Clinical Reasoning for “Impingement Syndrome”: A Step-by-Step Rule-Out Approach

If you’ve been told you have “Impingement Syndrome”, you might be picturing something in your shoulder getting “pinched” every time you lift your arm. And honestly, that story can feel both scary and oddly vague at the same time.

In my Toronto massage therapy practice, I treat “impingement syndrome” more like a starting label, not a final answer. The goal is to slow things down, listen carefully to your symptoms, and use a step-by-step rule-out approach to understand what’s most likely being irritated, and what needs a different kind of care.

Why “Impingement Syndrome” is a label, not a complete explanation

“Impingement syndrome” is often used as an umbrella term for pain around the front or side of the shoulder, especially with overhead reaching. In research and in many clinics, you’ll also hear terms like subacromial pain syndrome or rotator cuff–related shoulder pain, because the reality is usually more layered than one structure getting “caught.”

What matters most is this: your shoulder pain has a pattern. And patterns give us clues.

Step 1: Start with your story (because the timeline matters)

Before I even think about tissues, I want to understand the context.

I’ll usually ask things like:

• When did this begin, and was it sudden or gradual?
• Was there a specific moment (a lift, a fall, a workout), or did it creep in quietly?
• What changed recently: training volume, new desk setup, sleep, stress, carrying a bag?
• What movements feel sharp, and what movements feel more like fatigue or strain?
• Is it getting better, worse, or staying stubbornly the same?

This part is gentle, but it’s not “small talk.” It’s how we anchor the whole assessment.

Step 2: Rule out the stuff that shouldn’t wait

Massage therapy can be wonderfully supportive, but there are moments when the most caring next step is referral.

I’ll encourage you to seek medical assessment sooner if you have things like:

• A significant fall or force to the shoulder
• A sudden inability to lift the arm (especially after injury)
• Numbness, tingling, spreading symptoms down the arm, or marked weakness
• Fever, feeling unwell, or unexplained weight changes
• Pain that is intense and unrelenting, especially if it’s not influenced by movement at all

This isn’t about alarm. It’s about safety and good clinical reasoning.

Step 3: Map the pain pattern and movement triggers

Next, I’m looking for how the shoulder behaves.

In-session, this often includes:

• How your shoulder blade and upper back move when you lift your arm
• Which ranges feel “pinchy,” which feel stiff, and which feel weak or shaky
• Whether symptoms show up more in active movement (you moving) or passive movement (me moving the arm gently)
• Whether your neck movement changes the shoulder symptoms (sometimes it does)

You don’t need to know the names of the tests for this to be useful. What matters is that we’re building a clearer map.

Step 4: Consider the usual suspects (and the clues that point toward each)

A lot of structures can create “impingement-like” pain. The goal is not to guess, it’s to narrow thoughtfully.

Here are common contributors we consider, in plain language:

• Rotator cuff tendons (often the supraspinatus)
  Often feels like pain with lifting the arm, reaching outward, or controlled lowering. Sometimes it’s more “grabby” than sharp.
• Subacromial bursa (a sensitive cushion-like tissue)
  Can flare with repetitive overhead use and may feel hot, sharp, or very reactive, especially in certain ranges.
• Long head of the biceps tendon (front-of-shoulder ache)
  Often shows up with reaching forward, pulling, or tasks that load the front of the shoulder.
• AC joint irritation (top of the shoulder)
  Often more specific right at the top of the shoulder, sometimes aggravated by cross-body reaching.
• Neck referral (symptoms that “borrow” the shoulder)
  If neck position changes the pain, or if symptoms travel, we keep this on the table.

Also important: no single orthopedic test “proves” impingement. Clusters of findings can help rule things out more than they can perfectly label one structure.

Step 5: Make a plan (and know when to bring in extra support)

Once the picture is clearer, the care plan becomes calmer and more specific.

In massage therapy, the goal is usually to help reduce the protective guarding around the shoulder, improve comfort in surrounding tissues (neck, upper back, chest, posterior shoulder), and support easier movement so rehab work (if needed) is more tolerable.

And just as important: we track progress. If symptoms aren’t shifting in a reasonable way, or if the presentation suggests something beyond an RMT scope, I’ll encourage collaboration with a physiotherapist or physician.

One note that can feel reassuring: many people who’ve been told they have “impingement syndrome” do very well with conservative care over time, and the healthcare world has become more cautious about treating it like a simple “bone pinching tendon” story.

If you’d like support sorting through your shoulder symptoms with calm, thorough assessment and treatment, you’re welcome to book with me at Aurelia RMT in Toronto. We’ll take it step by step, and you won’t be rushed.