Inside This section

Home > Teaching > Question for Physiotherapists

Question for Physiotherapists

Internal Impingement of the Shoulder

Welcome to Orthosports Question for Physiotherapists May 2025. This month Dr Leigh Golding discusses internal impingement of the shoulder.

REMINDER: SAVE THE DATE Orthosports Annual Orthopaedic Updates, Saturday, 8th November, 2025, live @UNSW or via webinar. Registrations open later in the year.

If you have a Question that you would like answered on this monthly email please send to education@orthosports.com.au

QUESTION | A 25‐year‐old male baseball pitcher presents with posterior shoulder pain during the late cocking phase of his delivery. He reports morning stiffness, a decrease in pitch velocity, and pain that is reproduced on resisted internal rotation. How would you approach managing this?

Internal impingement is common among overhead athletes, and particularly common in throwing sports such as baseball and cricket. It occurs when the greater tuberosity of the humerus impinges against the posterosuperior glenoid rim during positions of abduction and external rotation, leading to compression of the articular surface of the rotator cuff. Adaptive changes—such as posterior capsular contracture and scapular dyskinesis—often contribute to this pathology [1].

The clinical examination typically reveals reduced internal rotation on the affected side compared to the non‐throwing shoulder. In addition to observing scapular dyskinesis and measuring range-of-motion deficits, several diagnostic tests can help confirm the diagnosis. For example, the posterior impingement test (performed with the arm abducted 90–110° and maximally externally rotated) frequently reproduces the patient’s pain. The relocation test, resisted internal rotation, and apprehension tests are also useful diagnostic maneuvers, while palpation may reveal tenderness along the posterior glenohumeral joint. Plain X-rays may show a Bennett lesion. MRI can clarify diagnostic uncertainty, often revealing associated articular-sided partial-thickness rotator cuff tears or SLAP lesions [2].

Management begins with offloading the shoulder by modifying or temporarily avoiding provocative activities (e.g. throwing). In the initial phase, conservative treatment focuses on pain control—using anti-inflammatory modalities—and gentle range-of-motion exercises. Stretching techniques, such as the “sleeper stretch,” are employed to alleviate posterior capsular tightness and improve internal rotation. Although corticosteroid injections may be used diagnostically in some instances to confirm the pain source, they are generally avoided as a long-term therapeutic option.

Rehabilitation should progress in a structured, phase-based manner. Early-phase rehabilitation emphasizes restoring range of motion and scapular stability through controlled stretching and neuromuscular re-education exercises. As pain subsides, a progressive strengthening program is introduced to rebalance the shoulder musculature. It is critical to target both the internal and external rotators; in healthy throwers, the external rotators should generate at least 66–75% of the force produced by the internal rotators [3]. Specific strengthening exercises include isometric contractions progressing to dynamic resistance exercises (both concentric and eccentric) for the external rotators, which are essential for decelerating the arm during throwing.

Finally, a gradual, supervised return-to-play (return to throwing) protocol is crucial. The athlete should progress from controlled therapeutic exercises to sport-specific drills, ensuring that sufficient strength, range of motion, and neuromuscular control are restored before resuming full competition. In throwing athletes, throwing load and intensity should be titrated carefully as symptoms allow.

Internal impingement can significantly compromise throwing performance, making early diagnosis and intervention critical. Without prompt management, athletes risk prolonged rehabilitation and extended time away from their sport. Collaborating with experienced practitioners in the diagnosis and treatment of internal impingement can help facilitate a timely return to play.

In cases that are refractory to high quality conservative care, arthroscopic surgical intervention, typically involving excision of the Bennett lesion, posterior capsular release, and debridement or repair of SLAP tears or partial-thickness rotator cuff tears may be necessary to enable optimal recovery and return to performance.

References

[1] Corpus KT, Camp CL, Dines DM, Altchek DW, Dines JS. Evaluation and treatment of internal impingement of the shoulder in overhead athletes. World J Orthop. 2016;7(12):776-784.

[2] Nakagawa S, Yoneda M, Hayashida K, Mizuno N, Yamada S. Posterior shoulder pain in throwing athletes with a Bennett lesion: Factors that influence throwing pain. J Shoulder Elbow Surg. 2006;15(1):72-77. https://doi.org/10.1016/j.jse.2005.05.010

[3] Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30(1):136-151.

D r Leigh Golding

Dec-2020	Wrist Ganglions	Dr Kwan Yeoh
Oct/Nov-2020	Medial Meniscal Root Tears	Dr Doron Sher
Sep-2020	Lumbar Stress Fractures	Dr Paul Annett
Aug-2020	Frailty and Healthy Ageing	Dr John Best
Jul-2020	Thumb – Collateral Ligament Tear	Dr Kwan Yeoh
Jun-2020	Shoulder Instability	Dr Doron Sher
May-2020	Hallux Rigidus	Dr John Negrine
Mar/Apr-2020	Achilles Tendon Ruptures	Dr Todd Gothelf
Feb-2020	Distal Biceps	Dr Doron Sher
Nov-2019	Clavicle Fracture Internal Fixation	Dr Doron Sher
Oct-2019	Femoracetabular Impingement (FAI)	Dr Paul Mason
Sep-2019	Imaging for Acute ACL Injuries	Dr Doron Sher
Aug-2019	Joint Relocation	Dr Paul Annett
Jul-2019	Guyon canal surgery	Dr Kwan Yeoh
Jun-2019	Whats new in ACL reconstruction 2019	Dr Doron Sher
May-2019	Cuneiform Fracture	Dr Todd Gothelf
Apr-2019	Flexor Tendon Injuries	Dr Kwan Yeoh
Mar-2019	Chronic Exertional Compartment Synd	Dr Paul Annett
Feb-2019	Achilles Tendon Rupture	Dr John Negrine
Nov-2018	Low Back Pain	Dr Paul Mason
Sep-2018	Concussion part 2	Dr John Best
Jul-2018	Concussion part1	Dr Paul Annett
Jun-2018	Thessaly & McMurray Test	Dr Doron Sher
May-2018	AC Joint	Dr Doron Sher
Apr-2018	Arthritis of the fingers	Dr Kwan Yeoh
Feb-2018	CLAVICLE fractures	Dr Doron Sher
Oct-2017	ACL Grafts	Dr Doron Sher
Sep-2017	Forefoot pain	Dr John Negrine
Aug-2017	Wrist Ganglion	Dr Kwan Yeoh
Jul-2017	Anterolateral Ligament Reconstruction	Dr Doron Sher
Jun-2017	Scapholunate ligament	Dr Kwan Yeoh
Apr-2017	Knee Brace – ACL Reconstruction	Dr Doron Sher
Mar-2017	Sesamoid fractures	Dr Kwan Yeoh
Feb-2017	Plantar Fasciitis	Dr Todd Gothelf
Nov-2016	Sternoclavicular Joint	Dr Doron Sher
Oct-2016	Proximal Humerus Fractures	Dr David Lieu
Sep-2016	Wrist Fractures	Dr Kwan Yeoh
Aug-2016	Patella Instability	Dr Doron Sher
Jul-2016	Snowboarders ankle	Dr Todd Gothelf
May-2016	Cortisone Injections	Dr Paul Annett
Apr-2016	Shoulder Instability_1	Dr Ivan Popoff
Mar-2016	Exercise after TKR	Dr Doron Sher
Dec-2015	Scaphoid OA	Dr Kwan Yeoh
Nov-2015	Greater Tuberosity Fractures	Dr Doron Sher
Oct-2015	Stress Fractures	Dr Paul Annett
Sep-2015	Boxers Fractures	Dr Kwan Yeoh
Aug 2015	Resistance Training	Dr John Best
July 2015	LARS Ligament	Dr Ivan Popoff
Jun-2015	Distal Biceps	Dr Doron Sher
May-2015	Latarjet procedure	Dr Jerome Goldberg
Apr-2015	TFCC Questions	Dr Kwan Yeoh
Mar-2015	Acute Ankle Sprains	Dr Todd Gothelf
Nov-2014	PRPP	Dr Paul Annett
Oct-2014	Driving After Surgery	Dr Doron Sher
Sep-2014	Distal Biceps Rupture	Dr Doron Sher
Aug-2014	Ankle Sprain	Dr Todd Gothelf
Jun-2014	Patella Dislocation	Dr Doron Sher
May-2014	Shoulder Instability	Dr Todd Gothelf
Apr-2014	De Quervains	Dr Kwan Yeoh
Mar-2014	Acromio-clavicular joint injuries	Dr Todd Gothelf
Feb-2014	Chronic Knee Pain	Dr Paul Annett
Dec-2013	Foot and Ankle Questions	Dr John Negrine
Oct-2013	Rotator Cuff Repair	Dr Todd Gothelf
Sep-2013	ACL Reconstruction	Dr Doron Sher
Jul-2013	Slipped Upper femoral epiphysis	Dr Rod Pattinson
May-2013	Skiers thumb	Dr Kwan Yeoh
Apr-2013	Bakers_Cyst	Dr Ivan Popoff
Mar-2013	Tibial Osteotomy vs UKR	Dr Doron Sher
Feb-2013	ALIF success rate	Dr Andreas Loefler
Jan-2013	Lisfranc Injuries	Dr Todd Gothelf
Nov-2012	Anterior Spinal Fusions	Dr Andreas Loefler
Oct-2012	MCL Injuries	Dr Doron Sher
Sep-2012	Compartment Syndrome	DrPaul Annett
Aug-2012	Carpal tunnel	Dr Kwan Yeoh
July-2012	Anterior Process Calcaneus Fx	Dr Todd Gothelf
Jun-2012	Tenodesis vs Tenotomy	DrJeromeGoldberg
May-2012	Osteoarthritis in the young active patient	Dr Doron Sher
Apr-2012	Syndesmosis Sprain	Dr Todd Gothelf
Mar-2012	Triangular Fiocartilage Injuries	Dr Kwan Yeoh
Jan-2012	Shoulder Replacement Older Population	Dr Jerome Goldberg
Dec-2011	Wrist Fracture	Dr Kwan Yeoh
Nov-2011	Adductor Tendon Tear	Dr Paul Annett
Oct-2011	Navicular Pain	Dr Todd Gothelf
Sep-2011	OCD Lesion	Dr Doron Sher
Aug-2011	Metal on Metal Hip Replacements	Dr Andreas Loefler
July-2011	Femoral Neck Stress Fract (Pt 2)	Dr John Best
Jun-2011	Femoral Neck Stress Fractures	Dr John Best
May-2011	PCL Injury Part 2	Dr Doron Sher
Apr-2011	PCL Injury Part 1	Dr DoronSher
Mar-2011	Prolotherapy Autologous Blood Injections	DrPaul Annett
Feb-2011	Shoulder Impingement	Dr Todd Gothelf
Dec-2010	Does Chondral Grafting Work	DrDoron Sher
Nov-2010	Shoulder Immobilisation-Dislocation	Dr Jerome Goldberg
Sep-2010	SLAP Lesions Stable Shoulder	Dr ToddGothelf
Jul-2010	Ankle Sprains	Dr Todd Gothelf
Jun-2010	Dislocation After THR	Dr Peter Walker
May-2010	Acupuncture Muscle Strength Programmes	Dr Paul Annett
April-2010	Full Thickness Rotator Cuff Tears	Dr JeromeGoldberg
Mar-2010	Skiing after TKR	Prof Warwick Bruce
Feb-2010	Fractures of the Clavicle	Dr John Trantalis
Jan-2010	Osteoarthritis of the Knee	Dr Doron Sher
Dec-2009	Fifrth Metatarsal Fractures	Dr Todd Gothelf
Nov-2009	Partial Rotator Cuff Tears	Dr Todd Gothelf

Inside This section

Question for Physiotherapists

Internal Impingement of the Shoulder

QUESTION | A 25‐year‐old male baseball pitcher presents with posterior shoulder pain during the late cocking phase of his delivery. He reports morning stiffness, a decrease in pitch velocity, and pain that is reproduced on resisted internal rotation. How would you approach managing this?

Swollen Ankle

Glenoid track and shoulder instability scoring system

Spontaneous Osteonecrosis

Side Strain

Tarsal coalition

Patella dislocation

Gout

Distal Biceps Rupture

Sport after Total Knee Replacement

High Tibial Osteotomy and Uni Knee Replacement

Achilles Tendon Ruptures

Lateral extra-articular tenodesis

Adding a Patch to Rotator Cuff Repairs

Imaging for ACL Injury

Glenoid Track and Shoulder Instability

OSTEOCHONDRITIS DISSECANS

Accessory Bones of the Foot and Ankle

Hypermobile Lateral Meniscus

Imaging in Musculoskeletal assessment

Shoulder Injury related to vaccine administration

Chondral Grafting in the knee

Syndesmosis Fixation

Hip Precautions following Total Hip Replacement

Reverse Shoulder Replacement Rehabilitation

Chronic Scapholunate Ligament Rupture

Assessing Sports Injury

Discoid Lateral Meniscus

Cavo-Varus (High Arched) Feet

Surgical Treatment of Unstable Shoulder

Full Thickness Tear of Supraspinatus Tendon

Medial Meniscal Root Tears

Wrist Ganglion & Carpal Instability

Lumbar Stress Fractures

Collateral Ligament Tear

Distal Biceps Rupture

Hallux Rigidus

Inside This section​

Question for Physiotherapists

Internal Impingement of the Shoulder

QUESTION | A 25‐year‐old male baseball pitcher presents with posterior shoulder pain during the late cocking phase of his delivery. He reports morning stiffness, a decrease in pitch velocity, and pain that is reproduced on resisted internal rotation. How would you approach managing this?

Inside This section