Shoulder Impingement Syndrome: What It Means When Your Shoulder Hurts Overhead

If you've been noticing shoulder pain when you reach for something on a high shelf, swing a tennis racket, or even try to sleep on your side, you're not alone. Shoulder impingement syndrome is one of the most common causes of shoulder pain I see in patients throughout the Nashville area — responsible for nearly half of all shoulder pain cases in orthopedic practice.

The encouraging news is that most cases respond well to treatment, especially when caught early. Here's what you need to know about this condition, how it's diagnosed, and what your options are when shoulder pain starts affecting your daily life.

What Is Shoulder Impingement Syndrome?

Shoulder impingement happens when the tendons of the rotator cuff - or the small fluid-filled sac called the subacromial bursa — become pinched beneath the acromion. The acromion is the bony arch at the top of your shoulder blade that forms a roof over the rotator cuff tendons.

Think of it this way: your rotator cuff tendons pass through a narrow channel each time you raise your arm. When that space gets crowded — from inflammation, bone spurs, a naturally curved acromion, or thickened bursa — the tendons get squeezed. That pinching is impingement.

The rotator cuff itself is made up of four muscles: the supraspinatus, infraspinatus, subscapularis, and teres minor. Together, they keep your arm centered in the shoulder joint and power nearly every overhead movement you make. The supraspinatus tendon is the most commonly affected in impingement, as it sits directly beneath the acromion and bears the most mechanical stress during arm elevation.

Who Gets Shoulder Impingement - and Why

Athletes and Active Adults

Shoulder impingement is especially common among athletes who perform repetitive overhead motions. Swimmers, baseball pitchers, volleyball players, and tennis players put enormous cumulative stress on the rotator cuff. Over weeks or months, that repetitive motion creates the kind of low-grade inflammation that leads to impingement.

It's not limited to athletes, though. Painters, construction workers, drywall installers, and window washers - anyone whose job keeps their arms elevated for extended periods - face similar risk.

Age-Related Changes

As we get older, the tendons naturally lose some of their elasticity and become more vulnerable to irritation. Bone spurs can also form on the underside of the acromion, further narrowing the subacromial space. Some patients have an acromion that's slightly curved or hooked from birth, which places them at higher structural risk throughout their lifetime.

Sudden Trauma

Less commonly, a fall, car accident, or sports collision can cause acute impingement. In these cases, symptoms tend to come on more suddenly rather than building gradually over time.

Recognizing the Symptoms of Shoulder Impingement

Patients with shoulder impingement syndrome typically describe pain at the front of the shoulder that sometimes radiates down the side of the arm. The pain tends to be worse with certain movements, particularly:

• Reaching overhead or lifting the arm above shoulder height
• Raising and lowering the arm in a slow, controlled motion
• Reaching across the body or behind the back
• Lying on the affected shoulder at night

Night pain is one of the more frustrating aspects of this condition. Patients often tell me they can manage during the day but can't find a comfortable sleeping position. That disrupted sleep adds up quickly and affects quality of life well beyond just the shoulder itself.

If the impingement involves rotator cuff tendinitis specifically, you might also notice stiffness, mild swelling, and occasionally a clicking or popping sensation when moving the shoulder through its range of motion.

How Shoulder Impingement Is Diagnosed - Including the Hawkins-Kennedy Test

Diagnosis begins with a thorough physical examination and a detailed conversation about your symptoms, your activity level, and what you were doing when the pain first appeared. Imaging studies like X-rays and MRI are useful for ruling out other conditions — rotator cuff tears, biceps tendon injuries, shoulder arthritis — but the physical exam is where the diagnostic picture really comes into focus.

The Hawkins-Kennedy Test

One of the most valuable clinical tools for identifying shoulder impingement is the Hawkins-Kennedy Test, first described in 1980. This is a passive examination maneuver performed in the office, requiring no equipment or imaging.

Here's how it works: the examiner raises your arm to 90 degrees out in front of you, bends your elbow to 90 degrees, and then gently rotates your forearm downward - which internally rotates the shoulder. This specific movement forces the supraspinatus tendon directly against the underside of the acromion and the coracoacromial ligament. If that motion reproduces your familiar shoulder pain, the test is positive.

Research has demonstrated that the Hawkins-Kennedy Test carries a sensitivity of approximately 79%, making it one of the most reliable physical examination maneuvers for detecting subacromial impingement. Equally important from a clinical standpoint, a negative Hawkins-Kennedy result is statistically powerful enough to effectively rule out impingement syndrome in most patients.

Neer's Sign

Another commonly used test is Neer's Sign, in which the examiner stabilizes the shoulder blade and passively lifts the arm in the plane of the scapula with the arm internally rotated. Pain during this maneuver suggests impingement of the supraspinatus tendon beneath the acromion. Neer's test carries a sensitivity of around 72%. Used together, these two maneuvers give a much clearer picture than either test alone.

Imaging

X-rays help identify bone spurs, acromion shape, and signs of arthritis that might be contributing to the problem. MRI provides detailed views of the soft tissue, allowing us to assess the condition of the rotator cuff tendons and bursa and rule out partial or full-thickness tears that would change the treatment approach.

Treatment Options for Shoulder Impingement Syndrome

The majority of patients with shoulder impingement syndrome improve with conservative treatment. Surgery is reserved for cases where non-operative care has been given a genuine trial - typically three to six months - without sufficient relief.

Rest and Activity Modification

The first step is reducing the load on the inflamed tissues. That means stepping back from the activity or sport that triggered the problem, at least temporarily. This doesn't mean complete inactivity, but it does mean avoiding the specific movements that provoke pain while healing begins.

Physical Therapy

Physical therapy is the cornerstone of conservative treatment. A skilled therapist will design a program specifically aimed at strengthening the rotator cuff muscles, restoring normal range of motion, and correcting any muscular imbalances or posture problems that may have contributed to the impingement in the first place. Most patients start noticing meaningful improvement within several weeks of consistent therapy.

Anti-Inflammatory Medications

Over-the-counter NSAIDs - ibuprofen and naproxen - can reduce both pain and inflammation, particularly in the early stages of treatment. These should be used short-term and under the guidance of your provider, as prolonged use carries its own risks.

Corticosteroid Injections

When pain is severe enough to limit participation in physical therapy, a corticosteroid injection into the subacromial space can provide significant relief. Research has shown a meaningful correlation between a good response to subacromial injection and favorable outcomes following surgical decompression, which makes the injection useful both therapeutically and diagnostically.

Surgical Treatment

When conservative care doesn't provide adequate relief, arthroscopic subacromial decompression is an effective option. During this minimally invasive procedure, the surgeon removes a portion of the undersurface of the acromion and any bone spurs, creating more room for the rotator cuff tendons. In some cases, the bursa is also removed. Most patients are able to return to full activity following appropriate rehabilitation.

Why Early Evaluation Matters

Here's what I tell my patients who have been pushing through shoulder pain for months hoping it will resolve on its own: the longer impingement goes unaddressed, the greater the risk of progression. What begins as tendinitis - manageable inflammation of the tendon - can progress to partial tendon tearing and eventually to a full-thickness rotator cuff tear. Each stage is more complex to treat and requires a longer recovery.

If your shoulder pain is affecting your ability to work, exercise, or sleep, that's your body telling you something that deserves professional attention. A thorough orthopedic evaluation takes the guesswork out of it and gives you a clear path forward.

Shoulder Pain in the Nashville Area? Schedule an Evaluation

Dr. Cory Calendine is a board-certified orthopedic surgeon specializing in joint conditions of the hip and knee, with deep experience evaluating and treating shoulder pain in patients throughout Franklin, Brentwood, Nashville, and the surrounding Middle Tennessee region.

If you're dealing with persistent shoulder pain that's limiting your activity, don't wait for it to worsen. Contact our office to schedule a consultation and find out exactly what's causing your pain — and what can be done about it.

This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider regarding your specific condition.