Shoulder Impingement – 3 Keys to Assessment and Treatment

Shoulder impingement really is a pretty broad term that most of us likely take for granted.  It has become such a junk term, such as “patellofemoral pain,” especially with physicians.  It seems as if any pain originated from around the shoulder could be labeled as “shoulder impingement” for some reason, as if that diagnosis is helpful to determine the treatment process.

Unfortunately, There is no magical “shoulder impingement protocol” that you can pull out of your notebook and apply to a specific person. [Click to Tweet]

I wish it were the simple.

A thorough examination is still needed.  Each person will likely present differently, which will require a variations on how you approach their rehabilitation.

But the real challenge when working with someone with shoulder impingement isn’t figuring out they have shoulder pain, that’s fairly obviously.  It’s figuring out why they have shoulder pain.



Shoulder Impingement: 3 Keys to Assessment and Treatment

To make the treatment process a little more simple, there are three things that I typically consider to classify and differentiate shoulder impingement.

  1. Location of impingement
  2. Structures involved
  3. Cause of impingement

Each of these can significantly vary the treatment approach and how successful you are helping each person.


Location of Impingement

The first thing to consider when evaluating someone with shoulder impingement is the location of impingement.  This is generally in reference to the side of the rotator cuff that the impingement is located, either the bursal side or articular side.

shoulder impingement assessment and treatment

See the photo of a shoulder MRI above.  The bursal side is the outside of the rotator cuff, shown with the red arrow.  This is probably your “standard” subacromial impingement that everyone refers to when simply stating “shoulder impingement.”  The green arrow shows the inside, or articular surface, of the rotator cuff.  Impingement on this side is termed “internal impingement.”

The two are different in terms of cause, evaluation, and treatment, so this first distinction is important.  More about these later when we get into the evaluation and treatment treatment.


Impinging Structures

To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against.  As you can see in the pictures below (both side views), your subacromial space is pretty small without a lot if room for error.  In fact, there really isn’t a “space”, there are many structures running in this area including your rotator cuff and subacromial bursa.

Shoulder impingement

You actually “impinge” every time you move your arm.  Impingement itself is normal and happens in all of us, it is when it becomes excessive or abnormal that pathology occurs.

I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation.  There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below.


Cause of Impingement

The next thing to look at is the actual reason why the person is experiencing shoulder impingement.  There are two main classifications of causes, that I refer to as “primary” or “secondary”shoulder  impingement.

Primary impingement means that the impingement is the main problem with the person.  A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below.  Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):

shoulder impingement


Secondary impingement means that something is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in it’s center of rotation and cause impingement.  The most simply example of this is weakness of the rotator cuff.

The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.  The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid.  The deltoid and larger muscles power the ship and move the arm.

Both muscles groups need to work together.  If rotator cuff weakness is present, the cuff may lose it’s ability to keep the humeral head centered.  In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:

evaluation and treatment of shoulder impingement


Other common reasons for secondary impingement include mobility restrictions of the shoulder, scapula, and even thoracic spine.  We see this a lot at Champion.  In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.

shoulder impingement mobility

If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited.  He’ll return to gym and start the process all over if we don’t restore this mobility restriction.

The funny thing about this is that people are almost never aware that they even have this limitation until you show them.



Differentiating Between the Types of Shoulder Impingement

In my online program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training.  There are specific tests to assess each type of impingement we discussed above.

The two most popular tests for shoulder impingement are the Neer test and the Hawkins test.  In the Neer test (below left), the examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion.  In the Hawkins test (below right) the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.

Shoulder impingement tests

You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement.  This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.

The Hawkins test (below left) can be modified and performed in a more horizontally adducted position.  Another shoulder impingement test (below right) can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.

how to assess shoulder impingement

There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Internal impingement is a different beast.

This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction.  As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc., the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum.  This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of time.

shoulder internal impingement



The test for this is simple and is exactly the same as an anterior apprehension test.  The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms.  Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms.  Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left).  Ween the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).

how to assess shoulder internal impingement


3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?

There are three main keys from the above information that you can use to alter your treatment and training programs based on the type of impingement exhibited:

Subacromial Impingement Treatment

To properly treat, you should differentiate between acromial and coracoacromial impingement.  Treatment is essentially the same between these two types of subacromial impingement, however, with coracoacromial arch impingement, you need to be cautious with horizontal adduction movements and stretching.  This is unfortunate as the posterior soft tissue typically needs to be stretched in these patients, but you can not work through a pinch with impingement!

A “pinch” is impingement of an inflamed structure!

Also, I would avoid elevation in the sagittal plane or horizontal adduction exercises.


Primary Versus Secondary Shoulder Impingement

This is an important one and often a source of frustration in young clinicians.  If you are dealing with secondary impingement, you can treat the persons symptoms all you want, but they will come back if you do not address the route of the pathology!

I do treat their symptoms, that is why they have come to see me.  I want to reduce inflammation.  However, this should not be the primary focus if you want longer term success.

This is where a more global look at the patient, their posture, muscle imbalances, and movement dysfunction all come into play.  Break through and see patients in this light and you will see much better outcomes.

A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain.  Again, using the example above, if you don’t have full mobility and try to force the shoulder through this tightness you are going to likely cause some issues.  This is especially true if you add speed, loading, and repetition to elevation, such as during many exercises.


Internal Impingement

One thing to realize with internal impingement is that this is pretty much a secondary issue.  It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize.   The athlete will show some hyperlaxity in this athletic “lay back” shoulder position.  Treat the cuff weakness and it’s ability to dynamically stabilize to relieve the impingement.  How to treat internal impingement is a huge topic that I cover in a webinar for my Inner Circle members.


Learn Exactly How I Evaluate and Treat the Shoulder

If you are interested in mastering your understanding of the shoulder, I have my acclaiming online program teaching you exactly how I evaluate and treat the shoulder and it’s $150 off for this week only!

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  • shoulder seminarThe evaluation of the shoulder
  • Selecting exercises for the shoulder
  • Manual resistance and dynamic stabilization drills for the shoulder
  • Nonoperative and postoperative rehabilitation
  • Rotator cuff injuries
  • Shoulder instability
  • SLAP lesions
  • The stiff shoulder
  • Manual therapy for the shoulder

The program offers 21 CEU hours for the NATA and APTA of MA and 20 CEU hours through the NSCA.

Click below to learn more, you can save $150 off the program now through Sunday October 30th at midnight EST.  Act now to not miss out on this special offer!



Should Everyone Deadlift?

Many people have called the deadlift, “the king of all exercises.”  And rightfully so, as there may not be a bigger bang-for-your-buck exercise out there.

In my opinion, the deadlift is the most underutilized exercise in rehabilitation.  Perhaps the move is intimidating?  Perhaps people are afraid of barbells?  Perhaps people are worried patients may hurt their backs?  Perhaps rehab professionals don’t know enough about strength and conditioning?

I always say that I am a much better physical therapist because I am also a strength coach, and always keep learning from many great strength coaches.

As the gap between rehab and performance continues to narrow, the deadlift may be the final exercise to cross the chasm.  We shouldn’t be afraid of the deadlift, however, we also need to understand the the conventional deadlift is not for everyone.


Why Everyone Should Deadlift

should everyone deadliftOne of the most important trends in rehabilitation and strength and conditioning over the last decade or two has been the move away from muscle-based exercises and shift towards movement-based exercises.  Rather than work on quad strength, work on squatting, for example.  (Photo credit by the man, the myth, and the deadlift legend Tony Gentilcore)

The deadlift is essentially a hip hinge pattern, which is extremely functional and equally elusive for many people.

Put simply, people can’t hinge anymore!  It’s amazing.

As our society changes and relies more on poor posture patterns, prolonged seated periods, and things like excessive use of smartphones, I’m amazed how it seems even kids can’t touch their toes anymore.

Working on a poor hip hinge pattern is extremely helpful for so many different issues that I see every day.  From back pain, to knee pain, to even poor sport performance.

We have become so anterior chain dominant.  Luckily, the deadlift hits the entire posterior chain in one big lift.  

So the the deadlift really helps with the hip hinge pattern, but there are so many other benefits including working on better posture, glute development, lower extremity power development, a stronger core, stronger lats, and even enhanced grip strength.  

You can see why it’s such a big bang-for-your-buck exercise.


Why Everyone Shouldn’t Deadlift

Wait a minute…

I just spent the first half talking about how beneficial the deadlift is for so many people.  Why shouldn’t everyone perform a deadlift?

Let me clarify – I’m talking about the conventional barbell deadlift.

Take a step back and remember that we are more concerned about movements, than muscles, right?  So luckily there are many variations of hinging, and even deadlifts, that can be utilized to achieve all the above great goals.

Perhaps the deadlift is so underutilized in the rehab setting because everyone just looks at the conventional barbell deadlift.  That’s like going straight to the top, saying that there is no way you can perform that exercise, then just scrapping all forms of deadlifts and hip hinge exercises.

Most people that walk into the door at Champion have no chance at being successful at a conventional barbell deadlift.  Among other things, you need:

  • Good mobility
  • An understanding of the hinge pattern neuromuscular pattern
  • The ability to load, essentially lift a weight with intent

Most people don’t have at least 2-3 of these qualities.

We’ll try to get them there with the right blend of mobility drills, corrective exercises, and manual therapy, but that doesn’t mean we have to wait to start deadlifting.  We just need to start at a more regressed level.

So, don’t immediately scrap the deadlift, find a way to incorporate it.  Work within your mobility and limited range, try a variation using a kettlebell or sumo stance, and use submaximal loads until you can groove a proper hip hinge pattern.

deadlift variations

One of my favorite resources on deadlift technique and variations is this excellent article by Mike Robertson.

As you improve, you can incorporate more advanced forms of the deadlift, but don’t simply scrap the deadlift until then, modify!


3 Ways to Modify a Deadlift so Anyone Can Perform

If you want to learn more, I have an Inner Circle webinar on 3 Ways to Modify the Deadlift so Anyone Can Perform.  In this presentation, I break down the 3 most common reasons why people often don’t perform a deadlift, the inability to load, poor hinge patterns, and altered hip anatomy.  Deadlifts are great, and really underutilized in rehab, but with these 3 modifications, anyone should be able to perform them.

To access this webinar:

3 Ways to Modify the Deadlift so Anyone Can Perform

The latest Inner Circle webinar recording on 3 Ways to Modify the Deadlift so Anyone Can Perform is now available.


 3 Ways to Modify the Deadlift so Anyone Can Perform

3 ways to modify the deadlift so anyone can performThis month’s Inner Circle webinar is on 3 Ways to Modify the Deadlift so Anyone Can Perform.  In this presentation, I break down the 3 most common reasons why people often don’t perform a deadlift: the inability to load, poor hinge patterns, and altered hip anatomy.  Deadlifts are great, and especially underutilized in rehab, but with these 3 modifications, anyone should be able to perform.

This webinar will cover:

  • Why deadlifts are so important
  • The 3 most common reasons why people can’t deadlift
  • How to regress and vary the movement
  • How to include at any stage of the rehab and performance spectrum

To access this webinar:


Working Core Training in 360 Degrees

The notion of core training has been around for years and years.  As far back as I can remember, people have been doing crunches, sit-ups, weighted side bends, and more.  You could walk into any gym in the world and probably see someone doing some sort of “core” exercise.

core training sit ups

Photo credit

Even today, there are still people performing sit-ups or some other variation in their training program.  But as we continue to learn more about the spine, these traditional core exercises may actually be disadvantageous.  According to Dr. Stuart McGill, a noted spine biomechanist from the University of Waterloo:

“The spine may be more prone to injury when they are in a fully flexed posture.”

Last time I checked, when someone is performing a sit-up, they are in a great deal of flexion.  

Many other studies by McGill and other researchers have been published on the increased risk of high repetition and/or loaded lumbar spine motion.  Since this research has been published, there has been a pendulum swing towards performing more neutral spine movements such as planks.

core training plank

In another study by Cholewicki and McGill in Clinical Biomechanics:

“One important mechanical function of the lumbar spine is to support the upper body by transmitting compressive and shearing forces to the lower body during the performance of everyday activities. To enable the successful transmission of these forces, mechanical stability of the spinal system must be assured.”

By performing some type of plank or neutral spine exercise, this can potentially train the core to transmit force from the upper body to the lower body or vice versa without compromising the spine.

Performing plank variations is great, but as humans, we move in multiple planes of motion.  Therefore, we need to train the core to function in all planes of motion.


Core Musculature

360 degree core trainingThere are many muscles that contribute to the functioning of a stable core position.  These muscles include:


  • Rectus Abdominis
  • Internal Obliques
  • External Obliques
  • Transverse Abdominis
  • Multifidi
  • Quadratus Lumborum
  • Diaphragm
  • Pelvic Floor
  • Latissimus Dorsi

There have been studies performed over the years saying that transverse abdominis or multifidi are the main stabilizers of the lumbar spine.  Study after study, many by McGill, have refuted that 1 or 2 muscles are the primary stabilizers of the spine.  McGill et al. in the Journal of Electromyography and Kinesiology found that:

“The collection of works synthesized here point to the notion that stability results from highly coordinated muscle activation patterns involving many muscles, and that the recruitment patterns must continually change, depending on the task.”

Therefore, when we are training or treating our clients, we should not be attempting to isolate one muscle we performing lifting tasks.  Some muscles may be more active than others in one task as compared to another.  Instead, we should be working to maintain a neutral spine position and to resist motion through the lumbar spine.

The McGill Big 3

McGill came up with a series of 3 exercises, entitled “The Big 3” to help teach and re-educate patients or clients returning from a low back injury on how to properly stabilize their spine.

They include:

McGill Curl-Up

Key Points:

  • Place finger tips under low back.
  • Maintain a neutral spine position at low back and neck.
  • Slightly lift shoulders off ground while maintaining spine position.

Bird Dog

Key Points:

  • Maintain a neutral spine.
  • Imagine you have a drink on your low back. Don’t let it spill

Side Plank

Key Points:

  • Start on your side in a hip hinged position (hips slightly flexed).
  • Bring hips forward, not up.

These exercises are great implements to add into the beginning of a strength and conditioning program or during a rehab program for someone returning from a low back injury.  But, these exercises are a foundation for movement.  If we are going to build core stability throughout, thence need to have a solid foundation as well as solid “walls and a roof.”


Core Training Progression

There are typically two functions of the core:

  1. Transmit force from the lower body to the upper body or vice versa.  
  2. Resist motion.  

For example, if you are a baseball player and are throwing or swinging a bat, you want to have some motion through your lumbar spine, but predominantly through the hips and thoracic spine.  If we try to stop motion at the lumbar spine, your effectiveness as an athlete will be subpar.

Don’t forget…  the spine needs to move.  This is something Mike has covered in his article Are We Missing the Boat on Core Training?

Regarding the other aspect of resisting motion, if you are going to pick something heavy up off the ground, you want to maintain a neutral spine posture so that your core can transmit force from your legs and into your arms as you lift to the implement.

We need to appreciate these two different situations as we program for our clients.

The three planes of movement that the core musculature works in is the:

  • Sagittal Plane
  • Frontal Plane
  • Transverse Plane

The sagittal plane is lumbar spine flexion and extension. The frontal plane is lateral flexion or sidebending.  The transverse plane is rotation to the right or left.

The following progressions are a big part of Mike Reinold and Eric Cressey’s Functional Stability Training For the Core program.


Anti-Extension Core Training

Anti-extension core training consists of the body’s ability to resist movement into lumbar spine extension or to slow down motion from a flexed position to neutral, or from neutral to extension.

Exercises that focus on anti-extension stability are:

RKC Plank

Key Points:

  • Pull your elbows toward your toes.
  • Squeeze your glutes as hard as you can.
  • Maintain a neutral spine.

TRX Fallouts

Key Points:

  • Maintain a neutral spine.
  • Tuck tailbone/bring belt towards chin.
  • Slide arms out while keeping neutral spine.

Farmer’s Carries

Key Points:

  • Hold relatively heavy weight in each hand.
  • Ribs down/neutral spine.
  • Walk.  Don’t lose neutral spine posture as you walk.

Dead Bugs

Key Points:

  • Flatten low back to ground so that spine is neutral.
  • Bring right arm overhead and left leg out away from body.
  • Do not lose neutral spine position.  Return to starting position.
  • Repeat on other arm/leg.

Tall Kneeling Anti-Extension Press

Key Points:

  • Setup cable at head height when in tall kneeling.
  • Maintain a neutral spine and press cable overhead.
  • Cable will try to pull you into extension.  Don’t let it.
  • The only thing moving should be your arms.

Anti-Lateral Flexion Core Training

Anti-lateral flexion core training consists of the body’s ability to resist movement into lumbar spine lateral flexion to the right or left or to slow down motion from a flexed position to neutral, or from neutral to the opposite laterally flexed position.

Exercises that focus on anti-lateral flexion core stability are:

Suitcase Carries

Key Points:

  • Hold weight in one hand.
  • Do not let weight pull you out of a tall, neutral posture.
  • Don’t overcompensate to and flex to the opposite side.
  • Walk.

Side Planks

Key Points:

  • Start on your side in a neutral spine, slightly hips flexed position.
  • Maintain neutral spine and bring hips forward.
  • Maintain a straight line from your head, shoulders, spine, hips, knees, and ankles.

Racked Carries

Key Points:

  • Maintain a tall posture similar to the suitcase carries.
  • Walk.

Anti-Rotation Core Training

Anti-rotation core training consists of the body’s ability to resist movement into lumbar spine rotation to the right or left or to slow down motion from a rotated position to neutral, or from neutral to a rotated position.

Exercises that focus on anti-rotation core stability are:

Anti-Rotation Press

Key Points:

  • Start behind cable arm.
  • When you press your hands away, don’t let the machine rotate you.  Maintain a neutral spine.
  • Perform facing both directions.

1/2 Kneeling Chops

Key Points:

  • Leg closest to the machine should be up.
  • Bring arms down and across your body to you far side hip.
  • Only move head and arms.
  • Perform on both sides.

1/2 Kneeling Lifts

Key Points:

  • Leg closest to machine should be down.
  • Same cues as chops, but bring cable to far side shoulder.

TRX Anti-Rotation Press

Key Points:

  • Feet should be in tandem.
  • Maintain a neutral spine position.
  • Don’t let your body rotate or sidebend during press.
  • Perform on both sides.


Multi-Planar Movements and Rotational Sport Athletes

Once the body has mastered the basic core progressions and anti-movement-based drills, it is important to incorporate multi-planar and rotational movements.  These movements work on incorporating movement through the hips and thoracic spine versus some of the movements before where basically no movement was occurring.

As mentioned before, these exercises will help the athlete and client to control themselves going from one position to another.  As a rotational sport athlete, we don’t want to completely limit any spine motion.  We want the body to be able to control and decelerate the body using the musculature versus passive restraints (ie. bone, ligament, etc.) at end range.  These can also be used by non-rotational sport athletes as well.

Sledgehammer Hits

Key Points:

  • Bring the sledgehammer up over one shoulder.  Don’t let it bring you into lumbar extension.
  • Hit the tire while maintaining a neutral spine.
  • Alternate per side.

Medicine Ball Overhead Slams

Key Points:

  • Raise the medicine ball overhead.
  • Avoid going into lumbar extension.
  • Slam the ball to the ground while maintaining a neutral spine.

Medicine Ball Overhead Rotational Slams

Key Points:

  • Bring the ball up overhead.  Don’t let it bring you into lumbar extension.
  • Throw while maintaining a neutral spine.

Medicine Ball Scoop Toss

Key Points:

  • Load your back leg with your weight.
  • Transfer weight quickly from back to front leg.
  • Majority of the motion should be coming from the thoracic spine and hips.
  • Perform on both sides.

Medicine Ball Shotput Toss

Key Points:

  • Load medicine ball at shoulder height.
  • Load back hip/leg.
  • Quickly drive off back leg and twist through hips/thoracic spine.
  • Perform on both sides.


Breathing and Core Training

Implementing breathing with core training is very important.  If we are constantly holding our breath while performing core exercises, then we are compensating using the valsalva maneuver versus training the musculature to have to stabilize throughout the exercise.

Related Articles:

*Disclaimer*: if you have heavy weight in your hands or on your back in the cases of a deadlift or squat, then I am a proponent of using the breath to brace the core and spine.  When it comes to core exercises as mentioned above, remember to breath.  

With the said, here are a couple of exercises where implementing the breath adds another component to the movement.

Anti-Rotation Press with Full Exhale

Key Points:

  • Same as before with Anti-rotation Press.
  • Complete full exhale when hands are out in front of your body.
  • Maintain proper form during exhale and inhale.

Prone Plank with Full Exhale

Key Points:

  • Same as before with Plank.
  • Complete full inhale and exhale without losing form.


Strength Training and Core Stability

Lastly, we can’t go through an entire article and not discuss the use of core stability and strength training.  I am a firm believer that just performing squats and deadlifts are not enough to improve core and trunk stability.  Adding some of the movements mentioned above can add another component to create a well-rounded training program.

When it comes to performing squats, deadlifts, etc., maintaining a neutral spine during the lifts is extremely important.  Yes, there are some elite level lifters out there who can sway away from a neutral position in one direction or the other.   For the vast majority of people performing strength movements such as these, a neutral spine should be maintained.

There you have it.  By incorporating core stability exercises throughout all planes of motion, it will allow your clients and/or athletes to reduce their risk for injuries as well as improve their performance.


Learn More About Core Training

If you want to learn even more about functional core training, check out Mike Reinold and Eric Cressey’s Functional Stability Training for the Core.  The program goes over many of these progressions and a whole lot more to help you completely understand the true role of the core and how to incorporate functional core training into your rehab and strength training programs:


About the Author

andrew_millettAndrew Millett is a Boston-based physical therapist in the field of orthopedic and sports medicine physical therapy.  He helps to bridge the gap between physical therapy and strength and conditioning.  Visit his website at





Which is the Best Position to Immobilize the Shoulder After a Dislocation?

Immobilization is commonly performed after acute first time shoulder dislocations.  The goal of immobilization is to protect the shoulder and allow healing in an attempt to minimize recurrent instability down the road, which isn’t uncommon.

Unfortunately, once you dislocate your shoulder, you have a decent chance of it happening again.

Traditionally, immobilization has occurred with the shoulder in a sling by the person’s side.  This puts the shoulder in adduction and internal rotation.  Considering that most anterior dislocations occur with the arm in an abducted and externally rotated position, this seemed to make sense to take stress of the tissue.

However, a study was published in 2001 by Itoi in the Journal of Bone and Joint Surgery discussing a new position of immobilization in shoulder external rotation.  

The authors used MRI to examine the capsule in both the position of shoulder internal rotation and external rotation.  They showed that the anterior capsule tissue was better approximated in the externally rotated position.  Other recent studies have agreed with these results.

which is the best position to immobilize the shoulder after a dislocation

This was an interesting finding and lead to a follow up study by the same group that was published in 2003 in the Journal of Shoulder and Elbow Surgery.  In this study, the authors prospectively assessed the recurrent instability rate in people that were immobilized in either internal or external rotation.

The results showed that there was a 30% recurrent instability rate in those immobilized in the traditional internally rotated sling position, compared to 0% in those immobilized in external rotation.


Which Position is Best to Immobilize the Shoulder After a Dislocation?

Based on these two studies, many began immobilizing the shoulder after dislocation in this position of external rotation.  There are now many shoulder immobilization braces on the market that position the shoulder in ER.

shoulder immobilization in external rotation

Since these two studies many have tried to replicate the original results of Itoi with mixed results.  

I must admit that any time a novel technique, clinical test, or approach is introduced in the literature and the original author has a 100% success rate, I proceed a little cautiously until others have replicated their research.

Clinically, there appears to be no difference in recurrence rates when comparing immobilizing the shoulder in either internal or external rotation.  This has been shown in several studies.

A recent meta-analysis was published in the American Journal of Sports Medicine that reviewed 6 randomized control trials and found no significant difference in recurrence rate.  This was consistent with a prior systematic review of the Cochran Database, which agreed.


Basic Science Vs. Clinical Studies

This is an interesting situation, where basic science studies appear to show that immobilization in external rotation may be theoretically more beneficial after shoulder dislocations, but clinical studies have not shown any benefit or reduced occurrence of recurrent instability.  It appears anatomically that immobilizing in a position of external rotation would put the labral tissue in the best position to heal.

I personally see this as a challenging study as many people are simply not compliant with immobilization after dislocations, especially once the acute trauma tends to settle down.  One particular study reported a compliance rate between 53-72%.  

That’s not great.

As of now, it seems like we need more research to make a more definitive decision.  However, keep in mind that these studies have not shown immobilization in internal rotation to be MORE beneficial, they just showed no difference between the two.  So as of now, if I dislocated my shoulder tomorrow, I would probably immobilize myself in external rotation based on the anatomical studies that show better tissue approximation.

For those out there, what are you seeing clinically in your area?  I would imagine this varies a lot based on your location and physicians you work with each day.  Are docs still immobilizing people in external rotation?  Have you found outcomes to differ from those immobilized in internal rotation?  Comment below and let me know.


How Rehab Differs Between Traumatic and Atraumatic Shoulder InstabilityHow Treatment Differs Between Atraumatic and Traumatic Shoulder Instability

If you are interested in learning more on this topic, I have an Inner Circle presentation on How Treatment Differs Between Atraumatic and Traumatic Shoulder Instability.  We discuss this topic, plus a lot more, in much greater detail.

How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability

The latest Inner Circle webinar recording on How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability is now available.


How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability

How Rehab Differs Between Traumatic and Atraumatic Shoulder InstabilityThis month’s Inner Circle webinar is on How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability.  In this presentation, I highlight the major differences in the evaluation and treatment process.

This webinar will cover:

  • The difference between traumatic and atraumatic shoulder instability
  • The import factors to consider that will change your rehab progression
  • Should you immobilize or not?
  • The primary focus for rehab for each type of instability

To access this webinar:


4 Myths of IASTM

Instrument assisted soft tissue mobilization (IASTM) is really a great manual therapy skill to have in your tool box.  However, there are many myths and misconceptions regarding IASTM that I really believe are holding people back from getting started and seeing the benefits of IASTM in their practice.

In this video, Erson Religioso and I discuss some of the myths of IASTM that led us to develop our online educational program at to teach people how and why we use IASTM:

4 Myths of IASTM


To summarize some of the myths of IASTM discussed in the video:

  • IASTM MythsIASTM does not have to be expensive to learn or perform.  You do not need to spend tons of money on certification courses and crazy expensive tools.  Erson and I have a quick and easy online educational program at that will get you started right away.  We even talk about how you can get useable tools for as little as $5!
  • IASTM does not have to be complicated to learn.  If you are already performing manual therapy or massage, you know everything you need to know to start using IASTM.
  • IASTM should not make everyone black and blue!  Let me actually rephrase that for emphasis, IASTM is not about being so aggressive that you leave large purple marks and essentially produce superficial capillary hemorrhage.  Some redness and petechia is OK, but the over aggressive black and blue is not ideal.
  • IASTM tools do not provide as much feedback as my hands.  IASTM is a way to compliment your hands, it is not a replacement!  In fact, it gives you a different feel that really helps your palpation skills.



Learn How to Start Performing IASTM Today!

Erson Religioso and I’s online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

IASTM Technique 2.0 has now be released with updated research, new content, and now includes how to perform cupping and use mobility bands!  Get started today!


Photo from Wikipedia

How and Why You Need to Learn IASTM

Learn IASTMErson Religioso and I have a nice video for you discussing why and how we both started using instrument assisted soft tissue mobilization (IASTM).  Like many people, I held out initially as I wanted to hear and see more.  However, the more I learned the more interested I became.

IASTM has now become a game changer for me and something I deeply integrate into my manual therapy techniques, and think you should too.  It doesn’t have to be complicated, expensive, or time consuming to start using IASTM.

In this video, Erson and I describe how and why they both started using IASTM, how we integrate IASTM with other manual techniques and exercise, the major benefits of IASTM, and then some brief technique demonstrations.


How and Why You Need to Learn IASTM


Learn How to Start Performing IASTM Today!

Erson Religioso and I’s online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

IASTM Technique 2.0 has now be released with updated research, new content, and now includes how to perform cupping and use mobility bands!  Get started today!


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