Internal Impingement Shoulder

Cause Of Shoulder Pain In The Throwing Athlete

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Internal impingement is a specific type of shoulder injury that is seen primarily in throwing athletes. Internal impingement consists of injury to the following structures:

  • The posterior labrum
    The labrum in the posterior-superior region of the shoulder is often frayed or partially torn. In more severe cases, the tear can extend up towards the attachment of the biceps tendon, a so-called SLAP tear.

The problem is caused from pinching of the tuberosity (top of the humerus) against the labrum. Patients with internal impingement characteristically lack internal rotation--the ability to fully rotate the shoulder inward.

Signs of Internal Impingement

The most common signs of this problem include:

  • Pain when throwing or overhead sports (such as tennis serves)
  • Tenderness common on the front of the shoulder (pectoralis minor tendon/corocoid process)
  • Tenderness around the scapula and the posterior shoulder capsule

Typically when these patients are examined their shoulder mobility is slightly abnormal.  Often these athletes have more external rotation than expected (which is common in throwing athletes), and slightly decreased internal rotation.

  Patients may notice this as difficulty reaching up the back as high on their affected side as their unaffected side.  Often these patients have subtle findings of instability of the shoulder joint.  The instability of the shoulder is thought to be a key component to why internal impingement develops.

Tests may include x-ray test which are usually normal.  An MRI generally shows some bone bruising (edema) the the ball of the ball-and-socket shoulder joint, a partial thickness tear of the rotator cuff, and damage to the labrum (although not typically a detachment of the labrum).

Treatment Options

Most patients start with noninvasive treatments to address the problems in shoulder mechanics.  Therefore, the focus on treatment is to regain normal shoulder rotation, and to improve the movement of the scapula throughout the motion of the shoulder.  The scapula is critical to normal shoulder mechanics because the scapula contains the socket of the shoulder joint.  If the socket does not move in a coordinated way with the rest of the shoulder, these symptoms of internal impingement can often result.

The good news is that the vast majority of patients, even high level athletes, can find relief of symptoms with these therapeutic efforts.  The key is working closely with a knowledgeable therapist or trainer, who understands the goal of improving shoulder mechanics.

  If the focus is solely on "strengthening" the shoulder, without the emphasis on proper shoulder mechanics, then the results may not be as good.

In patients who fail to improve despite a focused effort on therapy, there is a role for arthroscopic shoulder surgery.  Generally surgery is performed to address any damage to the rotator cuff or the labrum, and also to address instability of the shoulder joint that may be contributing to the problem.  Fortunately, most patients can resolve this condition with nonsurgical treatments, but for those without success in therapy, surgery may be a good alternative.

Sources:

Drakos MC, et al. "Internal Impingement of the Shoulder in the Overhead Athlete" J Bone Joint Surg Am, 2009 Nov 01; 91 (11): 2719 -2728.

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