Shoulder

Shoulder Impingement / Rotator Cuff Tendinopathy

Shoulder impingement syndrome is among the most common causes of shoulder pain in adults, affecting athletes, overhead workers, and active individuals alike. At Maryland Orthopedic Specialists, our sports medicine physicians diagnose and treat the full spectrum of rotator cuff tendinopathy — from mild subacromial irritation to advanced degenerative tendon disease — with evidence-based, individualized care at our Bethesda and Germantown offices.

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What is shoulder impingement / rotator cuff tendinopathy?

Shoulder impingement occurs when the rotator cuff tendons — most often the supraspinatus — are compressed between the humeral head and the undersurface of the acromion or the coracoacromial arch during shoulder elevation. This mechanical pinching creates repetitive microtrauma and inflammation within the subacromial space, leading to the spectrum of pathology collectively termed subacromial impingement syndrome or rotator cuff tendinopathy.

Shoulder impingement occurs when the rotator cuff tendons — most often the supraspinatus — are compressed between the humeral head and the undersurface of the acromion or the coracoacromial arch during shoulder elevation. This mechanical pinching creates repetitive microtrauma and inflammation within the subacromial space, leading to the spectrum of pathology collectively termed subacromial impingement syndrome or rotator cuff tendinopathy.

Subacromial Space and Acromial Morphology

The subacromial space contains the rotator cuff tendons, the subacromial bursa, and the long head of the biceps tendon. Its dimensions are influenced significantly by acromial shape. The Bigliani classification describes three acromial types: Type I (flat), Type II (curved), and Type III (hooked). A Type III hooked acromion reduces the subacromial space and is strongly associated with impingement and full-thickness rotator cuff tears. Os acromiale — a failure of acromial ossification centers to fuse — can also dynamically narrow this space.

Neer and Hawkins-Kennedy Impingement Signs

Two classic physical examination maneuvers identify subacromial impingement:

Neer sign: The examiner stabilizes the scapula and passively forward-flexes the patient's arm in internal rotation, compressing the supraspinatus against the anterior acromion. Pain reproduction is a positive test.
Hawkins-Kennedy test: The shoulder is brought to 90° of forward flexion and then internally rotated, driving the supraspinatus under the coracoacromial ligament. This is the most sensitive clinical test for subacromial impingement.

A positive Neer injection test — relief of pain after injection of local anesthetic into the subacromial space — further confirms the diagnosis.

Differentiating Impingement from Rotator Cuff Tear

Impingement and rotator cuff tears exist on a continuum but are clinically distinct. Weakness on resisted supraspinatus testing (empty-can or full-can test), a positive external rotation lag sign, or a drop-arm sign suggest a full-thickness tear rather than isolated tendinopathy. MRI or ultrasound imaging is required to define the integrity of the rotator cuff when clinical findings are ambiguous.

Treatment options

The vast majority of patients respond to non-operative management.

Physical Therapy (Mainstay Treatment)

A structured PT program targeting rotator cuff strengthening (particularly the infraspinatus and teres minor), scapular stabilization, and posterior capsule stretching remains the cornerstone of treatment. Programs of 6–12 weeks produce significant, durable pain relief in most patients.

Subacromial Corticosteroid Injection

Ultrasound-guided subacromial injection with corticosteroid and local anesthetic provides short-to-medium term pain relief, facilitates participation in PT, and is particularly effective for bursal inflammation. Injections are typically limited to two to three per shoulder per year to minimize tendon tissue effects.

NSAIDs and Activity Modification

Short courses of anti-inflammatory medication combined with activity modification reduce acute inflammatory burden.

Surgical Procedure

Subacromial Decompression / Acromioplasty

Arthroscopic shaving of the undersurface of the acromion to enlarge the subacromial space, relieve mechanical impingement on the rotator cuff tendons, and address the bony component of impingement syndrome.

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Arthroscopic Rotator Cuff Repair

Arthroscopic repair of a full or partial-thickness rotator cuff tear using suture anchors to reattach the tendon to its footprint on the greater tuberosity. Performed as an outpatient procedure at our ambulatory surgery center.

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Frequently Asked Questions

Can shoulder impingement go away on its own?

Mild impingement can improve with activity modification and home exercises, but formal PT is more reliable and faster. Most patients avoid surgery with proper conservative care.

Is impingement the same as a rotator cuff tear?

No. Impingement refers to mechanical compression of intact but inflamed tendons. A tear involves actual disruption of tendon fibers. However, chronic untreated impingement can progress to tearing over time.

How many injections can I receive?

We typically recommend no more than two to three corticosteroid injections per shoulder per year. Excessive corticosteroid use may weaken tendon tissue.

Will I need surgery?

Fewer than 10–15% of patients with impingement ultimately require surgical intervention. Surgery is reserved for those who fail at least 4–6 months of structured conservative care.

What does physical therapy for shoulder impingement involve, and how long until I feel better?

Physical therapy for shoulder impingement focuses on restoring the normal mechanics of the shoulder blade and rotator cuff through a progressive strengthening program targeting the periscapular muscles, rotator cuff, and posterior shoulder capsule stretching. Most patients begin to notice meaningful improvement within four to eight weeks of consistent therapy. A full course of treatment typically lasts two to four months, after which most patients with tendinopathy — without a tear — can return to full activity. At MOS, your surgeon or physiotherapist will reassess your response to treatment and adjust the plan if progress plateaus, including considering whether imaging or additional interventions are warranted.