Internal impingement is a spectrum of problems with the shoulder that usually only affects athletes involved in overhead sports.

Spectrum of problems with internal impingement

The findings in the shoulder of an athlete with internal impingement include partial tears of one of the rotator cuff tendons, a tear of the labrum, subtle anterior instability, and tightness of the posterior capsule. There is debate about the underlying cause. It is thought that either the microinstability or posterior capsular tightness causes the humeral head to rotate abnormally. When the shoulder is in an abducted and externally rotated position, the rotator cuff would be pinched between the labrum and humeral head. The portion of the tennis serve just before ball impact is an example of a shoulder position that can cause this type of pain in affected athletes.

Signs and symptoms of internal impingement

Athletes with internal impingement typically complain of pain in the back of the shoulder, especially when the shoulder is abducted and externally rotated. Even if the shoulder has some degree of instability, he or she usually denies feeling that the shoulder is popping out of place. A thorough exam can detect this subtle instability as well as any loss of motion. Decreased internal rotation from tightness of the posterior capsule is common.

Tennis player at risk for shoulder impingement

Treatment and return to sports

Nonoperative treatment is standard for early presentations of internal impingement. Ice, anti-inflammatory medications, and physical therapy are often successful. Rehab focuses on stretching the posterior capsule, strengthening the muscles around the shoulder blade, and improving shoulder function and mechanics.

If all of these approaches have been attempted extensively and the athlete is still limited with overhead activity, surgery may be necessary. Evaluation by a surgeon familiar with athletes’ injuries is helpful, as surgeries to clean out bone spurs and bursitis (as done with degenerative rotator cuff problems) usually is not helpful for internal impingement. Depending on the findings when examining the shoulder in surgery, treatment might involve repairing the torn labrum, cleaning up or fixing the partial rotator cuff tear, or tightening the capsule in the front of the shoulder. Fortunately, if a tennis player or other overhead athlete with shoulder pain seeks evaluation and treatment early, surgery for internal impingement can often be avoided.

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