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Shoulder impingement (subacromial impingement syndrome) causes pain on the outside of the shoulder when you lift your arm, reach overhead or lie on that side. The rotator cuff tendons and the bursa above them get pinched and irritated under the bony roof of the shoulder (the acromion). Dr. Andrew Dold, a board-certified sports medicine surgeon in Frisco, Texas, treats shoulder impingement, and most patients improve without surgery.

At a glance

  • Pain on the outside of the shoulder with overhead activity, and often at night
  • Caused by the rotator cuff and bursa being pinched under the acromion; bone spurs and the shape of the acromion can contribute
  • Diagnosed with an exam and X-rays; MRI when the diagnosis is unclear or a rotator cuff tear is suspected
  • Start with at least 3 to 6 months of non-surgical care: physical therapy, anti-inflammatories and sometimes an injection; about 70% of patients respond
  • If symptoms persist, arthroscopic subacromial decompression creates more room for the tendons; full recovery is generally about 3 months

Definition

Shoulder impingement syndrome was originally described by Dr. Neer in 1972 as shoulder pain, weakness, and dysfunction caused by chronic impingement of the rotator cuff beneath the coracoacromial arch. Repetitive microtrauma of the supraspinatus tendon’s hypovascular area causes progressive inflammation and degeneration of the tendon, resulting in bursitis, tendinopathy, and progressive rotator cuff tearing (partial-thickness tears that progress into full-thickness tears with time). Extrinsic compression of the rotator cuff tendon can occur at the undersurface of the acromion (usually due to subacromial impingement spurs or abnormal morphology of the acromion), the coracoacromial (CA) ligament, and the acromioclavicular (AC) joint.

Anatomy

The acromion, together with the coracoid process and the CA ligament, form the coracoacromial arch. The arch is the rigid structure through which the rotator cuff tendons, subacromial bursa, and humeral head must pass. The primary tendon making up the rotator cuff is the supraspinatus tendon. This is the most common affected tendon in rotator cuff pathology, including subacromial impingement syndrome. The supraspinatus tendon is confined above by the subacromial bursa and coracoacromial arch and below by the humeral head in an area referred to as the “supraspinatus outlet.” On average, there is 9 to 10 mm of space between the undersurface of the acromion and the humeral head in the supraspinatus outlet. This space is narrowed by abnormalities of the coracoacromial arch. Additionally, internal rotation and forward flexion of the arm also decreased the distance between the CA arch and the humeral head, decreasing the space for the supraspinatus tendon and aggravating symptoms associated with impingement syndrome (ex. Hawkins test for impingement). The subacromial bursa tissue overlies the supraspinatus tendon. Its function is to serve as a cushion and lubricate the interface between the rotator cuff and the overlying acromion and AC joint. Importantly, the bursa may become thick and fibrotic in response to progressive subacromial inflammation, further decreasing the volume of the subacromial space while aggravating the symptoms associated with impingement syndrome. Additionally, the supraspinatus tendon has a watershed area of hypovascularity located approximately 1cm medial to the insertion of the rotator cuff on the humeral hand. Due to the lack of blood supply, this area is predisposed to degenerative tearing and tendinopathy as well as tearing from overuse and repetitive microtrauma against the acromion. Together, this is subacromial impingement syndrome.

Acromial morphology most commonly accounts for narrowing of the supraspinatus outlet. Bigliani et al. published a study that described three types of acromial morphology:

  • Type I acromion is flat.

  • Type II acromion is curved.

  • Type III acromion is hooked.

Interestingly, the study also noted that in 70% of cadaver shoulders with rotator cuff tears a type III acromion was present.

Pathogenesis

Extrinsic or outlet impingement of the rotator cuff is caused by abnormalities of the CA arch, resulting in an overall decreased area for the rotator cuff tendons within the supraspinatus outlet. Other processes or pathologies that narrow the supraspinatus outlet must be considered when assessing a patient for impingement syndrome of the shoulder. These include:

  • Osteophytes of the AC joint, due to progressive osteoarthritis of the AC joint

  • Hypertrophy of the CA ligament

  • Malunion of a greater tuberosity or a clavicle fracture

  • Inflammatory subacromial bursitis

  • Calcific rotator cuff tendinitis

  • A flap from a bursal-sided rotator cuff tear

  • An unstable os acrominale (failure of fusion in one of the acromial ossification centers).

Natural History

Neer classified subacromial impingement into three distinct stages:

  • Stage 1: Lesions occur initially with excessive overhead use in sports or at work. This is a reversible process of edema and hemorrhage that is found in the subacromial bursa and adjacent rotator cuff tissue. This typically occurs in patients younger than the age of 25 years old.

  • Stage 2: In stage II lesions, the subacromial bursa may become irreversibly fibrotic and thickened, and tendinitis develops in the supraspinatus tendon. Typically, this lesion is found in patients 25 to 40 years of age.

  • Stage 3: As subacromial impingement progresses, stage III lesions might occur, with partial or complete tears of the rotator cuff tendon. Changes in the bone architecture at the anterior acromion and greater tuberosity may also develop. These lesions occur almost exclusively to patients older than the age of 40.

In terms of the natural history, stage I and II lesions typically respond to non-operative modalities including rest, activity modification, and nonsteroidal anti-inflammatories (NSAIDs). A subacromial corticosteroid injection may also help treat the subacromial bursitis and relieve refractory symptoms. Refractory stage II lesions and stage III lesions require operative intervention.

Patient History And Physical Finding

Patients with subacromial impingement syndrome of the shoulder typically complain of shoulder pain that is aggravated by overhead activities. The pain is typically localized to the lateral aspect of the acromion, extending distally into the deltoid muscle belly. Patients may also experience pain during the night, especially when lying on the affected shoulder. Most commonly, patients do not complain of a restriction in their range of motion but do experience aggravation of their symptoms with internal rotation and forward flexion of the shoulder that is most common with overhead exercises and activity. Physical examination methods to identify subacromial impingement syndrome include:

  • Palpation over the point of Codman: Palpation just anterior to the anterolateral corner of the acromion may produce tenderness that is a sign of supraspinatus tendinitis, tendinopathy, or an acute tear of the supraspinatus tendon.

  • Range of motion (ROM) Testing: patients with impingement often have limited internal rotation due to contracture of the posterior shoulder capsule. Active motion is typically more painful than passive motion especially during the eccentric phase of the motion arc.

  • Neer Impingement Sign.

  • Neer Impingement Test:  an injection of local anesthetic into the subacromial space followed by relief of pain on clinical impingement tests.

  • Hawkins Sign

A complete physical examination of the shoulder should be performed to evaluate and rule out other associated pathologies and other processes in the differential diagnosis. These include:

  • Acromioclavicular (AC) Osteoarthritis

  • Rotator Cuff Tears

  • Glenohumeral Instability

  • Biceps Pathology

  • Glenohumeral osteoarthritis

Imaging/ Diagnostic Studies

Standard radiographs of the shoulder should be taken that include standard anteroposterior (AP) orientations including internal and external rotation views as well as a supraspinatus outlet view. Acromiohumeral distance is the minimal distance between the undersurface of the acromion and the uppermost point of the humeral head. An acromiohumeral distance of less than 7 mm is considered abnormal and a potential cause of subacromial impingement.  An AP radiograph of the contralateral normal shoulder might be taken and used as a comparison view for the acromiohumeral distance.

Other studies, including MRI, CT scan, arthrography, and ultrasonography might be indicated based on the patient’s presentation and clinical examination as well as the findings on plain radiographs. Typically, these tests are reserved for patients whose diagnosis of impingement syndrome is not completely clear or understood from the history, physical examination, and plain radiographs. Additionally, these other modalities may help diagnose associated pathology of the soft tissues around the shoulder including the long head of biceps tendon, labrum, and rotator cuff tendon.

Differential DIagnosis

  • Rotator cuff pathology, including partial and full-thickness tears

  • AC joint osteoarthritis

  • Glenohumeral instability

  • Posterior glenoid and rotator cuff (internal) impingement

  • Glenohumeral osteoarthritis

  • Biceps tendon pathology (biceps tenosynovitis)

  • Adhesive capsulitis (aka. Frozen shoulder)

  • Cervical spine disease

  • Viral brachial plexopathy

  • Thoracic outlet syndrome

  • Neoplasm of the proximal humerus or shoulder girdle

  • SLAP tear

Nonoperative Management

All patients with subacromial impingement syndrome should undergo a course of non-operative management for at least 3 to 6 months. Non-operative treatment  modalities include:

  • Subacromial corticosteroid injections

  • NSAIDs (Nonsteroidal anti-inflammatory drugs)

  • Hot and cold therapies

  • Ultrasound

  • Physical Therapy

Approximately 70% of patients will respond to a conservative treatment protocol with success. The goal of therapy is to regain or improve ROM while improving symptoms of pain. Therapy should be advanced as the pain and inflammation subside. Posterior capsular contracture should also be addressed in physical therapy with progressive adduction and internal rotation stretching. Modalities to control pain are indicated in the acute setting.

Surgical Management

Operative intervention is indicated in patients that continue to have symptoms of impingement syndrome that are refractory to a progressive rehabilitation protocol of stretching and strengthening over a minimum 3- to 6-month period. If the diagnosis is not completely clear based on the initial tests, a more extensive diagnostic workup is warranted before surgical intervention. This will usually include an MRI or an MR arthrography (MRA) of the shoulder to rule out rotator cuff pathology and other internal derangement of the shoulder. Particular attention should be  paid to the acromial morphology, the status of the AC joint, and evidence of rotator cuff disease, as these disease processes often coexist in subacromial impingement syndrome. Two large placebo-controlled trials have shown that subacromial decompression alone is no more effective than placebo surgery or a structured exercise program for most patients with impingement (see the research summary below). For that reason, exercise-based treatment is the first and main treatment. Surgery is reserved for selected patients who do not improve after a thorough course of rehabilitation, particularly when another problem that surgery can address is present, such as a rotator cuff tear, a symptomatic AC joint, or a biceps or calcific tendon problem.

Subacromial Decompression / Acromioplasty

During subacromial decompression, an arthroscopic burr is introduced into the subacromial space and is used to resect abnormal, pathologic bone from the undersurface of the acromion. Resection begins at the anterolateral corner of the acromion and the desired depth of resection is estimated based on the diameter of the burr (usually 5.5mm). The depth of resection is achieved anteriorly from the anterolateral corner of the acromion to the medial acromial facet of the AC joint. All abnormal subacromial spurs are removed during the resection. AC joint bone spurs are also removed. Dr. Dold will also resect and release the coracoacromial (CA) ligament completely and visualize the undersurface of the deltoid at least 15mm posterior to the anterolateral corner of the acromion to ensure a complete subacromial decompression. The entirety of the procedure is done arthroscopically through small keyhole incisions. The patient is placed in a sling for comfort post-operatively and begins passive and active range of motion in physical therapy immediately following surgery. The physical therapy protocol is advanced as rapidly as motion and pain will allow. Full recovery is generally achieved by approximately 3 months postoperatively. However, patients with significant rotator cuff pathology or full thickness tears me take much longer to improve.

To schedule a consultation with Dr. Dold, contact us here.

What the research shows

Shoulder impingement (also called subacromial pain syndrome) has been studied in some of the highest-quality trials in orthopedics:

  • Surgery vs. placebo surgery: in the UK CSAW trial and the Finnish FIMPACT trial, removing bone from under the acromion (decompression) was no more effective than a placebo arthroscopy, and in FIMPACT no better than exercise therapy, with follow-up now reaching 10 years. A BMJ clinical practice guideline recommends against decompression surgery for most people with this condition.
  • Exercise works and lasts: a specific program of rotator cuff and shoulder blade strengthening reduced pain, improved function and reduced the need for surgery, with benefits maintained at 10 years in a randomized trial. Scapular stabilization and manual therapy can add benefit.
  • Cortisone injections give short-term pain relief that can make it easier to do the exercises, but large trials show no long-term benefit on their own.
  • PRP injections: several randomized trials and a meta-analysis report pain relief with PRP that lasted longer than with cortisone in rotator cuff tendinopathy, though the certainty of the evidence is low to moderate.
  • Shockwave therapy has limited evidence of benefit for non-calcific tendinopathy, while ultrasound and laser show only short-term effects.
  • Diagnosis: no single exam test confirms impingement, so Dr. Dold combines the history, several exam tests, X-rays and, when needed, ultrasound or MRI to look for rotator cuff tears or other causes of pain.

Frequently asked questions

What does shoulder impingement feel like?

Pain on the outside of the shoulder, often spreading toward the upper arm, that is worse when reaching overhead, reaching behind you, or lying on that shoulder at night.

Can shoulder impingement heal on its own?

Many cases improve with rest from aggravating activities, physical therapy and anti-inflammatory medicine. About 70% of patients respond to a non-surgical program.

How long should I try physical therapy before surgery?

Generally at least 3 to 6 months of a structured non-surgical program, including stretching and strengthening, before surgery is considered.

What is subacromial decompression?

An arthroscopic procedure in which bone spurs and thickened tissue under the acromion are removed through small incisions, giving the rotator cuff more room to move without being pinched.

Do I need surgery for shoulder impingement?

Usually not. Placebo-controlled trials show that most patients do as well with a structured exercise program as with decompression surgery. Surgery is considered when symptoms persist after thorough rehabilitation, especially if there is another problem such as a rotator cuff tear.

How long is recovery after subacromial decompression?

A sling is used for comfort, physical therapy starts right away, and full recovery is generally about 3 months. Recovery can take longer if the rotator cuff is also torn.

Is shoulder impingement the same as a rotator cuff tear?

No, but they are related. Long-standing impingement can irritate and wear the rotator cuff, and partial or full tears can develop over time, which is why persistent shoulder pain should be evaluated.

Ready to get it checked? Request an appointment online or call 469-850-0680. Our staff will contact you by phone and text within an hour of your request (during business hours, Monday–Friday, 8 am–5 pm). Walk-in visits are welcome Monday, Wednesday and Friday, 8:30–10:30 am at 6700 Dallas Parkway, Suite 100, Frisco, TX 75034. We see patients from Frisco, Plano, McKinney, Prosper, Little Elm, The Colony, Allen, Dallas and across North Texas. Same-day appointments available. Dr. Dold accepts most major insurance plans, including Medicare and Tricare. Please call 469-850-0680 to confirm your coverage.

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Considering surgery? Read about shoulder arthroscopy in Frisco, the minimally invasive procedure Dr. Dold uses for rotator cuff, labral and biceps problems.

Research cited on this page

  1. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-338. PubMed
    CSAW trial (UK): decompression and arthroscopy-only both gave slightly better outcomes than no treatment, but the difference was not clinically important; decompression added no benefit over arthroscopy alone.
  2. Paavola M, Kanto K, Ranstam J, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. Br J Sports Med. 2021;55(2):99-107. PubMed
    FIMPACT trial, 5 years: decompression gave no benefit over diagnostic arthroscopy or exercise therapy.
  3. Kanto K, Bäck M, Ibounig T, et al. Arthroscopic subacromial decompression versus placebo surgery for subacromial pain syndrome: 10 year follow-up of the FIMPACT randomised, placebo surgery controlled trial. BMJ. 2025;391:e086201. PubMed
    FIMPACT trial, 10 years: decompression offered no benefit over placebo surgery or exercise therapy.
  4. Vandvik PO, Lähdeoja T, Ardern C, et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ. 2019;364:l294. PubMed
    BMJ clinical practice guideline: strong recommendation against subacromial decompression surgery for subacromial pain syndrome.
  5. Petersson AH, Björnsson Hallgren HC, Adolfsson LE, et al. No need for subacromial decompression in responders to specific exercise treatment: a 10-year follow-up of a randomized controlled trial. J Shoulder Elbow Surg. 2025;34(6):e477-e487. PubMed
    Randomized trial, 10 years: specific exercise was effective, reduced the need for surgery, and responders had durable long-term outcomes.
  6. Holmgren T, Björnsson Hallgren H, Öberg B, et al. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ. 2012;344:e787. PubMed
    Randomized trial: a specific eccentric rotator cuff and scapular exercise program reduced pain, improved function and reduced the need for surgery.
  7. Hallgren HC, Holmgren T, Oberg B, et al. A specific exercise strategy reduced the need for surgery in subacromial pain patients. Br J Sports Med. 2014;48(19):1431-6. PubMed
    One-year follow-up: the benefit of specific exercises was maintained and reduced the need for surgery.
  8. Pieters L, Lewis J, Kuppens K, et al. An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. J Orthop Sports Phys Ther. 2020;50(3):131-141. PubMed
    Overview of systematic reviews: a growing body of evidence supports exercise therapy for subacromial shoulder pain.
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    Systematic review: exercise improves pain and function in rotator cuff tendinopathy.
  10. Zhong Z, Zang W, Tang Z, et al. Effect of scapular stabilization exercises on subacromial pain (impingement) syndrome: a systematic review and meta-analysis of randomized controlled trials. Front Neurol. 2024;15:1357763. PubMed
    Systematic review: scapular stabilization exercises reduce pain and improve function in subacromial pain syndrome.
  11. Desjardins-Charbonneau A, Roy JS, Dionne CE, et al. The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2015;45(5):330-50. PubMed
    Meta-analysis: manual therapy may decrease pain in rotator cuff tendinopathy.
  12. Steuri R, Sattelmayer M, Elsig S, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017;51(18):1340-1347. PubMed
    Meta-analysis: exercise should be considered first; tape, shockwave, laser or manual therapy may be added; NSAIDs and corticosteroids help short term.
  13. Hopewell S, Keene DJ, Marian IR, et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial. Lancet. 2021;398(10298):416-428. PubMed
    GRASP trial: subacromial corticosteroid injection gave modest short-term benefit and no long-term benefit; progressive exercise was not better than a best-practice advice session.
  14. Lazzarini SG, Buraschi R, Pollet J, et al. Effectiveness of Additional or Standalone Corticosteroid Injections Compared to Physical Therapist Interventions in Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Phys Ther. 2025;105(3). PubMed
    Systematic review: corticosteroid injection helps pain and function in the short term, especially combined with physical therapy.
  15. Hsieh LF, Kuo YC, Huang YH, et al. Comparison of corticosteroid injection, physiotherapy and combined treatment for patients with chronic subacromial bursitis – A randomised controlled trial. Clin Rehabil. 2023;37(9):1189-1200. PubMed
    Randomized trial: subdeltoid corticosteroid injection, alone or with physiotherapy, worked faster than physiotherapy alone, but recurrence was lowest with physiotherapy.
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    Cochrane review: subacromial corticosteroid injection may give small short-term benefit for rotator cuff disease; trials are small and varied.
  17. Masiello F, Pati I, Veropalumbo E, et al. Ultrasound-guided injection of platelet-rich plasma for tendinopathies: a systematic review and meta-analysis. Blood Transfus. 2023;21(2):119-136. PubMed
    Meta-analysis: ultrasound-guided PRP lowered pain scores at 1 to 6 months versus controls, with low-certainty evidence.
  18. Rossi LA, Brandariz R, Gorodischer T, et al. Subacromial injection of platelet-rich plasma provides greater improvement in pain and functional outcomes compared to corticosteroids at 1-year follow-up: a double-blinded randomized controlled trial. J Shoulder Elbow Surg. 2024;33(12):2563-2571. PubMed
    Randomized trial: a single subacromial PRP injection gave greater and more sustained improvement than a corticosteroid injection in rotator cuff tendinopathy.
  19. Kwong CA, Woodmass JM, Gusnowski EM, et al. Platelet-Rich Plasma in Patients With Partial-Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared With Corticosteroid Injection: A Double-Blind Randomized Controlled Trial. Arthroscopy. 2021;37(2):510-517. PubMed
    Randomized trial: both PRP and corticosteroid injections improved symptoms; PRP gave greater improvement at 3 months.
  20. Xiang XN, Deng J, Liu Y, et al. Conservative treatment of partial-thickness rotator cuff tears and tendinopathy with platelet-rich plasma: A systematic review and meta-analysis. Clin Rehabil. 2021;35(12):1661-1673. PubMed
    Network meta-analysis: PRP improved pain and function in tendinopathy and partial tears, though effects may not last long.
  21. Xue X, Song Q, Yang X, et al. Effect of extracorporeal shockwave therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2024;25(1):357. PubMed
    Systematic review: limited evidence that shockwave therapy improves pain and function in rotator cuff tendinopathy.
  22. Li C, Li Z, Shi L, et al. Effectiveness of Focused Shockwave Therapy versus Radial Shockwave Therapy for Noncalcific Rotator Cuff Tendinopathies: A Randomized Clinical Trial. Biomed Res Int. 2021;2021:6687094. PubMed
    Randomized trial: focused and radial shockwave were both effective for non-calcific rotator cuff tendinopathy.
  23. Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;2016(6):CD012224. PubMed
    Cochrane review: manual therapy and exercise may help, but evidence against placebo is limited.
  24. Page MJ, Green S, Mrocki MA, et al. Electrotherapy modalities for rotator cuff disease. Cochrane Database Syst Rev. 2016;2016(6):CD012225. PubMed
    Cochrane review: low-quality evidence that therapeutic ultrasound and laser give only short-term benefits.
  25. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964-78. PubMed
    Meta-analysis: no single shoulder exam test is diagnostic on its own for impingement.
  26. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93(2):229-36. PubMed
    Meta-analysis: diagnostic accuracy of clinical tests for subacromial impingement.
  27. Zhao Q, Palani P, Kassab NS, et al. Evidence-based approach to the shoulder examination for subacromial bursitis and rotator cuff tears: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2024;25(1):1028. PubMed
    Systematic review: physical examination tests for cuff tears and impingement have mostly low-quality evidence.
  28. Carr AJ, Murphy R, Dakin SG, et al. Platelet-Rich Plasma Injection With Arthroscopic Acromioplasty for Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015;43(12):2891-7. PubMed
    Randomized trial: acromioplasty improved outcomes to 2 years, and adding PRP did not change clinical outcomes.
  29. Karjalainen TV, Jain NB, Heikkinen J, et al. Surgery for rotator cuff tears. Cochrane Database Syst Rev. 2019;12(12):CD013502. PubMed
    Cochrane review: uncertain whether rotator cuff repair surgery gives clinically meaningful benefit over non-surgical care for symptomatic tears.

Medically reviewed by Andrew P. Dold, MD, FAOA, FAAOS, FACS, FRCSC. Last reviewed October 2026. This page is general information, not medical advice. Individual results vary.