If you have pain when lifting your arm, reaching overhead or lying on your shoulder, you may have been told you have ‘shoulder impingement’.
Traditionally, this was explained as a tendon or bursa being ‘pinched’ between the bones of the shoulder. It is an intuitive explanation – but modern research suggests the story is more complex.
Your pain is real, and the tissues around the shoulder can become sensitive. However, the idea that shoulder pain is simply caused by something being mechanically trapped or squashed is not well supported by current evidence.
Terms such as rotator cuff-related shoulder pain, rotator cuff tendinopathy and subacromial pain are increasingly used instead.
What is shoulder impingement?
The traditional model suggested that when you lift your arm, the space beneath the acromion – part of your shoulder blade – becomes smaller, compressing the rotator cuff tendons or nearby bursa.
In simple terms:
Less space → more pinching → irritated tissue → shoulder pain.
This theory influenced treatment for decades, including exercises intended to ‘open up’ the space and surgery to remove bone and create more room.
The problem is that shoulder pain does not behave as neatly as this model predicts.
Is something really being pinched?
Structures around the rotator cuff experience compression and load during normal shoulder movement. That does not necessarily mean those forces are harmful or causing your pain.
One of the strongest challenges to the traditional impingement model comes from studies of subacromial decompression surgery.
This surgery aims to create more space beneath the acromion. If mechanical pinching were the main cause of pain, this should provide a meaningful benefit.
However, placebo-controlled surgical trials have not shown this.
The CSAW trial found that decompression surgery did not provide a clinically important advantage over arthroscopy without the decompression itself.
Similarly, the FIMPACT trial found no meaningful benefit from decompression over placebo surgery. At its 10-year follow-up, decompression was still no better than placebo surgery or exercise therapy.
This does not mean compression never occurs. Rather, it challenges the idea that creating more space is the key to resolving this type of shoulder pain.
So what causes rotator cuff-related shoulder pain?
There is unlikely to be one single cause.
Symptoms may be influenced by a combination of factors, including:
- changes in physical activity or training
- doing more than the shoulder is currently accustomed to
- sensitivity of the rotator cuff and surrounding tissues
- age-related and load-related tendon changes
- previous injuries
- sleep, stress and general health
- the demands of your work or sport.
For this reason, treatment is usually more useful when it focuses on your symptoms, physical capacity and goals, rather than trying to identify one structure being ‘pinched’.
What about shoulder weakness?
People with shoulder pain can certainly produce less force during strength testing, but that does not necessarily mean weakness caused their pain.
A 2026 perspective paper by Cook, Lewis and Powell questioned the assumption that rotator cuff-related shoulder pain occurs because the shoulder is weak, or that becoming stronger is necessarily why rehabilitation works.
Pain itself can influence how much force someone produces during strength testing, and improvements in pain and function do not always correspond with large changes in measured strength.
That does not mean strength is unimportant. Greater strength can be very useful for work, sport and everyday function.
The distinction is that:
a strength deficit does not necessarily explain why your shoulder became painful, and strength gains are not necessarily the only reason rehabilitation helps.
Is there a test for shoulder impingement?
Tests such as the Hawkins–Kennedy, Neer and painful arc tests are commonly used during shoulder assessments.
They may provide useful information, but no single test can prove that a tendon is being pinched.
Current guidelines recommend interpreting these tests alongside your history and broader physical examination rather than relying on one test alone.
Do I need a scan?
Usually not straight away.
Current guidelines recommend against routinely using imaging simply to confirm rotator cuff tendinopathy during initial management.
Scans can show changes in tendons and other structures, but these findings do not necessarily explain your pain.
Imaging may be more appropriate following significant trauma, when another condition is suspected, or when symptoms are not improving as expected.
How does physiotherapy help?
Modern physiotherapy is less about trying to physically ‘open up’ the shoulder and more about helping you understand your symptoms, remain active and progressively return to the things you want to do.
1. Understand your shoulder pain
Being told that a tendon is repeatedly being pinched or damaged whenever you lift your arm can understandably make movement feel threatening.
A more useful explanation is that painful movement does not necessarily mean you are causing further damage.
Your physiotherapist can also assess whether your symptoms fit a common rotator cuff-related presentation or whether something else requires investigation.
2. Modify aggravating activities
Complete rest is rarely the long-term solution.
If certain movements are very painful, temporarily adjusting their load, range, volume or frequency can help settle symptoms while keeping you active.
The goal is then to gradually build those activities back up.
3. Use exercise to improve function and capacity
Exercise remains a key treatment for rotator cuff-related shoulder pain.
Depending on your symptoms and goals, rehabilitation might include:
- rotator cuff exercises
- pushing and pulling
- reaching and lifting
- overhead exercise
- work-specific or sport-specific movements.
There is no single best set of ‘shoulder impingement exercises’ for everyone, though a physio’s ranked list of shoulder exercises can be a useful starting point.
Exercise also does not need to be explained simply as correcting a weak or faulty shoulder. It may help by improving physical capacity, confidence with movement and tolerance of the activities you need to perform.
The large GRASP trial also found that a more intensive supervised progressive exercise program was not superior over 12 months to good-quality physiotherapy advice with a home exercise program.
Rehabilitation therefore does not necessarily need to be complicated to be effective.
4. Return to what matters to you
The ultimate goal is not a perfect test result – it is getting back to what you want to do.
That might mean reaching into a cupboard, returning to the gym, swimming, playing tennis or repeatedly working overhead.
Rehabilitation should gradually become specific to those demands.
What about hands-on treatment?
Manual therapy may provide short-term symptom relief for some people, but it does not need to be explained as putting the shoulder back into place or releasing an impingement.
If hands-on treatment helps you move more comfortably, it can be useful as an adjunct. Active rehabilitation remains the foundation of treatment.
Frequently Asked Questions
Is shoulder impingement a real condition?
The pain is real, but the traditional explanation is probably too simplistic.
Shoulder structures experience compression during normal movement, but current evidence does not support assuming that pain is simply caused by a tendon being pinched beneath the acromion.
Should I avoid overhead movements?
Usually not permanently.
If overhead movements are very painful, temporarily reducing their load, volume or range can help. The longer-term aim is generally to gradually restore your ability to use your arm overhead.
What are the best shoulder impingement exercises?
There is no single best exercise.
Your exercises should reflect your symptoms, current capacity and goals. Someone returning to swimming, for example, may need a different program from someone who simply wants to reach comfortably overhead.
Should shoulder exercises hurt?
Some discomfort during rehabilitation can be acceptable.
Pain does not automatically mean you are damaging your shoulder. However, exercises should be adjusted if they consistently aggravate your symptoms or leave you significantly worse afterwards.
Do I need to strengthen my rotator cuff?
Rotator cuff strengthening can be useful, particularly when strength is relevant to your goals.
However, shoulder pain does not automatically mean your rotator cuff is weak, and weakness does not necessarily explain why you developed pain.
Do I need an MRI?
Usually not at the beginning.
Imaging may be useful following significant trauma, when another condition is suspected, or when symptoms are not improving as expected.
Will a cortisone injection fix shoulder impingement?
A corticosteroid injection may provide short-term pain relief for some people, but it does not ‘fix’ an underlying impingement and is not considered first-line treatment for rotator cuff tendinopathy.
Do I need surgery?
For subacromial pain syndrome, current evidence does not show a meaningful benefit from subacromial decompression surgery over placebo surgery or exercise therapy.
Other shoulder problems – such as some traumatic rotator cuff tears or instability – are different and may require specialist assessment.
How long does it take to improve?
There is no single timeline.
Recovery depends on how long you have had symptoms, their severity, your general health and the activities you need to return to.
Rather than focusing on an exact number of weeks, look for gradual improvements in pain, function and what your shoulder can tolerate.
The bottom line
‘Shoulder impingement’ remains a common term, but the traditional idea that shoulder pain is simply caused by a tendon being pinched underneath a bone is not well supported by modern evidence.
Placebo-controlled surgical trials provide a particularly strong challenge to this model: surgically creating more space beneath the acromion has not produced better outcomes than placebo surgery.
At the same time, we should avoid replacing one overly simple explanation with another. Your shoulder is not necessarily painful because it is ‘weak’, just as it is not necessarily painful because something is being ‘pinched’.
For most people with rotator cuff-related shoulder pain, rehabilitation is therefore less about correcting one faulty structure and more about:
understanding the problem, staying active, managing aggravating activities, using exercise appropriately and gradually returning to the things that matter to you.
If shoulder pain is limiting your work, training, sport or everyday activities, a physiotherapist can assess your shoulder, determine whether further investigation is needed and develop an individualised rehabilitation plan.
This content provides general information only and is not a substitute for individual medical or physiotherapy advice.
References
- 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. The Lancet. 2018.
- Cook T, Lewis JS, Powell J. Rethinking strength testing in rotator cuff-related shoulder pain: a clinical tradition that lacks muscle. Journal of Manual & Manipulative Therapy. 2026.
- Desmeules F, Roy J-S, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care and Rehabilitation: A Clinical Practice Guideline. Journal of Orthopaedic & Sports Physical Therapy. 2025.
- Hopewell S, Keene DJ, Heine P, et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP). The Lancet. 2021.
- Kanto K, 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.
