Shoulder Impingement and Rotator Cuff Pain

Pain on lifting the arm to the side, worst between roughly 60 and 120 degrees, with night pain when lying on that side 2. The rotator cuff tendons and the bursa above them are the usual source.

The older model — a bony spur pinching the tendon — has been substantially revised. Current understanding puts more weight on tendon capacity and load than on shape, which changes the treatment from surgical decompression to progressive loading.

Randomised trials comparing subacromial decompression with placebo surgery and with exercise have not shown a clinically meaningful advantage for the operation in typical impingement.

This has changed guidelines in several countries. It does not mean surgery is never indicated — it means exercise should be tried properly first, and properly means a sustained programme of progressive loading rather than a leaflet.

Progressive strengthening of the rotator cuff and the scapular stabilisers, range work where movement is restricted, and correction of the loading pattern that provoked it. Pain during exercise up to a tolerable level is acceptable and does not indicate damage.

Injection is used where pain prevents someone starting the exercise, as a window rather than a treatment. Repeated injections into a tendon weaken it.

Inability to lift the arm at all after a fall, particularly over 60, suggests a large cuff tear. Restriction in every direction including passive movement suggests frozen shoulder, which needs a different approach.

Neck problems refer pain to the shoulder often enough that the neck is examined in every shoulder assessment. Shoulder pain with breathlessness or chest discomfort is a cardiac question and needs emergency assessment.

A large randomised trial compared arthroscopic subacromial decompression against a placebo operation and against no treatment. Both surgical groups — the real operation and the placebo operation — improved by a similar amount. The difference attributable to removing bone was small and of doubtful clinical importance.

That finding is why decompression is no longer a default step, and why a genuine course of exercise-based rehabilitation comes first. It also explains why people who had the operation years ago often report it helped: improvement was real, but not necessarily because of what was removed.

Rotator cuff and scapular control, because the mechanics of how the shoulder blade moves determine how much space the tendons work in. Range where it is restricted, then strength through that range, then the specific overhead patterns the person actually needs.

Load is progressed deliberately. A programme of light band exercises repeated indefinitely does not build the capacity the shoulder needs, and it is the most common version of failed conservative treatment.

Consistent, progressive work over a sustained period before conclusions are drawn. Improvement is usually gradual rather than sudden, and the last thing to return is comfortable overhead work.

We measure range and strength at the start and at intervals, so the judgement is based on numbers rather than on how the shoulder felt on a particular morning.

Night pain is often the worst part and the most disruptive. Sleeping on the affected side compresses the shoulder; a pillow supporting the arm and a semi-reclined position help most people.

For overhead work the aim is to reduce sustained time above shoulder height rather than to eliminate it — lowering the work, alternating tasks and taking the arm down between repetitions. Complete avoidance leaves the shoulder unprepared for the day it cannot be avoided.