Written on November 30, 2008 at 6:36 pm, by Eric Cressey
In Part I, I went into some detail on why I really didn’t like the catch-all term “shoulder impingement.” This week, I’m going to talk about the different kinds of shoulder impingement: external and internal.
External impingement, also known as outlet impingement, is the one we hear about the most. Here, we’re dealing with compression of the rotator cuff – usually the supraspinatus, and over time, the infraspinatus (and biceps tendon) – by the undersurface of the acromion. This impingement can lead to bursal-sided rotator cuff tears - and happens a lot more with ordinary weekend warriors and very common in lifters (not to mention much more prevalent in older populations.
External impingement can be further subdivided into primary and secondary classifications. In primary impingement, the cause is related to the acromion – either due to bone spurring or congenital shape. As you can see in the photo below, hook (II) and beak (III) are worst than flat (I), as there are marked difference in “clearance” under the acromion.
Secondary impingement, on the other hand, is usually related to poor scapular stability (related to both tightness and weakness, as described in last week’s newsletter), which alters the position of the scapula. In both cases, pain is at the front and/or side of the shoulder and is irritated with overhead activity, scapular protraction, and several other activities (depending on the severity of the tissue problems). You’ll also generally see a lack of external rotation range-of-motion, as these are folks who do too much bench pressing and computer work (both of which shorten the internal rotators).
Conversely, internal impingement, also known as posterosuperior impingement, really wasn’t proposed until the early 1990s. This form of impingement is more common in younger individuals who are involved in overhead sports, making it more of an “athletic impingement.” Adaptive shortening and scarring of the posterior rotator cuff in these athletes causes a loss of internal rotation and an upward translation of the humeral head during the late cocking phase of throwing (or swimming): external rotation and abduction. These issues are magnified by poor scapular control, insufficient thoracic rotation, and weakness of the rotator cuff.
When the humeral head translates superiorly excessively in this position, it impinges on the posterior labrum and glenoid (socket), irritating the rotator cuff and biceps tendon along the way. So, pain usually starts in the back of the shoulder, as you are seeing irritation of the posterior fibers of the supraspinatus and anterior fibers of the infraspinatus tendons. Gradually, this pain may “shift” toward the front as the biceps tendon, and that implies labral involvement. At least initially, the pain is purely mechanical in nature; it won't bother an athlete unless the "apprehension" position (full external rotation at 90 degrees of abduction) is created.
We often hear about SLAP lesions in the news. This refers to a superior labrum, anterior-posterior injury. In reality, when we are talking about labral injuries in overhead athletes as they relate to internal impingement, it’s mostly just posterior (although serious cases can eventually affect the anterior labrum, too). There are different kinds of SLAP lesions (1-4). Every baseball pitcher you’ll meet has a SLAP 1, which is just fraying. SLAP 2 lesions are far more serious and often require surgical intervention. SLAP 1 issues become SLAP 2 lesions when poor mobility and dynamic stability aren't established.
So, just to bring you up to speed, we’ve got two different kinds of impingement, one of which (external) has two subcategories that mandate different treatment strategies (primary = surgery, secondary = corrective exercise). We also have two separate areas where pain presents (external = front/side, internal = back). That’s just the tip of the iceberg, though, as we have two more considerations…
First, symptomatic internal impingement tends to be "mechanical pain." Unless you’re dealing with a more advanced case, athletes with symptomatic internal impingement only have pain when they get into the late cocking phase (and sometimes follow-through). It usually isn’t present when they’re just sitting around – and for this reason, they can usually be more aggressive in the weight room with upper body training. Keep in mind that I use the term “symptomatic” because I think that internal impingement is a physiological norm, just like I observed last week with external impingement. You're essentially just going to go out of your way to avoid this "apprehension" position in the weight room by omitting exercises like back squats. An apprehension test - illustrated in the most enthusiastic video in internet history - is a quick and easy assessment many doctors and rehabilitation specialists use to check for symptomatic internal impingement, as it reproduces the injury mechanism.
Second, and perhaps more importantly, you are dealing with two rotator cuff tears that are fundamentally different. It’s these differences that make me think doctors need to get rid of the term “impingement.” Here’s the scoop:
Let’s say that we have two guys with partial thickness tears of the supraspinatus – one from external impingement and one from internal impingement.
With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion). These issues will generally heal more quickly because the bursa actually has a decent blood supply.
With internal impingement, on the other hand, we’ve got an articular-sided tear, meaning that the wear on the tendon comes from underneath (glenoid). The tear is more interstitial in nature. Blood supply isn’t quite as good in this area, so healing is slower (or non-existent).
Traditionally, articular has been an athletic injury, and bursal has been a general population issue. This is not always the case, though.
Factor in the activity demands of overhead throwers, and they have more challenging tears and greater functional demands. Fortunately, they also typically have age and tissue quality on their sides, so things tend to even out.
With all these factors in mind, if a doctor ever tells you that you have "shoulder impingement," ask:
1. Internal or external?
2. If external, is it primary or secondary? (It’ll probably be both)
3. If internal, is there labral involvement? Biceps tendon?
4. If internal, what is the internal rotation deficit? (They should measure it, as this will begin to dictate the rehabilitation plan)
5. Given my age, activity level, and the nature of the tear, do you feel that surgical or conservative treatment is best?
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>>>With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion).
Although it’s counterintuitive and the subject of considerable discussion, I’m pretty sure that this isn’t correct. For all-comers with partial RCT tear, roughly 75% have an articular surface tear. Considering that external impingement is significantly more common than internal impingement (remember that all-comers represents the general population, of which overhead athletes are a small percentage), it stands to reason that articular surface tears are actually significantly more common than bursal surface tears despite the mechanism of tendon injury in external impingement.
Thanks for the info Eric –
What I’m looking for is information and exercises that prevent these shoulder problems in the first place!!!!! (for baseball players and weight training) — does your book “Optimal Shoulder Performance” cover what I need????
Paul – could be a number of things…subscapularis injury, etc. Really depends on location and nature of the pain. I’d check with a health care provider in your area for diagnosis/treatment.
eric, its seams like my 17 year old son has the internal impingment after pitching about 100 pitches at full speed one day right after 2 months off. he had pain in behind shoulder blade i raised his arm above his shoulder and manipulated his arm a little and felt the laxity in the shoulder. Then heard a crack like you would if you did it to your knuckles and the bones seam to shift back in place. he instantly had no more pain. he has not thrown yet after but he says his shoulder feels great. when do you think it will be safe to throw again and what else should be done. Also pitching while in pain he had a velocity drop fromm 86 to 77mph the next week when he was in pain.
thanks, Jim
I’d encourage you to get him checked out in person by both a qualified orthopedist and a physical therapist. If things check out okay, he can begin on a return-to-throwing program. Going from doing nothing to pitching off the mound is the worst thing he can do; it requires a gradual build-up.
hi eric. first of all i respect for how you helping people. i have an impingement syndrome at my right shoulder and wondering if you can tell me which type of impingement i have.. external or internal.. here is my mri image.. http://imageshack.com/a/img36/2296/4kgr.jpg
sorry for my bad english
August 28th, 2011 at 7:28 pm
>>>With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion).
Although it’s counterintuitive and the subject of considerable discussion, I’m pretty sure that this isn’t correct. For all-comers with partial RCT tear, roughly 75% have an articular surface tear. Considering that external impingement is significantly more common than internal impingement (remember that all-comers represents the general population, of which overhead athletes are a small percentage), it stands to reason that articular surface tears are actually significantly more common than bursal surface tears despite the mechanism of tendon injury in external impingement.
August 29th, 2011 at 5:26 am
Gene,
Thanks for the feedback; that’s research I haven’t come across. Do you have a link to the study in question?
Thanks!
August 30th, 2011 at 12:15 pm
Thanks for the info Eric –
What I’m looking for is information and exercises that prevent these shoulder problems in the first place!!!!! (for baseball players and weight training) — does your book “Optimal Shoulder Performance” cover what I need????
August 30th, 2011 at 12:17 pm
Absolutely, John! It’d be a great fit.
September 15th, 2011 at 6:01 pm
I ordered the dvd and it is great. i never received any book or wall charts. Was i supposed to receive them?
David
September 15th, 2011 at 6:20 pm
David – What wall chart are you referring to?
August 16th, 2012 at 8:29 am
What if I feel pain when doing internal rotation with my arm positioned as in test for internal impingiment? Is this sign of external impingiment?
August 16th, 2012 at 5:47 pm
Paul – could be a number of things…subscapularis injury, etc. Really depends on location and nature of the pain. I’d check with a health care provider in your area for diagnosis/treatment.
December 15th, 2013 at 7:33 pm
eric, its seams like my 17 year old son has the internal impingment after pitching about 100 pitches at full speed one day right after 2 months off. he had pain in behind shoulder blade i raised his arm above his shoulder and manipulated his arm a little and felt the laxity in the shoulder. Then heard a crack like you would if you did it to your knuckles and the bones seam to shift back in place. he instantly had no more pain. he has not thrown yet after but he says his shoulder feels great. when do you think it will be safe to throw again and what else should be done. Also pitching while in pain he had a velocity drop fromm 86 to 77mph the next week when he was in pain.
thanks, Jim
December 16th, 2013 at 7:37 am
Jim,
I’d encourage you to get him checked out in person by both a qualified orthopedist and a physical therapist. If things check out okay, he can begin on a return-to-throwing program. Going from doing nothing to pitching off the mound is the worst thing he can do; it requires a gradual build-up.
February 24th, 2014 at 5:43 am
hi eric. first of all i respect for how you helping people. i have an impingement syndrome at my right shoulder and wondering if you can tell me which type of impingement i have.. external or internal.. here is my mri image..
http://imageshack.com/a/img36/2296/4kgr.jpg
sorry for my bad english
February 26th, 2014 at 3:11 pm
Sorry, Melih; I can’t read MRI films.