Shoulder pain can make ordinary activities—reaching into a cabinet, putting on a jacket, lifting a child, exercising, or sleeping on your side—surprisingly difficult.
One common diagnosis is shoulder impingement, a term traditionally used when the rotator cuff tendons and nearby tissues become painful during lifting or overhead movement.
Although “impingement” may sound like a bone is simply pinching a tendon, the problem is usually more complex. Many clinicians now use terms such as rotator cuff–related shoulder pain or subacromial pain syndrome because tendon sensitivity, shoulder strength, activity level, movement patterns, and recovery capacity can all contribute.
The encouraging news is that most patients can improve without surgery.
Shoulder Pain by the Numbers
Shoulder pain affects approximately 1 in 6 people worldwide.
It is the third most common musculoskeletal complaint in primary care, after back and knee pain.
Impingement syndrome has historically been reported to account for approximately 44–65% of shoulder complaints seen in general practice.
Approximately 4 in 10 patients may continue to report symptoms one year after initially seeking care.
Most patients are initially treated without surgery, and exercise-based rehabilitation can improve pain and function.
What Is Shoulder Impingement?
The rotator cuff consists of four muscles and their tendons. Together, they help stabilize the shoulder and control movement of the arm.
Above the rotator cuff is the subacromial bursa, a small fluid-filled structure that helps reduce friction during movement. The tendons and bursa occupy an area beneath the upper portion of the shoulder blade, known as the acromion.
When these tissues become irritated or sensitive, movements such as reaching, lifting, pushing, or throwing can become painful.
Shoulder impingement is not always the result of a fixed structural blockage. Symptoms may be influenced by:
A sudden increase in lifting or overhead activity
Repetitive work above shoulder height
Throwing, swimming, racquet sports, or weight training
Rotator cuff weakness or reduced endurance
Limited shoulder or upper-back mobility
Inadequate recovery between activities
Returning to exercise after a period of inactivity
Age-related tendon changes
In many cases, the shoulder becomes painful when the demands placed on it exceed its current ability to tolerate those demands.
Patient Story: Shoulder Pain After Repetitive Lifting
A 47-year-old woman came to the Columbus Center for Sports and Regenerative Medicine with left shoulder pain.
She did not recall a fall, direct injury, or other trauma. However, she had recently performed repetitive lifting while helping with a garage sale.
She had already tried over-the-counter treatments and some home exercises without relief. She did not have pain radiating down the arm, numbness, or tingling.
Her experience illustrates how rotator cuff–related pain can begin without one major injury. An unfamiliar or repetitive activity may temporarily overload the shoulder and make the surrounding tissues increasingly sensitive.
What Does Shoulder Impingement Feel Like?
Symptoms may develop gradually or begin after a specific period of lifting, exercise, overhead work, or repetitive activity.
Common symptoms include:
- Pain along the front or outer side of the shoulder
- Pain when reaching overhead
- Discomfort while lowering the arm
- Pain when reaching behind the back
- Difficulty lifting weights or performing pushing exercises
- Pain when lying on the affected side
- Aching at night
- Reduced strength or endurance
Some patients experience a painful arc, meaning the shoulder hurts during a specific portion of arm elevation.
A painful arc commonly occurs while lifting the arm out to the side between approximately 60 and 120 degrees. The shoulder may feel less painful before or after that portion of the movement.
These symptoms are not unique to shoulder impingement. Rotator cuff tears, frozen shoulder, arthritis, biceps tendon problems, and conditions originating in the neck can cause similar complaints. An accurate clinical evaluation is therefore important.
What We Found During Her Examination
During the patient’s examination, she experienced a painful arc while lifting her arm out to the side between approximately 60 and 120 degrees.
She also had a positive empty-can test, which places demand on the supraspinatus portion of the rotator cuff, and a positive Hawkins test, which can reproduce pain arising from the rotator cuff or subacromial structures.
The combination of her history and examination supported a diagnosis of rotator cuff–related shoulder pain.
However, no single maneuver can confirm shoulder impingement by itself. Examination tests must be considered together with the patient’s symptoms, strength, range of motion, activity history, and neurologic findings.
Do You Need an X-Ray, Ultrasound, or MRI?
Not every patient with shoulder pain needs immediate imaging.
An X-ray may be appropriate when a clinician suspects arthritis, a fracture, calcium deposits, or another bone-related condition.
Diagnostic musculoskeletal ultrasound can evaluate the rotator cuff tendons, subacromial bursa, biceps tendon, and other structures in real time. It may help identify:
Rotator cuff tendinopathy
Partial- or full-thickness rotator cuff tears
Subacromial bursitis
Calcific tendinopathy
Biceps tendon abnormalities
An MRI may be considered after significant trauma, when there is substantial weakness, when a larger rotator cuff tear is suspected, or when symptoms continue despite an appropriate treatment program.
What MRIs Really Show
An abnormal MRI does not always explain why a shoulder hurts.
In a large population imaging study:
96% of completely pain-free shoulders had at least one rotator cuff abnormality on MRI.
99% of adults over age 40 had at least one rotator cuff abnormality, whether or not symptoms were present.
78% of full-thickness rotator cuff tears were found in shoulders with no pain.
These results do not mean MRI is unhelpful. They show why imaging must be interpreted in the context of the patient’s symptoms and examination.
A finding on a scan does not automatically identify the source of pain or determine whether surgery is necessary.
How Ultrasound Helped in This Case
A bedside musculoskeletal ultrasound examination was performed during the patient’s visit.
It did not show evidence of calcific tendinitis, a condition in which calcium deposits form within a rotator cuff tendon and may cause significant pain.
Because she had no significant trauma, neurologic symptoms, substantial weakness, or other concerning findings, an immediate MRI was not necessary.
Her ultrasound findings were interpreted together with her history and examination rather than being used as the sole basis for treatment.
How Is Shoulder Impingement Treated?
Most patients are initially treated without surgery.
Treatment should be individualized according to the severity of symptoms, examination findings, activity demands, medical history, and personal goals.
Modify Aggravating Activities
Complete rest is rarely necessary. Instead, the movements that repeatedly aggravate the shoulder may need to be temporarily modified.
This may involve:
Reducing overhead lifting
Decreasing exercise weight or volume
Adjusting throwing or swimming frequency
Avoiding repeated painful reaching
Using a more comfortable exercise range
Changing sleeping position
Allowing more recovery between sessions
The objective is not to avoid using the shoulder indefinitely. It is to reduce excessive irritation while preserving comfortable movement and gradually rebuilding capacity.
Begin Progressive Rehabilitation
Exercise-based rehabilitation is the foundation of treatment for rotator cuff–related shoulder pain.
A rehabilitation program may address:
Comfortable shoulder range of motion
Rotator cuff strength and endurance
Shoulder-blade strength and control
Scapular mobility
Upper-back mobility when appropriate
Progressive overhead tolerance
Work- or sport-specific demands
Research consistently supports exercise therapy for improving pain and function in people with rotator cuff–related shoulder pain.
Exercises should be selected and progressed according to the individual. A small amount of discomfort may sometimes be acceptable, but rehabilitation should not repeatedly cause severe pain or leave the shoulder substantially worse afterward.
Use Medication When Appropriate
Medication may be used for short-term symptom relief in selected patients.
Anti-inflammatory medications are not appropriate for everyone, particularly patients with certain kidney, gastrointestinal, cardiovascular, bleeding, or medication-related risks. Patients should discuss their individual risks with a qualified clinician.
Medication may make daily activity and rehabilitation more comfortable, but it does not replace shoulder strengthening and progressive return to activity.
Her Initial Treatment Plan
After discussing the available treatment options, the patient elected to begin with a nonsurgical approach.
She was prescribed a short course of scheduled medication to reduce pain and inflammation.
She was also given a structured home exercise program focused on:
Rotator cuff strengthening
Shoulder-blade control
Scapular mobility
Comfortable shoulder movement
Gradual return to lifting and exercise
The plan emphasized rebuilding the shoulder’s strength and tolerance rather than completely resting the arm.
Why Rotator Cuff and Shoulder-Blade Exercises Matter
The rotator cuff helps keep the ball of the shoulder centered within the socket during movement.
The muscles surrounding the shoulder blade help position the shoulder efficiently during reaching, lifting, pushing, pulling, and overhead activity.
When these muscles lack strength, endurance, or coordination, repetitive activities may place greater stress on sensitive shoulder tissues. Rehabilitation therefore commonly targets both the rotator cuff and the scapular stabilizers.
In one long-term study, patients completing a targeted rotator cuff and scapular exercise program were substantially less likely to select surgery than patients completing a more general exercise program.
What About a Cortisone Injection?
A corticosteroid injection into the subacromial bursa may provide short-term relief when pain interferes with sleep, daily function, or participation in rehabilitation.
However, an injection is not automatically required and does not address every contributing factor.
The GRASP trial, which included 708 patients, found that corticosteroid injection provided a modest benefit at eight weeks but no benefit at 12 months.
Corticosteroid injections alone have also not been shown to be more effective than physical therapy at mid- or long-term follow-up.
An injection may still have a role for selected patients, but it should usually support—not replace—a rehabilitation program. When an injection is appropriate, ultrasound guidance allows the physician to visualize the needle and target the intended location.
Does Shoulder Impingement Require Surgery?
Most patients with nontraumatic rotator cuff–related shoulder pain do not require surgery.
Surgical treatment may be appropriate when there is a significant traumatic tear, substantial persistent weakness, another structural condition requiring repair, or ongoing limitations despite an appropriate rehabilitation program.
For isolated subacromial pain, however, surgery has not consistently produced better outcomes than nonsurgical care.
The long-term follow-up of the FIMPACT trial found no meaningful benefit of arthroscopic subacromial decompression over placebo surgery for pain at rest or during arm activity.
A large systematic review similarly concluded that the added effects of surgery were too small to be clinically important when compared with physiotherapy alone.
These findings support a rehabilitation-first approach for most patients with nontraumatic impingement symptoms.
Age-Related Changes Are Common
Rotator cuff abnormalities become increasingly common with age, including among people who do not have shoulder pain.
Their prevalence rises from approximately 10% in people under age 20 to 62% in those over age 80.
Long-term studies also show that rotator cuff tears may progress over time in both painful and painless shoulders, regardless of whether surgery was performed.
These findings suggest that some rotator cuff changes reflect normal aging rather than a dangerous injury.
The goal should be to treat the patient’s pain and functional limitations—not simply the appearance of a tendon on a scan.
Can You Continue Exercising?
In many cases, yes, although the program may need to be temporarily adjusted.
Options may include:
Reducing the weight
Performing fewer sets or repetitions
Limiting the most painful range
Substituting a more comfortable exercise
Avoiding repeated training to failure
Allowing additional recovery
Gradually rebuilding overhead activity
Some patients may temporarily tolerate a landmine press, neutral-grip dumbbell press, or reduced-range exercise better than a traditional overhead press.
The correct modification depends on the diagnosis, symptoms, and activity goals.
Pain should not simply be ignored, but it also does not always mean that further tissue damage is occurring. A sports medicine evaluation can help determine an appropriate and productive activity level.
The Outcome: Pain-Free at Six Months
Six months after her initial visit, the patient had not experienced a return of her shoulder pain.
She was able to exercise, work, and complete her normal daily activities without limitations. She did not require an MRI, injection, or surgery.
Not every patient will recover in the same way or within the same timeframe. However, her experience illustrates an important principle: shoulder pain following repetitive overload can often improve through an accurate clinical evaluation, appropriate short-term symptom control, and progressive strengthening and mobility work.
She was advised to continue maintaining her shoulder strength and return for further evaluation if her symptoms recur.
CCSRM Evidence Pearls
Shoulder pain can develop after repetitive activity without a fall or traumatic injury.
A painful arc between approximately 60 and 120 degrees is commonly associated with rotator cuff–related shoulder pain.
MRI abnormalities are frequently present in people without pain.
Most patients improve with an individualized nonsurgical plan.
Rotator cuff and shoulder-blade strengthening can improve long-term function and reduce the likelihood of surgery.
Corticosteroid injections may offer short-term relief but are not a substitute for rehabilitation.
Subacromial decompression has not shown meaningful benefit over placebo surgery or physiotherapy for many patients with nontraumatic impingement symptoms.
Age-related tendon changes do not automatically require treatment or surgery.
When Should You See a Physician?
Schedule an evaluation when shoulder pain:
Persists despite modifying aggravating activities
Interferes with sleep
Limits work, exercise, or daily activities
Is accompanied by noticeable weakness
Continues to worsen
Returns whenever activity is resumed
Begins after a fall, collision, or sudden lifting injury
Seek more urgent medical evaluation if you cannot raise the arm after an injury, the shoulder appears deformed, there is significant swelling, or symptoms include progressive weakness, numbness, fever, chest pain, or shortness of breath.
Shoulder Pain Care at CCSRM
At the Columbus Center for Sports and Regenerative Medicine, we evaluate shoulder pain in athletes and active patients of all ages and activity levels.
Your visit may include:
A detailed sports medicine examination
Evaluation of shoulder strength, mobility, and mechanics
Review of your exercise, work, sport, and daily activity demands
Diagnostic musculoskeletal ultrasound when appropriate
A personalized nonsurgical treatment and rehabilitation plan
Ultrasound-guided procedures when medically indicated
Guidance for safely returning to exercise, work, or sport
The goal is not simply to identify an abnormality on a scan. It is to understand why your shoulder became painful and develop a plan that helps you return to the activities that matter to you.
Shoulder pain does not have to keep you from lifting, exercising, working, or participating in the activities you enjoy. Contact CCSRM to schedule a sports medicine evaluation.
Written by Ahmed Khan, MD, CAQSM
Board-certified. Sports and Regenerative Medicine Physician.
This article is intended for general educational purposes and does not replace an individualized medical evaluation, diagnosis, or treatment plan.
The patient story has been presented without identifying information. Individual outcomes vary, and this case should not be interpreted as a guarantee of results.
References and Further Reading
Lucas J, van Doorn P, Hegedus E, Lewis J, van der Windt D. A systematic review of the global prevalence and incidence of shoulder pain. BMC Musculoskeletal Disorders. 2022.
Consigliere P, Haddo O, Levy O, Sforza G. Subacromial impingement syndrome: management challenges. Orthopedic Research and Reviews. 2018.
Kuijpers T, van der Windt DAWM, van der Heijden GJMG, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004.
Pieters L, Lewis J, Kuppens K, et al. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. Journal of Orthopaedic & Sports Physical Therapy. 2020.
Holmgren T, Björnsson Hallgren H, Öberg B, Adolfsson L, Johansson K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome. BMJ. 2012.
Hopewell S, Keene DJ, Heine P, et al. Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP trial. The Lancet. 2021.
Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement. BMJ. 2018.
Karjalainen TV, Jain NB, Page CM, et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews. 2019.
Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of Shoulder and Elbow Surgery. 2014.
