Orthopedics focuses on the musculoskeletal system. Learn about the diagnosis, treatment, and rehabilitation of bone, joint, ligament, and muscle conditions.
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Diagnosing shoulder impingement is often a clinical process, meaning a skilled doctor can identify it just by moving your arm. However, because shoulder pain can also come from the neck, a tear, or arthritis, imaging is used to confirm the diagnosis and rule out other problems. The goal is to determine what is being pinched and why.
This section explains the diagnostic journey. We will cover the specific physical tests doctors use to provoke the pain (don’t worry, it’s brief!), the role of X-rays in seeing bone spurs, and why MRI is the ultimate tool for checking the health of the rotator cuff tendons.
The diagnosis starts with your story. The doctor will ask about the location of the pain. Impingement pain is typically felt on the outer upper arm (the “deltoid insertion”). Patients often say, “It hurts here,” while rubbing the side of their arm, even though the problem is up in the shoulder joint.
The doctor will ask about “painful arc.” Does it hurt only when reaching high? Does it hurt to reach for a seatbelt? These specific movements stress the subacromial space. A history of overhead work or sports is also a strong clue.
Doctors use “provocative tests” to reproduce your pain intentionally. While uncomfortable, a positive test confirms the diagnosis. The Neer test involves the doctor lifting your arm fully overhead while stabilizing your shoulder blade. This method jams the greater tuberosity of the humerus against the acromion. Pain indicates impingement.
The Hawkins-Kennedy Test involves flexing the arm to 90 degrees and forcibly rotating it inward. This drives the tendon under the ligament. Pain here is a classic sign of subacromial impingement. The doctor will also test your strength to ensure the rotator cuff isn’t torn. Weakness might suggest a tear, while pain with normal strength points more to tendonitis/impingement.
Sometimes, the best diagnostic tool is a needle. The “Impingement Test” involves injecting a local anesthetic (like lidocaine) directly into the subacromial space (the bursa).
If your pain disappears immediately after the injection and you can lift your arm without it, the test is positive. It confirms that the pain was coming from the bursa/tendon interface. If the pain remains, the problem might be inside the joint (like a labral tear) or coming from the neck. This test is highly accurate for localizing the pain source.
This procedure is diagnostic, not therapeutic initially. The goal is temporary numbing.
If the numbing medicine works, it proves the mechanics of the shoulder are fine, but the pain was inhibiting movement. This is a good sign that physical therapy will be effective.
If the doctor injects the shoulder and it still won’t move (it feels physically stuck), this indicates adhesive capsulitis (frozen shoulder) rather than simple impingement.
This distinction is crucial because the treatment for frozen shoulder is very different from the treatment for impingement.
X-rays are the first imaging step. They don’t show the tendon or bursa, but they show the container they live in. X-rays reveal the shape of the acromion (flat, curved, or hooked).
They show bone spurs on the underside of the acromion or under the AC joint (where the collarbone meets the shoulder). They also reveal whether the humeral head is elevated, a sign of a chronic rotator cuff deficiency. X-rays also rule out arthritis or calcific tendonitis (calcium deposits inside the tendon).
MRI is the gold standard for soft tissue. It uses magnetic fields to create detailed slices of the shoulder. An MRI shows the rotator cuff tendons clearly.
It can distinguish between fluid (bursitis), fraying (tendonitis/partial tear), and a complete hole (full-thickness tear). This distinction is vital because a full tear might require surgery sooner than simple bursitis. The MRI also shows the health of the muscles; if the muscle has turned to fat (atrophy), the tear is old and possibly irreparable.
Ultrasound is a fast, painless alternative to MRI. It uses sound waves to visualize the tendon. A major advantage of ultrasound is that it is dynamic.
The doctor can watch the tendon move in real-time as you lift your arm. They can actually see the tendon getting pinched under the bone (dynamic impingement). It allows for side-by-side comparison with the healthy shoulder. While user-dependent, a skilled ultrasound exam is highly accurate for diagnosing impingement and tears.
Unlike an MRI, which is a static picture, ultrasound is a movie. The doctor can ask you to move your arm into the exact position that hurts.
They can see if the bursa bunches up or if the tendon snaps. This dynamic information can be invaluable for understanding the mechanics of the impingement.
Ultrasound is frequently used to guide the diagnostic injection. By seeing the needle on the screen, the doctor can ensure the medication goes exactly into the bursa and not into the tendon itself.
This improves the accuracy of the injection and reduces pain during the procedure.
Shoulder pain can be deceptive. A pinched nerve in the neck (C5-C6 radiculopathy) can send pain radiating to the shoulder that feels exactly like impingement.
The doctor will check your neck range of motion and perform a Spurling’s test (tilting the head back and to the side). If this reproduces your shoulder pain, the issue is likely in the spine, not the shoulder. An MRI of the neck might be ordered to be sure.
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It involves a needle prick and some pressure as the fluid enters the bursa. Most patients tolerate it well, and the relief from the anesthetic is almost instant.
The X-ray shows the bone spur that is causing the tendon problem. Knowing if you have a Type III (hooked) acromion helps the surgeon decide if they need to shave the bone down (decompression) or just treat the inflammation.
Yes, MRIs make loud clanging noises. You will get headphones. If you are claustrophobic, ask about an “open MRI” or sedation.
Yes. Impingement is the rubbing. You can have severe impingement and bursitis (Stage 1 or 2) with a completely intact tendon. The goal of treatment is to stop the rubbing before it becomes a tear.
X-rays are instant. Ultrasound is real-time. MRI results usually take 24-48 hours for a radiologist to read and send a report to your doctor.
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