Shoulder Impingement in Overhead Athletes: Why It Happens and How to Get Back in the Game

Kathy Ryan-Ceisel, PT MHS | Algonquin Sports PT

Overhead Throwing Expert-Athletic Edge and Wellness Edge

Shoulder pain is one of the most common reasons overhead athletes seek medical care. Whether you’re a baseball pitcher, softball player, swimmer, volleyball athlete, or tennis player, repetitive overhead motion places tremendous stress on the shoulder complex.

Although many athletes are told they have “shoulder impingement,” modern sports medicine recognizes that this is often a symptom rather than the true diagnosis. In overhead athletes, shoulder impingement usually develops because of movement dysfunction, muscle imbalance, fatigue, or instability—not because a bone is simply “pinching” a tendon. Understanding the underlying cause is essential for successful treatment and preventing recurrence.

Shoulder Anatomy: Understanding the Overhead Athlete

The shoulder is the most mobile joint in the body, sacrificing stability for movement.

Key structures include:

• Glenohumeral joint

• Rotator cuff (Supraspinatus, Infraspinatus, Teres Minor, Subscapularis)

• Scapula

• Acromion

• Acromioclavicular (AC) joint

• Long head of the biceps tendon

• Labrum

• Bursa

• Capsule and glenohumeral ligaments

The rotator cuff compresses the humeral head into the socket while the scapular muscles position the shoulder blade to maintain a healthy subacromial space.

When any part of this system fails, painful impingement can develop.

Types of Shoulder Impingement

✨Primary (Structural) Impingement

Usually seen in older athletes.

Caused by:

• Bone spurs

• AC joint arthritis

• Hooked acromion

• Thickened coracoacromial ligament

✨Secondary (Functional) Impingement

This is the type seen most often in overhead athletes.

Common causes include:

• Scapular dyskinesis

• Rotator cuff weakness

• Posterior capsule tightness

• Glenohumeral Internal Rotation Deficit (GIRD)

• Shoulder instability

• Core weakness

• Poor thoracic mobility

• Hip mobility deficits

• Fatigue

• Throwing or serving mechanics

The shoulder isn’t “too tight”—it simply isn’t moving efficiently.

Internal vs External Impingement

External (Subacromial) Impingement

Compression occurs between:

• Supraspinatus tendon

• Bursa

• Acromion

Common during arm elevation.

Internal Impingement

Seen almost exclusively in overhead athletes.

Occurs when:

• The articular side of the rotator cuff contacts the posterosuperior glenoid and labrum during maximal external rotation.

Frequently associated with:

• Partial rotator cuff tears

• SLAP lesions

• Posterior capsule tightness

• Excessive external rotation

Why Each Sport Develops Shoulder Impingement

⚾ Baseball & Softball

Pitchers generate over 7,000 degrees/second of shoulder internal rotation, with distraction forces approaching body weight during follow-through.

Common contributing factors:

• GIRD

• Loss of shoulder flexion

• Scapular dyskinesis

• Poor kinetic chain sequencing

• Hip mobility deficits

• Fatigue

• Overuse

• High throwing workloads

Research shows cumulative throwing workload is a stronger predictor of injury than pitch counts alone.

🎾 Tennis

Serving creates repeated high-velocity overhead loading.

Risk factors include:

• Poor thoracic extension

• Tight posterior shoulder

• Weak scapular stabilizers

• Excessive training volume

• Fatigue during tournaments

Pain often occurs during the serve and overhead smash.

🏊 Swimming

“Swimmer’s Shoulder” affects up to 40-90% of competitive swimmers during their careers.

Contributing factors include:

• Extremely high training volume

• Poor scapular endurance

• Internal rotation weakness

• Hypermobile shoulders

• Poor stroke mechanics

• Muscle fatigue

Some elite swimmers perform over one million arm revolutions annually.

🏐 Volleyball

Serving and spiking create repetitive overhead loading similar to baseball.

Risk factors include:

• Scapular instability

• Weak posterior shoulder

• Thoracic stiffness

• Poor landing mechanics

• Excessive hitting volume

• Rotator cuff fatigue

⚠️Common Signs and Symptoms

Athletes often report:

• Pain with throwing or serving

• Pain during late cocking phase

• Night pain

• Loss of velocity

• Decreased control

• Fatigue

• Clicking

• Stiffness

• Weakness

• Pain reaching overhead

• Pain after activity

Many athletes first notice decreased performance before significant pain develops.

Physical Examination

A comprehensive evaluation should include:

✅Mobility

• Shoulder flexion

• Internal rotation

• External rotation

• Horizontal adduction

• Posterior capsule

• Thoracic mobility

• Hip mobility

✅Strength

Assess:

• Rotator cuff

• Serratus anterior

• Lower trapezius

• Middle trapezius

• Rhomboids

• Core

• Gluteals

✅Functional Testing

• Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST)

• Seated Shot Put Test

• Y-Balance Test

• Single-arm plank endurance

• Ball Drop Test

• Medicine ball throw

✅Special Tests

No single test is diagnostic.

Clinicians often combine:

• Hawkins-Kennedy

• Neer

• Empty Can

• Full Can

• External Rotation Resistance

• Posterior Impingement Test

• Apprehension/Relocation

• O’Brien

• Speed’s Test

Imaging

Imaging may include:

X-ray

Looks for:

• Bone spurs

• Arthritis

• Acromial shape

MRI

Evaluates:

• Rotator cuff tears

• Labral injuries

• Biceps pathology

• Bursa inflammation

MRI Arthrogram

Best for:

• SLAP tears

• Instability

• Internal impingement

Ultrasound may also be useful for dynamic rotator cuff evaluation.

⚕️Conservative Treatment

Over 80-90% of overhead athletes improve without surgery when the underlying cause is addressed.

Phase 1: Calm the Pain

Goals:

• Reduce inflammation

• Maintain motion

• Activity modification

• Manual therapy

• Soft tissue work

• Restore sleep

Phase 2: Restore Mobility

Focus on:

• Posterior capsule stretching

• Sleeper stretch (when appropriate)

• Cross-body stretch

• Thoracic extension

• Thoracic rotation

• Pec minor mobility

• Latissimus flexibility

• Hip mobility

Phase 3: Improve Stability

Progressively strengthen:

• Rotator cuff

• Serratus anterior

• Lower trapezius

• Posterior cuff

• Core

• Hips

• Single-leg stability

Research consistently demonstrates that scapular rehabilitation improves pain, function, and return-to-sport outcomes in overhead athletes.

Phase 4: Correct Mechanics

Address:

• Throwing mechanics

• Serving mechanics

• Swimming stroke

• Volleyball hitting mechanics

Video analysis often identifies kinetic chain deficits contributing to shoulder overload.

Phase 5: Progressive Loading

Gradually restore:

• Strength

• Plyometrics

• Deceleration training

• Sport-specific drills

• Interval throwing program

• Interval serving program

• Interval swimming program

• Hitting progression

🏋️‍♂️Role of Sports Physical Therapy

Sports physical therapy should identify why the shoulder became overloaded—not simply treat the painful tissue.

Comprehensive evaluation should include:

• Strength testing

• Range of motion

• Scapular control

• Functional movement

• Core assessment

• Hip mobility

• Thoracic mobility

• Video analysis

• Workload assessment

This whole-body approach is especially important in overhead athletes, where dysfunction elsewhere in the kinetic chain frequently contributes to shoulder symptoms.

👉When Is Surgery Needed?

Surgery is reserved for athletes who fail high-quality rehabilitation or have structural pathology.

Common procedures include:

• Arthroscopic subacromial decompression (less common today for isolated impingement)

• Rotator cuff repair

• SLAP repair or biceps tenodesis

• Labral repair

• Capsular stabilization

• Debridement of partial tears

The trend in modern sports medicine is toward preserving anatomy and avoiding unnecessary decompression procedures unless clear structural pathology exists.

🚦Return-to-Play Guidelines

Athletes should not return based solely on pain relief.

Before returning, they should demonstrate:

✅ Full pain-free ROM

✅ Symmetrical or sport-appropriate shoulder strength

✅ Normal scapular mechanics

✅ Completion of plyometric progression

✅ Completion of interval throwing/serving/swimming/hitting program

✅ Sport-specific functional testing

✅ No pain during or after activity

Suggested Timeline (Typical, Variable by Severity)

Injury	Estimated Return
Mild impingement	2–6 weeks
Moderate tendinopathy	6–12 weeks
Internal impingement	8–16 weeks
Rotator cuff irritation	8–16 weeks
Post-operative repair	6–12 months

Progression should follow soreness-monitoring guidelines. Athletes should have no more than mild soreness that resolves within 24 hours and should not experience progressive loss of velocity, accuracy, or strength.

📢Injury Prevention

The best treatment is prevention.

Successful overhead athletes consistently maintain:

• In-season strength training

• Rotator cuff endurance

• Scapular stability

• Thoracic mobility

• Hip mobility

• Recovery days

• Sleep

• Proper throwing and serving mechanics

• Gradual workload progression

Research has repeatedly shown that structured arm-care and shoulder-prevention programs reduce shoulder and elbow injuries while improving performance.

Final Thoughts

Shoulder impingement is rarely caused by a single structure being “pinched.” Instead, it represents the result of repetitive overload, fatigue, mobility restrictions, muscular imbalance, and inefficient movement patterns throughout the kinetic chain.

For baseball, softball, tennis, swimming, and volleyball athletes, a comprehensive sports medicine approach—combining accurate diagnosis, individualized rehabilitation, workload management, and progressive return-to-play—offers the greatest opportunity for a safe return to competition and long-term shoulder health.

Pain in shoulder? Let us help you get on the road to recovery. Call today for your arm care assessment.

Athletic Edge & Wellness📍 Algonquin, Illinois📞 224-505-3343🌐 www.edge360wellness.com

Athletic Edge and Wellness, Illinois Baseball Edge and 1Top Prospect in Algonquin are your professional throwing partners in baseball/softball performance and arm care: We offer private and team instruction, velocity enhancement, command sessions, throwing form, coaching clinics, Flightscope video assessment, data analytics, physical therapy, performance therapy, normatec recovery, and collegiate recruiting under one roof. Come experience the difference from our pros in the field.