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Shoulder Impingement and Tendonitis

Diagram of a Normal Shoulder

Injury Description

Also referred to as “swimmer’s shoulder”, shoulder impingement and the resulting tendonitis is one of the most commonly occurring injuries in sports. Especially common in sports where the arm is used in an overhead motion (i.e. swimming, baseball), the pain is usually felt on the tip of the shoulder or part way down the shoulder muscle.  Pain is triggered when the arm is lifted overhead or twisted in a certain direction.  In extreme cases, pain will be present at all times and may even wake the injured individual from a deep sleep.  Throwing overhand or working overhead may become impossible.


The tendons of the muscles that lift the arm, and the associated bursa (fluid filled sac that prevents friction) pass through a very tight channel of bone in the shoulder (see diagram).  When the arm is raised, this channel becomes compressed, which applies pressure on the soft tissues that pass through it.  When the arm is used overhead, it can bring the asymmetric bony prominence of the upper arm (humerus) to pinch or “impinge” against the roof of the shoulder joint.  This pinch inflames the rotator cuff and leads to tendonitis.  If left too long, shoulder impingement can actually result in a tear of the rotator cuff.

Diagram of Shoulder Tendonitis Caused by Overuse

Predisposing Factors

  • Overuse: This is the most common cause of the problem. Repetitive overhead motions routinely pinch tendons passing through the shoulder and inflame the rotator cuff

  • Weak Muscles: When the muscles are weak, more force is exerted on the tendons and bursae, causing inflammation and pain (tendonitis, bursitis)

  • Technique: Improper or inappropriate swimming or throwing techniques

  • Strenuous Training: One hard throw may start the problem

  • Previous Injury: Pre-existing injuries or conditions in the shoulder

  • Alignment: Loose shoulder joints may make some patients more susceptible

  • Bone Spurs: Impingement of osteophytes (bone spurs) on the shoulder joint causing impingement syndrome


Rest: Use pain as your guide.  You are only aggravating the condition if you continue activity while experiencing pain.  In extreme cases, you should refrain from using your arm for daily activities like lifting a briefcase or opening doors.
Ice: In the early stages, apply ice (frozen peas work great) to your shoulder twice a day for 15 minutes.  Always apply ice for 15 minutes after any activity that uses your arm.
Range: When use of your arm is limited, range exercises must be done twice daily.  Bend at the waist and let your arm hang down.  Then make large circles with your arm.  These pendulum exercises will prevent your shoulder from becoming stiff or “freezing up”.
Physiotherapy: The physiotherapist will initially try to reduce the inflammation in your shoulder.  Later, therapy will be designed to strengthen the shoulder to prevent the problem from recurring.
Medication: Your doctor may prescribe anti-inflammatory medications.   These make up a very important part of treatment.
Cortisone: In certain circumstances, an injection of cortisone into the shoulder may be used.  This is usually done as a secondary treatment to supplement therapy.  After an injection you should not attempt any vigorous activity for 7-10 days.
Surgery: Occasionally surgery is required to treat this condition.  If calcium deposits occur or bone spurs are present, surgery may be necessary to correct these problems.

Risks include stiffness, infection, nerve & blood vessel damage, bleeding, persistent symptoms, phlebitis, anesthetic problems, pneumonia, etc.   MAKE SURE YOU UNDERSTAND ALL OF THESE PRIOR TO SURGERY.

Rotator Cuff Tears: If the muscle is found to be torn at arthroscopy, an open incision may be required to repair the rotator cuff.


General Principles
It is the overhead motion of the arm that aggravates this condition.  In severe cases, all sports using the arm should be avoided.   When returning to sport, athletes should go back carefully. Take it easy initially and limit the duration of playing time.  Slowly increase the intensity of activities as the strength of your arm improves.  In some sports like tennis or squash, you can even learn new techniques to use to avoid the troublesome overhead motions.

Throwing Sports
Initially, an underhand or side-arm throw will be easier than an overhand throw.  Make sure to warm up well first.  Start nice and easy with a casual soft toss before gradually increasing to harder throws.  Try and maintain a smooth throwing motion, as this will use more of your body strength and relieve the pressure on the shoulder.

Breast stroke or side stroke will be easier than front crawl or butterfly strokes.  Sometimes the back stroke causes less pain.   Perform any sprints early in your swimming workout before you are fatigued.  Consult a swimming coach to see if a change of your swimming style can help relieve the problem.


Do not attempt exercising while the pain is severe.   After the pain has subsided, it is of utmost importance to strengthen the shoulder muscles in order to prevent the condition from recurring.  Exercises will be taught to you by your physical therapist.


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