causing pain, inflammation, and over time, tendon damage.
The hallmark finding is the “painful arc”: pain occurs as the arm is raised from 60° to 120°, after which the pain often reduces as the greater tuberosity clears the acromion.
What Causes Impingement?
The underlying cause is not the acromial anatomy alone — it is the muscle imbalance that allows the humeral head to ride upward during arm movement:
- Rotator cuff weakness — the rotator cuff depresses the humeral head during elevation; weakness allows the head to rise and compress the subacromial contents
- Scapular dyskinesis — poor shoulder blade control (particularly reduced upward rotation) reduces subacromial clearance
- Thoracic kyphosis — a rounded upper back tilts the scapula forward, reducing the functional subacromial space
- Tight posterior capsule — drives the humeral head anterosuperiorly during arm elevation
Physiotherapy Treatment
- Rotator cuff strengthening — progressive resistance external rotation and internal rotation exercises to restore the humeral head depressor mechanism
- Scapular strengthening — lower trapezius and serratus anterior exercises to restore upward rotation of the scapula during arm elevation
- Thoracic mobilisation — extension mobilisation of the thoracic spine to reduce the kyphosis that limits subacromial space
- Posterior capsule stretching — horizontal adduction and sleeper stretch for the posterior shoulder
- Manual therapy — glenohumeral joint mobilisation to improve joint mechanics and reduce pain
The Surgery Question
The UK CSAW trial and Finnish FIMPACT trial both found no difference between arthroscopic subacromial decompression and physiotherapy at 2 years for subacromial pain syndrome. Australian guidelines recommend physiotherapy as the primary treatment for shoulder impingement, with surgery considered only after adequate conservative management.
Frequently Asked Questions
Does shoulder impingement require surgery?
Very rarely. Multiple high-quality trials have shown that physiotherapy produces equivalent long-term outcomes to arthroscopic subacromial decompression surgery for shoulder impingement. Surgery is generally considered only after 3–6 months of quality physiotherapy without adequate improvement. Physiotherapy is always the appropriate first treatment.
What makes shoulder impingement worse?
Overhead reaching and lifting, sleeping on the affected side, reaching behind the back, repetitive arm-above-shoulder tasks, and forward-shoulder posture. Understanding and temporarily avoiding these aggravating factors while rehabilitation exercises restore the muscle balance is key to recovery.
What exercises are good for shoulder impingement?
The core exercises for shoulder impingement rehabilitation are: rotator cuff strengthening (particularly external rotation and internal rotation in low-load positions initially), scapular stabilisation (lower trapezius, serratus anterior), and thoracic extension mobility. Overhead press and lateral raises are typically restricted until adequate rotator cuff strength is achieved.
Is shoulder impingement the same as a rotator cuff tear?
No, but they often coexist. Shoulder impingement involves compression of the intact rotator cuff tendons within the subacromial space. A rotator cuff tear involves an actual structural tear in one or more tendon. Impingement is more common and generally responds faster to physiotherapy. Partial rotator cuff tears also respond well to physiotherapy without surgery in many cases.
Ashley Haleel
Physiotherapist & Owner — Better Physiotherapy Bundoora