Emphasising the importance of the scapula muscles and posture during the golf swing!

Protracting or ’rounding forward’ of the shoulders for any golfer is not only detrimental to their technique and performance but it can predispose to shoulder joint issues such as rotator cuff impingement or pectorals major impingement.

Work on drawing the shoulders back and opening the chest, repeat this movement as part of a warm up if you’re a golfer.

Focus on keeping the back straight and the chest up to prevent tight chest muscles and weak back muscles!

1.Rounding of the shoulders (bad posture)

2. Drawing the shoulder up and back thus opening the chest

Danny Gosshawk BSc (Hons) MSST
Director PureBody Health Limited
Clinical Director 
PureBody Health Sports Injury Clinic
Director of Strength & Conditioning 


One of the most common physical complaints is shoulder pain. Shoulder or ‘subacromial’ impingement syndrome is a common condition also known as Swimmer’s shoulder or Thrower’s shoulder. It is a condition whereby certain structures that pass through the shoulder joint are intermittently compressed or pinched with specific arm movements. This can subject the rotator cuff tendon to pain, inflammation, thickening or even partial tearing. This can also result in inflammation of the bursa located in the subacromial space, this is known as bursitis.


Your shoulder is comprised of three bones, your upper arm bone (humerus), your shoulder blade (scapula) and your collarbone (clavicle).

The supraspinatus tendon is one of the four rotator cuff tendons within the shoulder joint. It arises from the supraspinous fossa of the shoulder blade and travels beneath the acromion plate of the scapula (tip of the shoulder blade) to insert to the greater tubercle of the humerus.  It is this tendon that is most commonly affected by impingement syndrome.

The area below the acromion is known as the sub-acromial space. Within this space there is a lubricating fluid sac known as a bursa between the supraspinatus tendon and the acromion that allows the tendon to move freely, and prevents friction when arm movements are performed.

Impingement syndrome in itself is not a diagnosis, but rather a clinical sign. Impingements syndrome is an umbrella term for a range of different pathologies which may include: bone spurs, rotator cuff tendinopathy or injury, labral tears, shoulder instability or biceps tendinopathy.  Your sports injury specialist will help you to determine exactly what the cause of your complaint is.

Symptoms of Shoulder Impingement

Rotator cuff pain commonly causes local swelling and tenderness at the front of the shoulder; however, pain may also refer down the side of the shoulder and/or arm. You may also have pain and/or stiffness when attempting to move the arm, particularly when lifting the arm, or lowering the arm from an elevated position.

It is common in the early stages for individuals to avoid seeking treatment as symptoms originally may be mild such as:

  • Mild pain that is present with activity and rest
  • Pain located at the front of the shoulder that may radiate to the side of the arm
  • Sudden, sharp pain with lifting or reaching
  • Athletic populations may have pain with overhead movements such as swimming, throwing or serving a tennis ball.

It is important that the problem is addressed as soon as possible to prevent further damage to structures within the shoulder. The problem may become more chronic in nature, and complications may develop that ultimately increase the length of time required to rehabilitate your injury. More chronic symptoms may include:

  • Pain at night – particularly when lying in bed on the affected side
  • Loss of strength or range of motion
  • Difficulty performing overhead tasks or other activities such as placing the arm behind your back, buttoning your collar or zippering a dress.

Causes of Shoulder Impingement

The subacromial space is a small gap between the acromion and humerus in which the rotator cuff tendon passes through. One of the most common causes of impingement is a reduction of the subacromial space, resulting in intermittent pinching of the tendon or inflammation of the bursa.

Mechanisms of subacromial space reduction:

  • A type III acromion that possesses an anomalous process is said to increase the risk of impingement (Bigliani, 1986)
  • Osteoarthritic changes of the Acromioclavicular joint (ACJ) or calcification of the Coracoacromial arch
  • Poor scapula movement, in particular type I dyskinesis whereby the scapula adopts an anterior tilt (Struyf et al, 2011)
  • Kinematic deviations such as superior migration of the humeral head due to rotator cuff weakness or tight capsular structures (Ludewig et al, 2002)


However, shoulder impingement can also develop secondary to a rotator cuff tear. Tearing of the rotator cuff tendon can cause inflammation and thickening of the tendon, which reduces the space in which the tendon is free to move as it passes through the shoulder joint.

Types of Shoulder Impingement

External Impingement

External impingement can be further categorised as primary or secondary:

Primary– Usually due to bony anomalies, such as a hooked acromion as aforementioned. This can sometimes be due to congenital or degenerative changes such as small bony spurs forming on the arch of the acromion.

Secondary– Due to poor scapula stabilisation which alters the position of the acromion. The most common cause of this is a muscle imbalance which consists of weakness of a muscle known as the serratus anterior in combination with pec minor tightness.

Internal Impingement

This occurs predominantly in the more athletic population. Repetitive movements of the arm, mainly 90 degrees of shoulder abduction combined with external rotation, commonly causes a narrowing of the subacromial space.

Stages of Shoulder Impingement

Stage 1: Commonly affecting patients younger than 25 years of age. Usually inflammation and oedema (swelling) is present. You may also have a painful arch of movement, but full range of motion. The condition is usually reversible with conservative management alone at this stage.

Stage 2: Commonly affecting patients 25-40 years of age. A continuation of stage 1. With the addition tendonitis of the rotator cuff tendon. There may be a small limitation of range of motion.

Stage 3: Commonly affecting patients > 40 years old. There may be disruption/tearing of the rotator cuff tendon. Prolonged pain and weakness, particularly with abduction and external rotation of the arm. Injection therapy or surgery may be implicated.

Treatment for Shoulder Impingement

The aims of treatment and rehabilitation for shoulder impingement syndrome at to achieve the following:

  • Reduce Pain and Inflammation
  • Restore a pain free Range of Motion (ROM)
  • Correct length-tension relationships (muscle imbalances)
  • Improve postural control
  • Strengthen inhibited musculature and increase the capacity of the tendon to cope with activity

Self-help to reduce pain and inflammation

It is important to rest from all aggravating activities, particularly those that involve movements overhead. Your tendon needs the opportunity to recover, if you are performing activities that repetitively pinch or catch the tendon, you may cause further damage and worsen the condition.

NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen can be particularly useful in decreasing inflammatory episodes, however anti-inflammatory medication should only be taken in moderation. You should not take ibuprofen if you are asthmatic.

Apply ice to the affected area 15 minutes at a time, ideally every 2-3 hours. Do not apply ice directly to the skin.

This period of rest, anti-inflammatory medication and icing should be performed for one week.

Sports Massage– Sports massage can be particularly useful in the treatment of shoulder impingement. Your sports injury specialist can perform various techniques that help to reduce inflammation of the tendon, mobilise tight soft tissues that contribute to poor scapula posture and function and reduce trigger point formation.

Myofascial Release– It is common for individuals with shoulder impingement to develop tightness of the fascia (a continuous network of connective tissue) between the pectoral and deltoid musculature. This is a common cause of rounded shoulder posture, and therefore a predisposition to developing impingement symptoms. Your sports injury specialist will perform techniques to stretch the fascia and release tension from the tissues affected to permit improved posture.

Capsular Stretching & Joint Mobilisation-Tightness of the posterior capsule of the shoulder joint is commonly found in patients with shoulder impingement. This tightness causes the humerus to elevate and therefore reduce the sub-acromial space, thereby compressing the tendon. Your sports injury specialist may perform some manual therapy techniques that help to loosen the capsule and restore your joint alignment and function.

Proprioceptive Neuromuscular Facilitation– For those that read our previous issue, you may already be aware of the Proprioceptive neuromuscular facilitation (PNF) techniques are.

For those that may not be familiar- PNF techniques are a passive stretching technique that helps to override tension signals sent from the muscles through the central nervous system (CNS) to the brain. These techniques, not only help to improve your joint range of motion, but PNF techniques also help to improve posture, increase the tendon’s capacity to tolerate loading, and reduce pain.

Rehabilitation for Shoulder Impingement


Stretching of the shoulder joint is particularly important throughout all phases of rehabilitation. They should be performed regularly, ideally on a daily basis. It is important that full mobility is regained in order for your rehabilitation to be successful. This will also help to restore your biomechanical function of the shoulder joint and specifically the rhythm of the scapula, therefore preventing ongoing impingement.

Below we outline specific stretches that should be performed on a regular basis, ideally daily.

Chest/Pectoral Stretch


Place your arm in 90 degrees of abduction and bent the elbow to 90 degrees also. Fix your forearm to a fixed point, such as a doorframe, squat rack, Swiss ball or wall depending on where you are and what is available. Lean forward gently so that your chest surpasses your arm. Hold the stretch for 30 seconds and repeat three times. You should aim to lean forward more with each effort.

Anterior Deltoid Stretch


This is performed similarly to the pectoral stretch. However, instead of adopting the above position. You should aim to reach higher such as the top of the door frame. This will bias the stretch towards the deltoid musculature. Hold the stretch for 30 seconds and repeat three times.

Supraspinatus Stretch


Place your hand behind your lower back and maintain contact. Use your other hand to gently pull your elbow forward, you should feel a stretch towards the back of the shoulder. However, this may also feel like it is stretching other areas around the shoulder. Again, hold the stretch for 30 seconds and repeat three times.


Sleeper’s Stretch

This stretch is a personal favourite of ours here at PureBody Health. It is a simple, yet fantastic exercise that targets the posterior capsule of the shoulder. As aforementioned, tightness of this capsule may cause the humerus to elevate and contribute to impingement of the shoulder. Therefore, this stretch is aimed at preventing the superior migration of the humerus. This also helps to restore your internal rotation range of motion of the shoulder joint.



Strengthening Exercises:

The following exercises are aimed at improving the function of the rotator cuff muscles that stabilise the shoulder joint and the scapula, as well as focusing on the upper back muscles that play an integral role in postural control. These exercises are particularly important in aiding the stretches in improving your shoulder joint alignment, function and biomechanics.

Early Stage Strengthening Exercises

Positional Isometrics- This type of strengthening exercise is particularly useful for increase the contractile ability of the rotator cuff tendons and facilitates an improved tolerance to loading and activity. They also help to improve your scapula stability.

Shoulder Abduction Isometric

Stand 6inches approximately from a wall, side on. Place the back of the hand against the wall, with the elbow locked out straight and apply a resistance against the wall, around 60-80% of your strength. Hold for 10 seconds, rest for 10 seconds and repeat 10 times.





Shoulder External Rotation Isometric

Perform as above but with the elbow bent to 90 degrees, instead of locked out straight. This will bias a different movement, and therefore a different rotator cuff tendon, known as your infraspinatus; that is responsible for externally rotating the shoulder.





Scapula Retractions

  • Extend your thoracic spine (upper back) and pinch the shoulder blades together.
  • Raise both arms to at least 90 degrees out in-front of you, you should aim to reach as high as possible without losing the position of your shoulder blades.

For alternative exercise, check our Instagram page and follow us!

The above exercises should be performed twice daily, for one week and with no pain or symptoms before progressing onto the mid-stage rehabilitation exercises. If you experience pain with any of the above exercises, please consult your sports injury specialist.


Middle Stage Strengthening Exercises

External Rotation in Lying

  • Lay on your unaffected side, place rolled up towel or cushion between your elbow and side. Your upper arm should rest on the towel, and keep the elbow fixed to your side. Your palm should be facing the floor
  • Rotate your shoulder so as to move the arm towards the ceiling as far as possible
  • The key to this exercise is the eccentric loading phase or the returning phase. This should be controlled and performed with a relatively slow tempo. Take 3 seconds to return to the starting position of the exercise. Start with a light weight, around 2kg and aim to perform 12-20 repetitions.
  • This can also be performed in standing with a resistance band or cable machine.


Internal Rotation in Lying

  • Lay with the affected arm at the bottom, with the forearm parallel to the floor. Rotate the arm in the opposite direction to the above exercise (towards the abdomen).
  • Again, the eccentric phase of the exercise is particularly important and should be performed with good control and a relatively slow tempo. Take three seconds to lower the arm back to the starting position. Start with a light weight, around 2kg and aim to perform 12-20 repetitions.
  • This can also be performed in standing with a resistance band or cable machine.

Shoulder Abduction

  • Standing with your arm at your side. Lock the elbow out straight.
  • Raise the arm laterally (sideways) without bending the arm, to 90 degrees and slowly lower back down to our side to the starting position. Start with a light weight, around 2kg and aim to perform 12-20 repetitions.
  • This can also be performed in standing with a resistance band or cable machine.

Your sports injury specialist can also assist you with more advanced late stage rehabilitation. To discuss your symptoms, treatment or rehabilitation, please contact the PureBody Health Sports Injury & Rehabilitation Clinic Team!

Kind regards,

Dan Baker

Senior Therapist.