The American Journal of Medicine (2005) 118, 452 455

REVIEW

Shoulder impingement syndrome

Michael C. Koester, MD, Michael S. George, MD, John E. Kuhn, MD

The Vanderbilt Shoulder Center, Vanderbilt Sports Medicine, Nashville, Tennessee.

ABSTRACT Subacromial impingement syndrome is a common cause of shoulder pain. The purpose of
this article is to review the clinical presentation, physical examination findings, and differential
diagnosis of impingement syndrome. Using an evidence-based approach, we propose an algorithm for
the management of subacromial impingement syndrome including indications for nonoperative man-
agement, advanced imaging, and operative management.
2005 Elsevier Inc. All rights reserved.

Shoulder pain is a common presenting complaint for become painful, and a general loss of strength may be noted.
patients of all ages and activity levels. Subacromial im- Onset of shoulder pain and weakness following a fall in an
pingement syndrome (SIS) encompasses a spectrum of sub- individual over 40 years of age should raise concern for a
acromial space pathologies including partial thickness rota- complete tear of the rotator cuff.
tor cuff tears, rotator cuff tendinosis, calcific tendinitis, and
subacromial bursitis. These conditions may all present sim-
ilarly and are often distinguishable only by magnetic reso-
nance imaging (MRI) or arthroscopy. In this article we Examination findings
present the clinician with key historical and physical exam-
A thorough examination of the neck and shoulder is
ination findings, a differential diagnosis, and an algorithm to
critical to properly diagnosing SIS. Strength testing of the
guide management and referral of patients with SIS.
upper extremities as well as neck and shoulder ranges of
motion should be carefully assessed. In SIS, active and
passive shoulder range of motion is typically normal. The
Clinical presentation muscles of the rotator cuff are best isolated with 3 separate
maneuvers. To isolate the subscapularis, the patient places
Although impingement symptoms may arise following their hand behind the back and attempts to push away the
trauma, the pain more typically develops insidiously over a examiners hand (Figure 1), a maneuver called the lift-off
period of weeks to months. The pain is typically localized to test. Next, with the arms at the sides and the elbows flexed,
the anterolateral acromion and frequently radiates to the the examiner resists the patient in external (Figure 2) rota-
lateral mid-humerus. Patients usually complain of pain at tion of the shoulder. Next, to isolate the supraspinatus,
night, exacerbated by lying on the involved shoulder, or which may be painful with SIS, the patient abducts the arms
sleeping with the arm overhead. Normal daily activities to 90, forward flexes to 30, and internally rotates each
such as combing ones hair or reaching up into a cupboard humerus so that the thumbs are pointed to the floor. A
downward force is then applied to the forearms as the
patient resists (Figure 3).
Requests for reprints should be addressed to John E. Kuhn, MD , Chief
of Shoulder Surgery, Vanderbilt Sports Medicine, 2601 Jess Neely Drive, Two provocative examination techniques are highly sen-
Nashville, TN 37212. sitive but not very specific for diagnosing SIS. Neers sign
E-mail address: j.kuhn@vanderbilt.edu. (Figure 4) elicits pain with maximum passive shoulder el-

0002-9343/$ -see front matter 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2005.01.040
Koester et al Shoulder Impingement Syndrome 453

Figure 1 Examining the subscapularis using the lift-off test. Figure 3 Examining the supraspinatus. Pain or weakness may
This may be painful or weak with tears of the anterior supraspi- be seen in disorders of the rotator cuff.
natus or subscapularis.

It is 5 times more likely to occur in patients with diabetes

evation and internal rotation while the scapula is stabilized. 1 mellitus4 and has been associated with hypothyroidism.
Hawkins sign (Figure 5) is pain with passive forward ele- Adhesive capsulitis often presents with unremitting shoul-
vation to 90 and maximum internal rotation.2 These 2 tests der pain at rest, and early stages of adhesive capsulitis may
have a negative predictive value of greater than 90% when present much like impingement syndrome. Later, patients
combined.3 Marked rotator cuff weakness with positive will develop progressive loss of motion, with loss of internal
impingement signs may indicate a complete cuff rupture. rotation an early sign of the motion loss (Figure 6). Patients
The Neer impingement test involves injecting the subacro- with adhesive capsulitis will be limited in both active and
mial space with 10 mL of local anesthetic and observing an passive ranges of motion, particularly in contrast to SIS,
amelioration of pain with these provocative tests.1 where passive motion is unrestricted.
Cervical radiculopathy may present with unilateral shoulder
pain. This can be particularly difficult to sort out in older
patients who may have both rotator cuff pathology and cervical
Differential diagnosis spine osteoarthritis. The patient with shoulder pain of a cervi-
cal origin may have pain and spasm in the trapezius muscles
Narrowing the etiology of shoulder pain can be difficult and a limited neck range of motion. They may also experience
as a number of conditions often coexist in older individuals. pain, numbness, or paresthesias radiating to the arm and hand.
The etiology of adhesive capsulitis is unknown, although Symptoms may be provoked by hyperextension and lateral
thought to be inflammatory in nature. The disease is more rotation of the neck (Spurlings maneuver). A key historical
commonly encountered among women in their 50s and 60s. detail may be that pain is alleviated when the forearm is rested
above the head.

Figure 2 Examining the external rotators of the shoulder. This

may be painful or weak with tears of the supraspinatus or infraspi- Figure 4 Neers sign. A provocative test where pain is sugges-
natus. tive of impingement syndrome.
454 The American Journal of Medicine, Vol 118, No 5, May 2005

evaluating, and treating SIS. Each of the reviewed trials was

scored on methodological design and each scored relatively
poorly. The few trials that were moderately well designed
offered limited evidence to support the efficacy of physical
therapy in SIS.
In addition to physical therapy and medications, activity
and workplace modifications must be discussed. Patients
should attempt to discontinue overhead activities until
symptoms diminish. It may be helpful to discuss living
within a window in which they consciously attempt to keep
their hands within an area in front of their body during
activity. The window should be from chest to waist and 2
to 3 feet wide, allowing the patient to avoid reaching over-
head, away from the body, or behind the back, all of which
will exacerbate their symptoms.
Figure 5 Hawkins sign. A provocative test where pain is sug-
Bearing in mind that the literature offers few truly well-
gestive of impingement syndrome.
conducted trials regarding the management of SIS, we
present an algorithm of our recommended management of
Degenerative changes within the acromioclavicular (AC) SIS based upon a synthesis of the best available literature
joint and osteolysis of the distal clavicle are often found in (Figure 7). Note that an MRI is not recommended until at
individuals with a history of heavy labor or weightlifting but least a 6-week therapeutic trial has been implemented unless
may occur in anyone. The pain may be present over the AC a complete rupture is suspected.
joint itself or be referred to the upper shoulder and neck.
Sleeping on the affected side and overhead movements exac-
erbate the symptoms. Physical examination typically confirms
the diagnosis with marked tenderness over the AC joint and
Indications for referral and surgical options
pain with compression of the joint through adduction of the When conservative management fails to relieve the symp-
elevated arm. Osteoarthritis of the glenohumeral joint presents toms associated with SIS or a complete cuff rupture is seen on
with a painful diminished range of motion. Arthritic changes in MRI, operative intervention may be warranted. Historically,
either joint are apparent on radiographs. open anterior acromioplasty with resection of the coracoacro-
mial ligament and the subacromial bursa achieved excellent
pain relief.7 Today, arthroscopic subacromial decompression
with release of the coracoacromial ligament and resection of
Management the subacromial bursa has been shown to achieve similar re-
The natural course of SIS is poorly described, but evi- sults without the violation of the deltoid insertion that is nec-
dence suggests that the condition is not self-limiting.5 The essary in the open procedure.8 Shoulder arthroscopy also al-
initial management of shoulder impingement has tradition- lows an evaluation of the glenohumeral joint and the integrity
ally included physical therapy, nonsteroidal anti-inflamma- of the rotator cuff. Pathological conditions of the glenohumeral
tory drugs (NSAIDs), and corticosteroid injection. A recent
systematic review of 8 randomized controlled trials (RCTs)
evaluated the efficacy of corticosteroid injection in the treat-
ment of rotator cuff tendonitis (Koester MC, Dunn WR,
Spindler KP, Kuhn JE. Does corticosteroid injection im-
prove short term outcomes for rotator cuff tendonitis? A
systematic review [unpublished]). Two of the trials also
evaluated NSAIDs versus injection and placebo. Only 2 of
the 8 trials showed clinically relevant improvements in pain
and range of motion in the injection groups as compared
with placebo. However, in both of these studies the out-
comes of patients treated with injection and oral NSAIDs
were equivocal.
Physical therapy is frequently implemented to lessen
pain and improve function in SIS. A systematic review of
manual and physical therapy treatment in SIS by Desmeules
et al.6 revealed only 7 RCTs that met their criteria for Figure 6 Limited passive internal rotation of the glenohumeral
review. They reported a lack of uniformity in defining, joint. This finding is an early sign of adhesive capsulitis.
Koester et al Shoulder Impingement Syndrome 455

Figure 7 Treatment algorithm for subacromial impingement syndrome. SIS subacromial impingement syndrome; NSAID nonste-
roidal anti-inflammatory drug; PT physical therapy.

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