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Shoulder Impingement (Internal)

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Original Editor - Joshua Caldwell, Phillip Williams, Gary Diekhoff, Bryan McAdams as part of the Texas State University Evidence-based Practice ProjectTop Contributors - Joshua Caldwell, Phillip Williams, Gary Diekhoff, Bryan McAdams, Ahmed M Diab, Rachael Lowe, Kim Jackson, Admin, Evi Jacobs, Deborah Huart, Mandeepa Kumawat, Tarina van der Stockt, Fasuba Ayobami, Ewa Jaraczewska, Katherine Knight, Naomi O'Reilly, Jess Bell, Alexandra Stead, WikiSysop, George Prudden, Simisola Ajeyalemi, Vidya Acharya, Wanda van Niekerk, Robin Tacchetti, Jelle Habay, Vijay Rajaram and Jeremy Brady

Introduction

Internal impingement is a common cause of posterior shoulder pain in overhead athletes.[1][2][3][4] It was originally described by Walch and colleagues as excessive or repetitive contact between the posterior aspect of the greater tuberosity of the humeral head and the posterosuperior glenoid rim when the arm is in extreme abduction and external rotation (ABER), the late-cocking position of throwing.[5] [6] In this position the articular surface of the rotator cuff (typically the posterior supraspinatus / anterior infraspinatus) and the posterosuperior labrum can be compressed between those bony surfaces.[7][8][9] Two topographic subtypes are recognised: posterosuperior internal impingement, which is by far the more common presentation in throwers, and anterosuperior internal impingement, which is uncommon.[9][10]

Clinically Relevant Anatomy

Internal impingement is an intra-articular, glenohumeral phenomenon. The relevant anatomy is the posterosuperior glenohumeral contact zone in ABER, not the coracoacromial arch. The coracoacromial arch and subacromial bursa are involved in the subacromial (external) impingement.[7][9] [11]

Glenohumeral structures of the contact zone

Greater tuberosity of the humerus: the posterior facet approximates the glenoid in ABER.[12]

Posterosuperior glenoid rim and labrum: the opposing surface; repetitive contact is associated with posterosuperior labral fraying and SLAP lesions.[9] [13][14]

Articular-sided rotator cuff: partial-thickness tears typically occur at the junction of the infraspinatus and supraspinatus insertions on the humeral head, on the articular (undersurface) rather than bursal side.[7] [8][15]

Posterior and posteroinferior capsule, including the posterior band of the inferior glenohumeral ligament (IGHL): contracture here is the tissue basis of GIRD and can alter the humeral head’s instant centre of rotation, driving posterosuperior translation in ABER.[13] [16]

Long head of biceps and superior labrum: the ''peel-back'' mechanism in ABER loads the posterosuperior labral biceps anchor.[9][13]

Scapulothoracic articulation

The scapulothoracic “joint” has no ligaments of consequence; stability is entirely muscular. Its orientation determines glenoid version in space and therefore whether ABER contact is physiological or excessive.[17] The muscles primarily controlling scapulothoracic motion include the serratus anterior, trapezius (upper, middle, and lower fibers), rhomboid major, rhomboid minor, levator scapulae, and pectoralis minor, while the latissimus dorsi contributes indirectly through its effects on humeral and trunk motion within the kinetic chain. This coordinated muscle activity provides the stability and mobility required for normal scapular kinematics.[18]

Serratus anterior and lower fibres of trapezius are the key upward rotators and are the most important scapulothoracic muscles for overhead function.[17][19]

Rotator cuff as glenohumeral stabilisers

The four RC tendons: subscapularis (anterior), supraspinatus (superior), infraspinatus (posterior) and teres minor (posterior) centre the humeral head and resist excessive anterior, posterior, superior or inferior translation.[7][20] In internal impingement, the lesion, when present, is articular-sided at the supra-/infraspinatus junction.[7]

Epidemiology

Internal shoulder impingement

Internal impingement of the shoulder is estimated to affect 44%–65% of all individuals experiencing shoulder pain.[21] The incidence of isolated internal impingement is not established: the syndrome overlaps with GIRD, SLAP lesions, partial articular-sided cuff tears and scapular dyskinesis, and it is diagnostically difficult.[7] [11] [22] The typical patient is an overhead or throwing athlete (baseball, tennis, volleyball, swimming, cricket, water polo) who repeatedly places the arm in external rotation and (hyper)abduction.[23] [13] Most published series describe elite baseball pitchers.[24] Non-elite athletes and non-athletes can be affected; in older non-athletic patients concurrent degenerative cuff or biceps pathology is more likely and should be sought.[7] [11]

Aetiology

Internal shoulder impingement is currently understood as a multifactorial condition rather than a purely structural impingement phenomenon.[5] It most commonly affects overhead athletes exposed to repetitive shoulder loading in positions of abduction and external rotation (ABER), such as baseball pitchers, tennis players, volleyball players, swimmers, and javelin throwers.[13] [23] During these movements, the articular side of the posterior rotator cuff (primarily the supraspinatus and infraspinatus) may come into contact with the posterosuperior glenoid and labrum. While this contact can occur physiologically, repetitive loading and accompanying biomechanical deficits can make it symptomatic.[4]

Symptomatic internal impingement develops through the interaction of several factors:

  • Glenohumeral Internal Rotation Deficit (GIRD): Repetitive overhead activity may lead to posterior capsular and posteroinferior shoulder tightness, reducing internal rotation. This can alter humeral head kinematics and increase posterosuperior contact during the late cocking phase of throwing. GIRD remains one of the most consistently reported findings associated with internal impingement.[25]
  • Posterior Capsular Contracture: Tightening of the posterior capsule can contribute to abnormal humeral head translation and increased shear forces on the posterosuperior labrum and under surface of the rotator cuff during overhead activity.[8]
  • Scapular Dyskinesis: Altered scapular positioning or movement affects glenoid orientation and shoulder stability, potentially increasing rotator cuff compression and mechanical stress. Scapular dyskinesis commonly coexists with internal impingement and is considered an important modifiable factor.[5][7] [8]
  • Microinstability and Excessive Anterior Humeral Translation: Repetitive throwing may produce subtle anterior capsular laxity and dynamic instability, allowing excessive humeral head motion. This can increase contact between the rotator cuff and glenoid during overhead movements.[26]
  • Adaptive Changes in Overhead Athletes: Sport-specific adaptations, including increased humeral retroversion, altered rotational range of motion, and changes in soft tissue stiffness, may contribute to the development of symptoms when they exceed the athlete's capacity for compensation.[27]

Clinical Presentation

History alone is a weak discriminator, symptoms are variable and often nonspecific.[5] Patients with internal impingement typically report chronic shoulder pain during overhead activities, particularly during movements requiring combined abduction and external rotation.[28] Symptoms are most frequently reported in overhead athletes, including baseball pitchers, tennis players, volleyball players, swimmers and other throwing athletes.[5]

Subjective Findings

Common symptoms include:

  • Deep, poorly localised posterior shoulder pain, particularly during the late cocking and early acceleration phases of throwing.[5]
  • Pain provoked by positions of abduction and maximal external rotation (ABER).[5]
  • Reduced athletic performance, including decreased throwing velocity, accuracy, endurance or control.[5][29]
  • Shoulder stiffness or perceived loss of motion, especially internal rotation.[5]

Physical Examination Findings

Clinical examination may reveal:

  • GIRD, characterised by reduced internal rotation on the dominant side compared with the contralateral shoulder.[30]
  • Increased external rotation range of motion, often as a sport-specific adaptation in overhead athletes.[31]
  • Posterior shoulder tightness and evidence of posterior capsular restriction.[32]
  • Scapular dyskinesis, including altered scapular positioning, reduced upward rotation or abnormal movement patterns during arm elevation. [33]
  • Rotator cuff weakness or fatigue, particularly involving the external rotators and scapular stabilisers.[34]

Associated Conditions

Internal impingement commonly coexists with:

  • Articular-sided partial-thickness tears of the supraspinatus or infraspinatus
  • Superior labrum anterior-to-posterior (SLAP) lesions.
  • Shoulder microinstability and anterior capsular laxity.
  • Scapular dyskinesis and SICK scapula syndrome.[5]

Kirchhoff and Imhoff topographic subtypes

The topographic subtypes described by Kirchhoff and Imhoff classify internal shoulder impingement according to the site of impingement within the glenohumeral joint and the structures affected.[9]

Subtype Contact Typical lesions
Posterosuperior (common) Articular cuff (posterior SS/anterior IS) against posterosuperior glenoid and labrum in ABER Articular-sided partial cuff tears, posterosuperior labral/SLAP lesion, GIRD, SICK scapula, Bennet lesion
Anterosuperior (uncommon) Articular subscapularis/biceps pulley against the anterosuperior glenoid in flexion-internal rotation Upper subscapularis and biceps pulley lesions; not the typical thrower's pattern

Differential Diagnosis

Contact findings described in internal impingement also occur in asymptomatic throwing shoulders.[11] Diagnosis therefore rests on the whole clinical picture: age, sport, symptom timing, disability, and whether the examination cluster is coherent.[5] Conditions that share the presentation, and that may coexist, include:

Diagnostic Procedures

Physical examination is essential for diagnosing impingement syndromes.[36] Imaging such as MRI[9] and radiographs, help in confirming the diagnosis and tracking treatment progress. Magnetic resonance imaging has been used frequently to diagnose pathologic conditions of the shoulder. Its sensitivity and specificity for the detection of labral tears and rotator cuff disease are on the order of ‡95%. Magnetic resonance imaging has the advantage of being able to detect intra-substance tears that may be difficult to visualize with arthroscopy. The findings of magnetic resonance imaging of patients with internal impingement are usually more subtle. Findings on magnetic resonance imaging of patients with internal impingement include mature periosteal bone formation at the scapular attachment of the posterior aspect of the capsule (The Bennet lesion) and moderate to severe posterior capsular contracture at the level of the posterior band of the inferior glenohumeral ligament.[8]

Outcome Measures

The following outcome measures can assist clinicians in evaluating pain, shoulder function and sport-specific performance in individuals with internal shoulder impingement:

  • Shoulder Disability Questionnaire (SDQ): The SDQ is a measure covering 16 items designed to evaluate functional status limitation in patients with shoulder disorders.[37] This questionnaire is a valid and reliable instrument.[37][38][39]
  • Shoulder Pain and Disability Index (SPADI): The SPADI developed by Roach et al., consists of a separate 5-item pain scale and an 8-item disability scale, with the preceding week as the recall frame.[37]The questionnaire was found to have good internal consistency, test re-test reliability, and criteria and construct validity in a sample of 37 male outpatients with shoulder complaints.[40][38][39]
  • Shoulder Rating Questionnaire (SRQ): Shoulder Rating Questionnaire by l'Insalata et al. consists of 19 items with a 5-point ordinal answer scale: 4 relate to pain, 6 to daily activities, 3 to recreational and athletic activities, 5 to work, and 1 to satisfaction. The Shoulder Rating Questionnaire also includes a visual analogue scale for global assessment, as well as an item to indicate the domain of most important improvement.[37][38]
  • Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score: An athlete-specific, 10-item patient-reported outcome measure developed for the overhead throwing athlete, with each item scored on a 10 cm visual analogue scale (total score 0-100, higher scores indicating better shoulder/elbow function). As internal impingement is predominantly a condition of overhead and throwing athletes, the KJOC has greater construct relevance to this population than the generic shoulder questionnaires above. It has been the subject of active cross-cultural validation work over the past five years, including Finnish, Greek and Japanese versions in overhead and collegiate baseball athletes, and has also been evaluated as a discriminative tool between throwing with and without pain in youth and high-school baseball athletes, although it was not originally validated for this younger age group.[41] [42] [43]

Other frequently used questionnaires to determine the progression of symptoms such as pain, disability and other outcomes include the following:

  • Simple Shoulder Test (SST)
  • Disabilities of the Arm, Shoulder and Hand (DASH)
  • Constant-Murley Scale (CMS)
  • Oxford Shoulder Instability Score (OSIS)
  • Western Ontario Shoulder Instability Index (WOSI): A 21-item, four-domain patient-reported outcome measure (physical symptoms, sport/recreation/work, lifestyle, emotional impact) originally developed for shoulder instability. Given the frequent coexistence of anterior microinstability with internal impingement in throwers, it may be a useful adjunct measure, though it currently lacks validation studies specific to the internal impingement population within the last five years.[44]

Examination and Clinical Findings

When evaluating a patient with suspected internal impingement syndrome, it is very important to get a thorough history, as it is an important element of the clinical diagnosis.[8] However, diagnosing internal impingement on the history alone is extremely difficult as symptoms tend to be variable and non-consistent.[7] 

Common examination findings in patients with internal shoulder impingement
Clinical technique Typical findings in internal impingement
Observation: posture, scapular position at rest and through elevation, muscle bulk, throwing-arm hang Dominant shoulder often lower, with increased bulk. Scapular malposition: protracted, anteriorly tilted, prominent inferior medial border (SICK pattern). Abnormal scapulohumeral rhythm on elevation[45]
Active and passive ROM: glenohumeral IR and ER at 90° abduction (total rotation arc), horizontal adduction, ABER symptom reproduction; cervical and thoracic motion GIRD: IR loss >20° versus the non-throwing side, often with a gain in ER. Total rotation deficit of >5° is a reported injury marker in pitchers.[46]
Joint accessory motion: glenohumeral, scapulothoracic, acromioclavicular, sternoclavicular Reduced dorsal (posterior) glenohumeral glide when the posterior capsule is tight.[47]
Strength: rotator cuff (especially ER at 0° and 90°), serratus anterior, middle and lower trapezius, rhomboids Weak external rotators, lower trapezius and serratus anterior are typical. Scapular-retractor fatigue reduces cuff force production[48]
Flexibility: posterior shoulder, pectoralis minor/major, latissimus, levator scapulae, upper trapezius, cervical and thoracic

SICK Scapula: Burkhart et al. have reported that scapular protraction is also a common finding in these patients.[7]   This is characterised by scapular malposition, a prominent inferior medial border, coracoid pain, and scapular dyskinesia, all of which can be picked up in the basic examination during palpation and observation of the scapula. Tyler et al. reported that scapular retractor muscle fatigue led to an overall decrease in force production of the rotator cuff muscles as well as the decreased strength of the scapular stabilisers.[49]

Tests for Internal Impingement

Special tests used in the assessment of internal shoulder impingement
Test Procedure and positive finding Accuracy notes
Posterior impingement sign (Meister) Arm passively placed in 90–110° abduction, 10–15° extension, and maximal external rotation. Positive = deep posterior shoulder pain. Sensitivity 75.5%, specificity 85% for articular-sided cuff tears and posterior labral lesions. A negative test is more useful for ruling out than a positive test is for ruling in. [50]
Relocation test Posterior shoulder pain in ABER that is relieved by a posteriorly directed force on the proximal humerus. Used as a supportive finding, not a stand-alone rule-in test. Distinguish from the apprehension/relocation pair used for anterior instability, where the relieved symptom is apprehension rather than posterior pain.[7] [10]

Tests for SLAP lesions, anterior laxity (apprehension, anterior release), and the subacromial impingement cluster may be positive or negative; there is no proven combination that identifies internal impingement, and concurrent pathology is the rule rather than the exception.[14] [51]

Tests for Associated Conditions

Tests for other shoulder pathologies may be positive or negative due to the variable clinical presentation of internal impingement.[52]

SLAP Lesions: Although the validity of physical examination tests used to detect SLAP lesions is controversial, the fact that these lesions are a common finding with internal impingement warrants the need to perform at least some combination of the following tests[53]:

Laxity of the anterior GH joint capsule: The following have proven diagnostic accuracy: Generally positive but may be negative

Medical Management

Conservative management of internal impingement is an appropriate initial approach, particularly in patients who do not report an acute traumatic event.[35] Medical management can be divided into non-surgical and surgical treatment.

Non-Surgical Treatment

Interventions that are recommended in the literature in early disease when the shoulder is stiff and can be poorly localised are:[8][35][54]

  • Rest
  • Ice (cryotherapy)
  • NSAID’s (or other oral-anti-inflammatory meds)
  • Corticosteroid injection[9]

All these interventions will be used in addition to a structured, supervised physical therapy regimen.[54]

Surgical Treatment

Surgery for internal impingement may be indicated if improvements have not been seen with a prolonged rehab protocol specifically designed to correct any impairments, imbalances, deficiencies and/or pathologic findings.[55]

The following are indications for surgical approach: [56]

  1. Failed nonoperative treatment
  2. Partial thickness rotator cuff tear (PASTA-Partial articular supraspinatus tendon avulsion) compromises the integrity of the rotator cuff
  3. Partial rotator cuff tears >50%
  4. Bennett lesion
  5. Peel-back labral lesion[57]
  6. SLAP lesion
  7. Dislocation

For the surgical treatment, There are a number of different surgical approaches typically used in the management of internal shoulder impingement, including:

  • Arthroscopic interventions[7]:is commonly performed when conservative management has failed and the underlying pathology has been clearly identified. The procedure allows direct visualisation of intra-articular structures and enables targeted treatment of associated lesions, such as rotator cuff pathology, labral injuries, capsular abnormalities, or impinging osseous changes. Surgical management should be tailored to the patient's symptoms, clinical findings, functional requirements, and the specific pathological findings identified during assessment.[7]
  • Subacromial decompression[58]
  • Debridement of rotator cuff tear[58]
  • Completion of rotator cuff tear by arthroscopic repair[58]

Physiotherapy Management

Prevention/Early Management

Athletes reporting shoulder tightness, stiffness, persistent loss of motion, pain, or an inability to "loosen up" during overhead activity should be clinically reassessed. Activity modification and targeted rehabilitation addressing posterior shoulder tightness, glenohumeral mobility deficits, scapular dysfunction, and kinetic-chain impairments may be indicated to reduce the risk of progression to shoulder pathology.[59][60][61] Internal impingement frequently exists along a spectrum of associated shoulder pathologies. Therefore, rehabilitation should begin with careful evaluation for glenohumeral instability, SLAP lesions, labral pathology, and partial-thickness articular-sided rotator cuff tears, as these conditions may influence prognosis, rehabilitation progression, and return-to-sport outcomes.[8][35]

Strengthening and Rehabilitation of the Shoulder

Shoulder rehabilitation should address the impairments contributing to internal impingement and progressively prepare the athlete for a safe return to activity. Key components are outlined below:

  • Progressive rotator cuff strengthening should focus on improving dynamic glenohumeral stability and humeral head centring during overhead movements. Both open and closed kinetic chain exercises may be incorporated according to the rehabilitation stage.[60]
  • Address glenohumeral internal rotation deficit (GIRD) through posterior shoulder mobility interventions, including cross-body stretching, sleeper stretching, manual therapy, and exercise programmes designed to restore total rotational motion.[59]
  • Improve posterior shoulder flexibility and reduce posterior shoulder tightness through targeted stretching and mobility interventions, as posterior shoulder tightness is recognised as a contributing factor to shoulder dysfunction in overhead athletes.[59]
  • Correct muscle imbalances and deficits in neuromuscular control through progressive strengthening and sensorimotor training of the shoulder complex. Rehabilitation should address deficits in coordination, movement quality, and force-couple function.[60]
  • Strengthen the scapular stabilisers, particularly the serratus anterior, middle trapezius, and lower trapezius, to improve scapular mechanics and optimise force transfer during overhead activity.[62]
  • Incorporate kinetic-chain rehabilitation, including trunk, hip, and lower-limb strengthening, as impairments throughout the kinetic chain may increase stress on the shoulder during throwing and other overhead sports.[63]
  • Progress to sport-specific rehabilitation, including an interval throwing programme once strength, range of motion, scapular control, and symptom resolution have been achieved. Rehabilitation should include monitoring of throwing volume and workload.[61]

Routine Management

Although the rehabilitation framework proposed by Ann Cools and colleagues[29] remains historically important, current management of internal shoulder impingement should be guided by contemporary evidence and an individualised impairment-based approach. Rehabilitation should address modifiable factors including glenohumeral internal rotation deficit (GIRD), posterior shoulder tightness, scapular dyskinesis, rotator cuff dysfunction, kinetic chain deficits, and sport-specific movement patterns. Treatment progression should be criterion-based and guided by symptom response, restoration of range of motion, strength, neuromuscular control, and functional performance.[60] In overhead athletes, rehabilitation should ultimately progress to sport-specific training and a graduated return-to-throwing or overhead activity programme. For non-athletic individuals, rehabilitation goals should be tailored to the functional demands of daily activities, occupation, and recreational pursuits rather than sport-specific performance requirements.[60][61]

Management of internal shoulder impingement is commonly structured into progressive rehabilitation phases, each with specific goals aimed at restoring pain-free function and facilitating a safe return to sport.

Phase 1 (Pain Reduction and Movement Restoration)
  • Patient education and activity modification to reduce provocative overhead loading.
  • Restore pain-free shoulder ROM, with particular attention to posterior shoulder tightness and GIRD (glenohumeral internal rotation deficit).[64]
  • Posterior shoulder stretching (cross-body stretch, sleeper stretch when appropriate) and manual therapy techniques targeting posterior capsule restrictions.[64][65]
  • Closed-chain stability exercises and proprioceptive training to enhance sensorimotor control and co-contraction of the rotator cuff and scapular stabilisers.[65]
  • Assessment and correction of kinetic chain deficits involving the trunk, pelvis, and lower extremities.[17]
Phase Two (Strengthening and Dynamic Control Phase)
  • Progress rotator cuff and scapular strengthening exercises according to symptom response and movement quality.[60]
  • Incorporate both open and closed kinetic chain exercises.[60]
  • Introduce eccentric loading and endurance-based training to prepare for the high demands of overhead activities.[60]
  • Continue management of GIRD and posterior shoulder tightness through stretching, mobility exercises, and manual therapy where indicated.[59]
  • Posterior shoulder flexibility should be monitored throughout rehabilitation to maintain shoulder rotational range of motion.[59]
  • Athletes should demonstrate satisfactory movement quality before progressing to higher-velocity overhead tasks.[61]
Phase Three: Functional Rehabilitation and Return to Sport
  • Continue progressive strengthening of the rotator cuff and scapular musculature, with emphasis on strength, endurance, dynamic stability, and neuromuscular control during sport-specific activities.[60]
  • Progress to advanced plyometric training, beginning with bilateral activities and advancing to unilateral drills as movement quality, strength, and symptom control improve. Exercises should gradually increase in speed, load, and sport-specific demands.[60][61]
  • Integrate kinetic-chain training to ensure efficient force transfer between the lower limbs, trunk, scapula, and upper extremity during overhead movements.
  • Introduce a graded return-to-throwing or overhead activity programme. Progression should be based on symptom response, restoration of shoulder range of motion, adequate strength, scapular control, and successful completion of functional performance tasks.[60][61]
  • Monitor training load and workload tolerance throughout the return-to-sport process to minimise reinjury risk and support successful return to performance.[61]

Additional Considerations

Rehabbing the GIRD Component:

Management of glenohumeral internal rotation deficit (GIRD) should begin during the initial stages of rehabilitation and continue throughout the treatment programme. Stretching interventions aimed at improving posterior shoulder soft-tissue flexibility are commonly incorporated into both treatment and prevention programmes for overhead athletes.[16]

Joint Mobilisations:

Glenohumeral anterior-posterior joint mobilisations may be used to address posterior capsule tightness and improve internal rotation range of motion. However, mobilisation techniques should be avoided in the presence of clinically significant instability. Grade IV end-range dorsal glide mobilisations are typically performed with the patient in supine lying, the shoulder positioned in 90° of abduction, and the humerus maintained in either neutral or end-range internal rotation.[29]

Thoracic and cervicothoracic manipulations:

Spinal manipulations can be used to improve mobility in these regions and have demonstrated beneficial short-term and long-term effects on pain and function in individuals with shoulder disorders.[66] [67] Several studies have shown a significant improvement in symptoms of shoulder impingement syndrome when a thoracic manipulation was combined with exercise. The benefits of a thoracic or cervicothoracic manipulation for internal impingement have yet to be studied, but based on the similar presentation of these two syndromes and the low-risk to benefit ratio of manipulation, these procedures may add a huge benefit to treatment.[66][67]

These interventions may provide additional clinical benefit when incorporated into a comprehensive rehabilitation programme, although their specific effects in internal shoulder impingement require further investigation.[66][67]

Whole-body kinetic chain:

Whole-body kinetic-chain exercises are commonly introduced early during rehabilitation to prepare the athlete for a return to sport-specific activity. Interventions may target core stability, lower-limb control, balance, and coordinated movement patterns to optimise force transfer throughout the kinetic chain. Examples include performing shoulder external rotation exercises while seated on an exercise ball or incorporating single-leg stance tasks during upper-limb strengthening exercises.[29]

The cross-body stretch is another popular stretch for the posterior capsule and can be performed by moving the arm into horizontal adduction. This stretch has been shown to be superior for stretching the posterior capsule and for increasing internal ROM. [68]

Clinical Bottom Line

Rehabilitation for internal impingement should consist of several critical interventions including reversing GIRD in those with posterior shoulder tightness, creating improved dynamic stabilisation of the glenohumeral joint through use of specific exercise techniques in those with hypermobility due to acquired instability, and developing neuromuscular control in those with scapular dyskinesis. Exercises should emphasise both scapular and rotator cuff muscle recruitment patterns in order to improve strength, endurance, and motor control.[69]Special attention should be paid to correction of GIRD through the “sleeper stretch” which allows posterior capsular stretching. In a study of high-level tennis players performing daily “sleeper stretch” exercises, patients were found to have significant increases in both internal rotation and total rotation, as well as a 38% decrease in the prevalence of shoulder problems.[5]

References

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  2. ↑ Chelli M, Grimberg J, Lefebvre Y, Peduzzi L, Hardy A, Sanchez M et al. Internal impingement of the shoulder: An international survey of 261 orthopaedic surgeons. Orthop Traumatol Surg Res. 2019;105(8S):S207-S212.
  3. ↑ Peduzzi L, Grimberg J, Chelli M, Lefebvre Y, Levigne C, Kany J et al. Internal impingement of the shoulder in overhead athletes: Retrospective multicentre study in 135 arthroscopically-treated patients. Orthop Traumatol Surg Res. 2019;105(8S):S201-S206.
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  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Corpus KT, Camp CL, Dines DM, Altchek DW, Dines JS. Evaluation and treatment of internal impingement of the shoulder in overhead athletes. World journal of orthopedics. 2016 Dec 18;7(12):776.
  6. ↑ Walch G, Boileau P, Noel E, Donell ST. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. Journal of shoulder and elbow surgery. 1992 Sep 1;1(5):238-45.
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 Heyworth BE, Williams RJ 3rd. Internal impingement of the shoulder. Am J Sports Med. 2009 May;37(5):1024-37.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 Drakos MC, Rudzki JR, Allen AA, Potter HG, Altchek DW. Internal impingement of the shoulder in the overhead athlete. J Bone Joint Surg Am. 2009 Nov;91(11):2719-28.
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  10. ↑ 10.0 10.1 Jobe CM, Coen MJ, Screnar P. Evaluation of impingement syndromes in the overhead-throwing athlete. J Athl Train. 2000 Jul;35(3):293-9.
  11. ↑ 11.0 11.1 11.2 11.3 Spiegl UJ, Warth RJ, Millett PJ. Symptomatic internal impingement of the shoulder in overhead athletes. Sports medicine and arthroscopy review. 2014 Jun 1;22(2):120-9.
  12. ↑ White EA, Skalski MR, Patel DB, Gross JS, Tomasian A, Heckmann N, Matcuk Jr GR. Isolated greater tuberosity fractures of the proximal humerus: anatomy, injury patterns, multimodality imaging, and approach to management. Emergency Radiology. 2018 Jun;25(3):235-46.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Kibler WB, Sciascia AD, Grantham WJ. The shoulder joint complex in the throwing motion. Journal of Shoulder and Elbow Surgery. 2024 Feb 1;33(2):443-9.
  14. ↑ 14.0 14.1 Kibler WB, Dome D. Internal impingement: concurrent superior labral androtator cuff injuries. Sports Med Arthrosc. 2012 Mar;20(1):30-3
  15. ↑ Fares MY, Lawand J, Daher M, Suarez JD, Kayepkian T, Koa J, Geagea E, Abboud JA. Glenohumeral internal rotation deficit: insights into pathologic, clinical, diagnostic, and therapeutic characteristics. Clinics in Shoulder and Elbow. 2024 Apr 4;27(4):505.
  16. ↑ 16.0 16.1 Minhaj S, Afridi ZK, Rubab S, Qazi Z, Siddiqui M. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: systematic review. Archives of Physical Medicine and Rehabilitation. 2025 Jan 1;106(1):91-7.
  17. ↑ 17.0 17.1 17.2 Kibler WB, Stone AV, Zacharias A, Grantham WJ, Sciascia AD. Management of scapular dyskinesis in overhead athletes. Operative techniques in sports medicine. 2021 Mar 1;29(1):150797.
  18. ↑ Kibler WB, Lockhart JW, Cromwell R, Sciascia A. Managing scapular dyskinesis. Physical Medicine and Rehabilitation Clinics. 2023 May 1;34(2):427-51.
  19. ↑ Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. British journal of sports medicine. 2014 Apr;48(8):692-7.
  20. ↑ Thacher RR, Varady NH, Khilnani T, Camp CL, Dines JS. Current concepts on the management of shoulder instability in throwing athletes. Current Reviews in Musculoskeletal Medicine. 2024 Sep;17(9):353-64.
  21. ↑ Emadi SP, Sohani SM, Salehi R, Darzi MT. Research Paper. Relationship Between Pain, Muscle Strength, Function, and Quality of Life in Overhead Players With Chronic Internal Shoulder Impingement. Function & Disability Journal 2024;7
  22. ↑ Lee J, Kim HP, Shon MS. Internal impingement of the shoulder in sports activity: common overuse injury. Arthrosc Orthop Sports Med 2023;10:55-66
  23. ↑ 23.0 23.1 Lin DJ, Wong TT, Kazam JK. Shoulder Injuries in the Overhead-Throwing Athlete: Epidemiology, Mechanisms of Injury, and Imaging Findings.Radiology 2018;286(2):370-87.
  24. ↑ Yanai T, Crotin R, Du T. Proximal to distal sequencing impacts on maximum shoulder joint angles and the risk of impingement in baseball pitching involving a scapular independent thoracohumeral model. Scandinavian Journal of Medicine & Science in Sports. 2023 Aug;33(8):1322-34.
  25. ↑ Jácome-López R, Tejada-Gallego J, Silberberg JM, García-Sanz F, San José FG. Treatment of glenohumeral internal rotation deficit in the general population with shoulder pain: An open single-arm clinical trial. Medicine. 2023 Sep 22;102(38):e35263.
  26. ↑ Arguello AM, Till SE, Reinholz AK, Okoroha KR, Barlow JD, Camp CL. Managing shoulder instability in the overhead athlete. Current Reviews in Musculoskeletal Medicine. 2022 Dec;15(6):552-60.
  27. ↑ Arguello AM, Till SE, Reinholz AK, Okoroha KR, Barlow JD, Camp CL. Managing shoulder instability in the overhead athlete. Current Reviews in Musculoskeletal Medicine. 2022 Dec;15(6):552-60.
  28. ↑ Al Hammadi MI, Shah ZA, Rathod RK, Seddik MA, Hammadi MI, Shah ZA. Shoulder impingement pain syndrome: pathophysiology, diagnosis, and a review of current treatment strategies. Cureus. 2025 Sep 11;17(9).
  29. ↑ 29.0 29.1 29.2 29.3 Cools AM, Declercq G, Cagnie B, Cambier D, Witvrouw E. Internal impingement in the tennis player: rehabilitation guidelines. British journal of sports medicine. 2008 Mar;42(3):165-71.
  30. ↑ Rose MB, Noonan T. Glenohumeral internal rotation deficit in throwing athletes: current perspectives. Open access journal of sports medicine. 2018 Mar 19:69-78.
  31. ↑ Wilk KE, Obma P, Simpson CD, Cain EL, Dugas J, Andrews JR. Shoulder injuries in the overhead athlete. Journal of orthopaedic & sports physical therapy. 2009 Feb;39(2):38-54.
  32. ↑ Mihata T, Gates J, McGarry MH, Neo M, Lee TQ. Effect of posterior shoulder tightness on internal impingement in a cadaveric model of throwing. Knee Surgery, Sports Traumatology, Arthroscopy. 2015 Feb;23(2):548-54.
  33. ↑ Roche SJ, Funk L, Sciascia A, Kibler WB. Scapular dyskinesis: the surgeon’s perspective. Shoulder & Elbow. 2015 Oct;7(4):289-97.
  34. ↑ Zago M, Kawczyński A, Klich S, Pietraszewski B, Galli M, Lovecchio N. Fatigue-induced scapular dyskinesis in healthy overhead athletes. Frontiers in bioengineering and biotechnology. 2020 Apr 21;8:302.
  35. ↑ 35.0 35.1 35.2 35.3 Behrens SB, Compas J, Deren ME, Drakos M. Internal impingement: a review on a common cause of shoulder pain in throwers. The physician and sportsmedicine. 2010 Jun 1;38(2):11-8.
  36. ↑ Andrew D, Chhabra A. Imaging of Shoulder Impingement Syndrome. InImaging of the Shoulder: Techniques and Applications 2025 Feb 4 (pp. 193-216). Cham: Springer Nature Switzerland.
  37. ↑ 37.0 37.1 37.2 37.3 Heijden van der GJ, Leffers P, Bouter LM. Shoulder Disability Questionnaire design and responsiveness of a functional status measure. J Clin Epidemiol 2000;53 (1): 29-38
  38. ↑ 38.0 38.1 38.2 Paul A, et al. A comparison of four shoulder-specific questionnaires in primary care. Ann Rheum Dis 2004;63:1293-1299.
  39. ↑ 39.0 39.1 Bot SD, Terwee CB, van der Windt DA, Bouter LM, Dekker J, de Vet HC. Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Ann Rheum Dis. 2004 Apr;63(4):335-41.
  40. ↑ Croft P, Pope D, Zonca M, O'Neill T, Silman A. Measurement of shoulder related disability: results of a validation study. Ann Rheum Dis. 1994 Aug;53(8):525-8.
  41. ↑ Sukanen M, Pajari J, Äyrämö S, Paloneva J, Waller B, Häkkinen A, Multanen J. Cross-cultural adaptation and validation of the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score in Finnish-speaking overhead athletes. BMC Sports Science, Medicine and Rehabilitation. 2022 Nov 7;14(1):190.
  42. ↑ Paraskevopoulos E, Plakoutsis G, Papandreou M. Cross-cultural adaptation and validation of the Greek version of the Kerlan-Jobe orthopaedic clinic shoulder and elbow score in Greek overhead athletes. F1000Research. 2023 May 15;12:498.
  43. ↑ Sasagawa K, Kawabata M, Takaki N, Tsuruike M, Ellenbecker TS, Tsuihiji Y, Watanabe H, Takahira N, Hirose N. reproducibility and validity of the Kerlan-Jobe orthopedic clinic shoulder and elbow score (Japanese version). Cureus. 2024 Apr 27;16(4).
  44. ↑ Cheewakongkiat P, Cheevasuvit F, Kulkamthorn N. Validity of the Thai version of the Western Ontario shoulder instability index in shoulder instability. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology. 2026 Jul 1;45:50-4.
  45. ↑ Kibler BW, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. JAAOS-journal of the American academy of orthopaedic surgeons. 2012 Jun 1;20(6):364-72.
  46. ↑ Wilk KE, Macrina LC, Fleisig GS, Porterfield R, Simpson CD, Harker P, Paparesta N, Andrews JR. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. The American journal of sports medicine. 2011 Feb;39(2):329-35.
  47. ↑ Myers JB, Oyama S, Wassinger CA, Ricci RD, Abt JP, Conley KM, Lephart SM. Reliability, precision, accuracy, and validity of posterior shoulder tightness assessment in overhead athletes. The American Journal of Sports Medicine. 2007 Nov;35(11):1922-30.
  48. ↑ Tyler TF, Cuoco A, Schachter AK, Thomas GC, McHugh MP. The effect of scapular-retractor fatigue on external and internal rotation in patients with internal impingement. Journal of Sport Rehabilitation. 2009 May 1;18(2):229-39.[1]
  49. ↑ Tyler T, Nicholas S, Lee S, Mullaney M, McHugh M. Correction of Posterior Shoulder Tightness is Associated with Symptom Resolution in Patients with Internal Impingement. American Journal of Sports Medicine 2010;38:114-120
  50. ↑ Meister K, Buckley B, Batts J. The posterior impingement sign: diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. American journal of orthopedics (Belle Mead, NJ). 2004 Aug 1;33(8):412-5.
  51. ↑ Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database of Systematic Reviews. 2013(4).
  52. ↑ Leschinger T, Wallraff C, Müller D, Hackenbroch M, Bovenschulte H, Siewe J. Internal impingement of the shoulder: a risk of false positive test outcomes in external impingement tests?. BioMed research international. 2017;2017(1):2941238.
  53. ↑ Familiari F, Huri G, Simonetta R, McFarland EG. SLAP lesions: current controversies. EFORT open reviews. 2019 Jan 28;4(1):25-32.
  54. ↑ 54.0 54.1 Spiegl UJ, Warth RJ, Millett PJ. Symptomatic internal impingement of the shoulder in overhead athletes. Sports Med Arthrosc Rev. 2014 Jun;22(2):120-9.
  55. ↑ Lazarides AL, Alentorn-Geli E, Choi JH, Stuart JJ, Lo IK, Garrigues GE, Taylor DC. Rotator cuff tears in young patients: a different disease than rotator cuff tears in elderly patients. J Shoulder Elbow Surg. 2015 Nov;24(11):1834-43.
  56. ↑ Kirchhoff C, Imhoff AB. Posterosuperior and anterosuperior impingement of the shoulder in overhead athletes—evolving concepts. International orthopaedics. 2010 Oct 1;34(7):1049-58.
  57. ↑ Internal Impingement https://www.orthobullets.com/shoulder-and-elbow/3054/internal-impingement (last assessed 11th november 2018)
  58. ↑ 58.0 58.1 58.2 Greiwe RM, Ahmad CS. Management of the throwing shoulder: cuff, labrum and internal impingement. Orthop Clin North Am. 2010 Jul;41(3):309-23.
  59. ↑ 59.0 59.1 59.2 59.3 59.4 Fukushima Y, Avilineni M, Kao M, Tirmizey H, Faber KJ, Furtado R, Sadi J. An evidence-informed rehabilitation management framework for posterior shoulder tightness: A scoping review. Shoulder & Elbow. 2024 Mar;16(1_suppl):74-88.
  60. ↑ 60.00 60.01 60.02 60.03 60.04 60.05 60.06 60.07 60.08 60.09 60.10 Sciascia AD. Rehabilitation of the painful shoulder. Journal of Shoulder and Elbow Surgery. 2024 Feb 1;33(2):494-506.
  61. ↑ 61.0 61.1 61.2 61.3 61.4 61.5 61.6 Schwank A, Blazey P, Asker M, Møller M, Hägglund M, Gard S, Skazalski C, Andersson SH, Horsley I, Whiteley R, Cools AM. 2022 Bern consensus statement on shoulder injury prevention, rehabilitation, and return to sport for athletes at all participation levels. journal of orthopaedic & sports physical therapy. 2022 Jan;52(1):11-28.
  62. ↑ Schory A, Bidinger E, Wolf J, Murray L. A systematic review of the exercises that produce optimal muscle ratios of the scapular stabilizers in normal shoulders. International journal of sports physical therapy. 2016 Jun;11(3):321.
  63. ↑ Borms D, Maenhout A, Cools AM. Incorporation of the kinetic chain into shoulder-elevation exercises: does it affect scapular muscle activity?. Journal of Athletic Training. 2020 Apr 1;55(4):343-9.
  64. ↑ 64.0 64.1 Minhaj S, Afridi ZK, Rubab S, Qazi Z, Siddiqui M. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: systematic review. Archives of Physical Medicine and Rehabilitation. 2025 Jan 1;106(1):91-7.
  65. ↑ 65.0 65.1 Swanson BT, Hagenbruch M, Lapaan B, Skipalskiy K. Combined Effects of Glenohumeral Mobilization, Stretching, and Thoracic Manipulation on Shoulder Internal Rotation Range of Motion. International Journal of Sports Physical Therapy. 2024 Apr 1;19(4):394.
  66. ↑ 66.0 66.1 66.2 Cite error: Invalid <ref> tag; no text was provided for refs named :20
  67. ↑ 67.0 67.1 67.2 Cite error: Invalid <ref> tag; no text was provided for refs named Boyles
  68. ↑ McClure P, Balaicuis J, Heiland D, Broersma M, Thorndike C, Wood A. A Randomized Controlled Comparison of Stretching Procedures for Posterior Shoulder Tightness. Journal of Orthopaedic and Sports Physical Therapy. (2007) 37:108-114
  69. ↑ Robert C. Manske, Meggan Grant-Nierman,Brennen Lucas Clinical Commentary Shoulder Posterior Internal Impingement in the Overhead Athelete The International Journal of Sports Physical Therapy | Volume 8, Number 2 | April 2013 |
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