The shoulder is one of the most complex joints in the human body. The many tendons, ligaments, and muscles that hold it together give it an incredible range of motion. Unfortunately, this freedom of motion makes it the most unstable joint in the body. As tendons are stretched during movement, they can be rubbed and pinched between bones causing them to become irritated and inflamed. If this happens enough, you might end up with internal or external shoulder impingements. You may get one or the other depending on your movements and what population you are a part of. It is not uncommon for someone to have both types based on their age and level of activity. Lets start with a quick explanation of internal and external shoulder impingements and how to test for them.

External Shoulder Impingement

The most common form of shoulder impingement typically happens in older adults due to postural instability and years of degeneration. It is characterized by pain in the front of the shoulder during movements which require lifting the arms above the head. Degeneration and inflammation narrow the shoulder cavity while overhead movements pinch the tendons over and over. In short, your having a space issue. This can greatly decrease your comfortable range of motion and, if left untreated, can lead to greater shoulder injuries.

Test Yourself:

Lateral Neer’s Test:

  1. Keeping your arms straight, bring them from your side to above your head, bringing your thumbs together.
  2. Do this as if you were against a wall, tracing the wall with your hands (not out in front of you). 
  3. Repeat the motion, but this time while internally rotating (internal rotation is the motion you make when pouring a glass of milk).
  4. Pain during this test indicates shoulder external impingement.

Jobe Test:

  1. Put your arms straight out in front of you with your hands at shoulder level.
  2. Internally rotate the arm (think pouring a glass of milk!).
  3. Have someone lightly place downward force to the top of your forearms.
  4. Try to resist any movement.
  5. Pain in the shoulder during this test also indicates external impingement. 

Avoid:

If the above tests show positive signs for external impingement, try to avoid any overhead arm movements until you improve mid-back mobility, shoulder range of motion, and pectoral tightness. Avoid the following exercises until your shoulder has time to heal and build up foundation strength.

  • Overhead weight lifting places tremendous stress on the shoulder joint. These may increase inflammation of the shoulder capsule and slow down the healing process.
  • Jumping Jacks place repeated strain on the tendons in your shoulder. While this is a great exercise normally, they will only further irritate the impingement.

Instead:

Focus on movements that open the chest and shoulders and encourage strengthening your posture. Good posture will provide more space for the shoulder to move through their full range of motion with less resistance and irritation.

  • Wall-Slides are a great way to improve mobility in the shoulders and thoracic spine, as well as relieve tension in the pectoral muscles.

  • Now would be a good time to try out those resistance bands that you have been eyeing for a while. There are TONS of good exercises you can do with them including band pulls and band internal/external rotations.

               

Internal Shoulder Impingement

Internal impingement is most common for athletes in sports that involve throwing or other overhead movements. Such sports include swimming, baseball, climbing, volleyball, racket sports, and weightlifting. It is characterized by pain in the back of the shoulders during movements which involve rotating the arm outwards or pulling the arm back, as in the cocking phase of a baseball pitch or freestyle stroke. The repeated rapid stretching and tightening of the muscles and tendons in the shoulder joint leads to imbalances between the front and the back of the shoulder. This causes irritation, rubbing, and breakdown of the posterior cuff, eventually leading to impingement during arm elevation.

Test Yourself:

Hawkin’s-Kennedy:

    1. Extend your affected arm straight out to the side with your elbow at shoulder-level bent up at a 90 degree angle.
    2. Keeping your elbow in place, rotate your arm inwards, bringing your hand down and as far back as possible.
    3. Pain in the shoulder indicates internal impingement.

Modified Hawkin’s-Kennedy:

    1. Set up as you would for the Hawkin’s-Kennedy test, arms straight out to the side and elbows flexed up at 90 degrees.
    2. This time try to stay in this position and resist any movement while having a friend place forward pressure on the back of the wrist (Make sure your friend has one hand supporting the elbow to isolate any movement while the other is pressing on the back of the wrist).
    3. Pain in the shoulder during this test also indicates internal impingement.

Avoid:

The big mistakes you want to avoid involve retracted the shoulder blades with the arm up. Think of the Hawkin’s Kennedy test; now avoid any exercise that puts you into that position and causes pain.

  • Back Squats require the athlete to hold the bar on his/her shoulders with the shoulders abducted and retracted. This motion irritates the posterior cuff and increases impingement.
  • Shoulder Presses allow the shoulders to move through their range of motion while under load and retracted backwards. This motion is what we are trying to avoid!
  • Wall-Slides (while great for external impingement rehab), are ill-advised for those with internal impingement. Once again, they encourage the same friction and irritation in the posterior cuff that caused the impingement in the first place!

Instead:

The focus should be on avoiding exercises that place your elbows at shoulder height and with the shoulders internally rotated (the “pouring a glass of milk” motion). Always remember to engage your shoulder-blades down and back during any arm movement.

  • Front Squats are a great alternative to back squats because your arms are out front and elbows close together. This places very little stress or tension on the posterior cuff. An even better modification to front squats are cross-face front squats. With cross-face front squats your hands are on the bar over the opposite shoulder.

  • Narrow Grip Presses (push press, front press, etc.) are still an option for an athlete with an internal impingement. The trick here is to make sure to keep the elbows close to each other.

  • Narrow Grip Push-Ups are still a very effective body-weight training exercise if you have an internal impingement. Just make sure you keep elbows close, glutes tight, and abs braced!

As with any injury, creating a safe and purposeful program is a must. You have already done most of the work by getting all the way through this article, now you just need to apply it! Always consult a medical professional or physical therapist if you are injured or experiencing abnormal pains or weaknesses. Most importantly, never continue performing exercises that will set you back! The biggest barrier to rehab isn’t always the injury itself. Your mental state is incredibly important. As a personal trainer I often hear clients lament over their injury and how it affects their top lifts. Look at it as an opportunity to go back to the basics; think about your form and technique. Try new exercises that you wouldn’t have tried before – bust out those resistance bands! You might surprise yourself with a new workout routine with more variation and focus than you had before. Injuries are something that are bound to happen, and shoulder impingements are certainly not an exception. Do the research, create a plan, and stick to it.