Shoulder Impingement – Why This Is A Lazy & Unhelpful Diagnosis For You & Your Patient
Posted By: Andy Barker
I used to think it was and I admit I gave it to my patients and the athletes that I worked with as a diagnosis.
Day after day…
Week after week.
This was until I realised it’s not even a diagnosis.
And worse than that…
I started to find that giving my patients this inaccurate diagnosis was actually detrimental to my treatment plan and patient adherence!
Once I stopped giving this as a diagnosis I noticed a big change in patient understanding and adherence to my treatment planning…
Meaning quicker and more consistent results, even with tricky shoulder and hip cases.
In this blog I’ll show exactly why ‘impingement’…
– Is NOT a diagnosis and what it actually is
– Is a lazy diagnosis and what you should focus your and your patients attentions on instead
– Should never be used and how to give a diagnosis to a subacromial bursa or cuff issue (the injuries that you would normally call ‘impingement’) without a mention of the word impingement.
Why shoulder impingement is not a diagnosis
The reason you should not use ‘impingement’ as a diagnosis?
Because it is a mechanism NOT a diagnosis.
‘Impingement’ is describing what is happening at a joint.
Usually we see impingement at the shoulder and at the hip.
Regardless of where this impingement is happening it is not a diagnosis you should you and give to your patients.
A diagnosis is describing what structure is causing a patients problem.
Like an ACL injury (ligament), or shoulder ACJ (joint) or an Achilles injury (tendon).
The ‘diagnosis’ of impingement fails because it does not identify a specific structure.
It’s also important to remember that it is normal to ‘impinge’ at the end of range of any joint.
You are squashing tissues together between bony surfaces.
Try this yourself right now…
Take your arm…
Take it to 90 degrees shoulder flexion and then…
Maximally internally rotate your arm (take your hand towards the floor).
What have you just done?
You’ve just done a Hawkins-Kennedy test.
You have taken your glena-humeral joint to end range of shoulder internal rotation.
Or put simply…
You have just impinged your own shoulder.
For most of us, it feels uncomfortable, because it should.
Giving A Shoulder ‘Impingement’ Diagnosis Another Way
But what if your patient has positive impingement signs like pain with overhead activities…
Maybe a painful arc when you test flexion or abduction…
Or even pain with ‘impingement’ tests like the Hawkins-Kennedy or Empty Can test?
First of all…
Don’t label their injury as impingement as this is not a diagnosis.
You know doubt already know that differentiating between structures at the shoulder, and particularly within the subacromial space (bursa and cuff tendons) is almost impossible…
So why not tell your patient this?
Tell them that some of the structures between the ball and the socket joint of their shoulder that are irritated and that when they do x, y or z, these positions or movements put additional pressure on this region of the shoulder…
And this is why they are getting the symptoms they are getting.
Then focus on your patients problems.
Focus on the problems they have like the pain, the loss of range of movement (ROM) or reduced strength.
These problems require a solution.
These solutions are your treatment plan.
Your treatment plan is made up of your hands-on techniques and the rehab exercises to prescribe.
But What If My Patient Asks For A Diagnosis?
What do you do if your patients asks you directly for a diagnosis?
What if they say something like this…
‘So Andy, what is it exactly that is causing my shoulder pain?’
‘Is it a tendon, or muscle…’
‘I thought it might be the joint. Is that right?’
Tell them that it is likely to be their bursa or rotator cuff tendons that are causing their symptoms.
You might need to show them on a model or image to help explain what these things are.
Keep this explanation as broad and brief as possible.
Once this is done…
Focus your patients attention to their symptoms (their problems) like a loss of ROM or strength…
Then the solutions (your treatment plan).
This might sound something like this…
‘So Mrs Smith we have found that you struggle most with movements above your head, like putting dishes away in the cupboard at home…
Firstly, we want to reduce the pain in your shoulder to make those tasks easier for you to do and help you regain some of that lost movement in your shoulder…
I’ll start by doing some hands-on work around to the front of your shoulder to try to reduce your current pain and then after the will go through a couple of exercises you can do at home that will help continue your recovery.
Does this sound ok with you?’
Mrs Smith’s problem is putting the dishes away – or in physio terms, loaded overhead movement.
The solution is reducing her pain and restoring her lost ROM.
There was no diagnosis given to Mrs Smith…
Instead the focus was on the problems and how we were going to fix them (the treatment plan).
If you can understand that most patients don’t actually care about a diagnosis then you will find it much easier to keep your patients on track with their treatment plan…
And they will actually adhere to their home exercise plan!
Patient do not want a diagnosis.
They really don’t.
They just want to be fixed.
Mrs Smith does NOT care if he has a infraspinatus or subscapularis cuff injury or need to know she has sub-acromial bursitis…
She just wants to be able to lift her plates over her head after she’s washed them without getting pain in her shoulder.
If you feel sometimes confused with your patients shoulder assessment and unsure about what the diagnosis might be…
How do you think your patient feels?
Most patients have zero idea about what is actually going on with their injury and how to fix it, hence why they have come to see you.
They want some solutions to the problems they have and that is why overcomplicating it for your patient…
Telling them they have ‘bursitis’ or a ‘labrum’ issue only makes patients more confused and is not helpful.
It also makes you as their therapists often focus on the diagnosis rather than the solutions and how you are going to fix them.
Keep things simple.
Don’t feel like you have to give a diagnosis.
And if you do, quickly change your patients focus away from the diagnosis and to what they need to focus on to fix the problems they have.
If you can communicate this well to to your patients, using this simple problem and solution based method, patients will understand what you are saying…
They will understand how your treatments and rehab will actually help them get back to their job, activities or sports that they want to get back to.
When this happens it means patients will actually go away and doing their home exercise programme!
How good would that be!
How To Put This Into Action…
I know the shoulder can feel like struggle…
And that making a diagnosis and managing patients with shoulder issues can seem overwhelming at times.
Alongside injuries to the neck and lower back the shoulder is the joint I get asked about the most…
This is why I put together this FREE CPD resource…
The 5 Breakthrough Steps To Confidently Treat The Shoulder Right Every Time, Avoid Mistakes And Stop You Feeling Less Adequate Than Other New Grads
In this special resource you will also discover…
The #1 Reason Why New Grads Can’t Seem To Get The Right Diagnosis No Matter How Hard They Try!
Why You Should Never Trust People Who Tell You That The Shoulder Is ‘Complex’ And What You Should Do Instead
The Honest Truth About Getting Great Results With Shoulder Pain Patients And Why It Can Be So Much Easier Than You Ever Imagined!
And Much, Much More!
PS. Even though this is a ‘shoulder’ resource, all the content and everything you rehab can be applied to ALL your other joint assessments, treatments and rehab!
Get Your FREE COPY Right HERE.