Published: September 21, 2026
Shoulder pain in an overhead athlete can reflect an issue with the mechanics of the shoulder rather than a single traumatic injury. Internal rotator cuff impingement is one example, occurring in association with overhead activity and the positions used during throwing.
When evaluating possible shoulder impingement syndrome, recognizing the pattern — and understanding how glenohumeral internal rotation deficit (GIRD) fits into it — can help distinguish impingement from other causes of shoulder pain and identify patients who may need orthopedic evaluation.
In internal impingement, the rotator cuff tendon can become compressed between the labrum and the glenohumeral joint during certain overhead positions.
In a recent installment of Norton Healthcare’s continuing medical education “MedChat” podcast, Caleb Davis, M.D., an orthopedic sports medicine specialist with Norton Orthopedic Institute, discussed internal impingement in overhead athletes and associated it with the late cocking phase of pitching, when the shoulder is positioned for the transition into the throwing motion. The condition also can occur with other overhead activities.
Internal impingement is often associated with GIRD, which refers to loss of internal rotation at the glenohumeral joint. It is often associated with thickening of the posterior capsule, which limits the shoulder’s ability to internally rotate.
When evaluating an overhead athlete with possible shoulder impingement syndrome, this makes range of motion an important part of the assessment. A limitation in internal rotation can be a clue that altered shoulder mechanics are contributing to the patient’s symptoms.
The late cocking phase places the shoulder in a position of substantial rotation as the athlete prepares to accelerate the arm. This phase is central to internal impingement because of the relationship it creates between the rotator cuff, labrum and glenohumeral joint during overhead activity.
This makes the patient’s activity history particularly useful. Asking what movement reproduces the symptoms can provide information that simply identifying the location of the pain may not.
Not every painful shoulder in an overhead athlete represents impingement. The history and examination can help distinguish internal impingement from other sources of shoulder pain.
Rotator cuff tendinitis is another overuse condition to consider. Traumatic instability and labral pathology represent a different category and may be suggested by the mechanism of injury or by symptoms such as a sense of instability.
With anterior instability, patients may describe discomfort or apprehension when the shoulder is externally rotated and abducted — the position used during the throwing motion. Posterior labral pathology may produce pain with loading, such as with bench pressing or pushups.
These distinctions are important when evaluating a patient who presents with what initially appears to be shoulder impingement syndrome. The goal in primary care is not necessarily to identify the precise orthopedic lesion at the initial visit, but to recognize when the presentation fits a mechanical/overuse pattern and when findings suggest another process that warrants further evaluation.
Multidirectional instability (MDI) is another pattern to consider, particularly when instability occurs without a significant traumatic event.
Patients with MDI have hypermobility that may allow the shoulder to subluxate or feel as though it is coming out of the socket. They also may demonstrate hypermobility in other joints.
Recognizing this pattern matters because the treatment approach differs from that of traumatic instability. Treatment emphasizes strengthening the supporting soft tissues and muscles through physical therapy, avoiding surgery whenever possible, although rehabilitation can be prolonged.
When GIRD or internal impingement is a consideration, range of motion — particularly internal rotation — is relevant, since loss of internal rotation is connected to posterior capsular thickening and internal impingement.
The examination also should assess for findings that could point away from a straightforward impingement presentation. Loss of passive range of motion, swelling or deformity are red flags, particularly in the setting of trauma.
Specific examination maneuvers also can help distinguish instability and labral pathology. The apprehension and relocation tests can help evaluate anterior instability.
Treatment starts with stopping or modifying the activity that is provoking symptoms, followed by rehabilitation and physical therapy.
Physical therapy can provide exercise and can be a way to provide structure, monitor progress and guide the athlete through a gradual progression back toward activity.
The rehabilitation approach also can extend beyond the glenohumeral joint, with periscapular strengthening to improve stability and support from the shoulder blade muscles, along with attention to core movement and hip rotation, because efficient overhead movement involves more than the shoulder itself. Structured throwing and pitching programs, such as those offered through Norton Sports Health Performance & Wellness Center, can help build this broader base of strength.
For multidirectional instability, the emphasis is likewise on strengthening the supporting soft tissues and muscles through therapy. Rehabilitation can be prolonged, and these patients should be operated on as little as possible.
Pain relief can be useful while an athlete modifies activity and begins rehabilitation. For appropriate patients, acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) may provide symptomatic relief; medication choice should account for the patient’s other medical conditions, medications and contraindications.
For persistent shoulder pain, a single corticosteroid injection may be considered in selected patients for short-term improvement in pain and function, per the American Academy of Orthopaedic Surgeons’ 2025 clinical practice guideline for rotator cuff injuries.
This should be approached as short-term symptom management rather than a substitute for activity modification, rehabilitation and physical therapy.
The shoulder joint does not generate an overhead movement in isolation.
Injury prevention and rehabilitation should emphasize strengthening the periscapular muscles as well as the contribution of the core and hips, since athletes can become overly focused on generating the throwing motion through the glenohumeral joint while neglecting the contribution of the rest of the body.
That broader approach can be incorporated into rehabilitation rather than focusing exclusively on the painful shoulder.
Many overuse shoulder conditions can be managed nonsurgically with appropriate activity modification and rehabilitation.
The threshold for referral should be lower when there is evidence of traumatic or structural pathology. Several findings warrant earlier evaluation:
A specialist then may perform additional examination maneuvers and determine whether advanced imaging is appropriate.
Importantly, referral does not necessarily mean surgery. Most overuse conditions are successfully treated with conservative care and physical therapy. The patients who require surgery are more commonly those with traumatic instability or labral pathology.
For primary care clinicians evaluating shoulder pain in an overhead athlete, internal impingement is one potential explanation when symptoms are associated with overhead mechanics, particularly the late cocking phase of throwing.
GIRD can be an important associated finding: Loss of internal rotation is linked to internal impingement and posterior capsular thickening.
At the same time, GIRD should not become a default explanation for every painful throwing shoulder. A history of trauma, instability, swelling, deformity or loss of motion should prompt consideration of other pathology and may warrant earlier orthopedic evaluation.
Use the history and examination to identify the pattern of shoulder pain and the findings that change the next step, rather than assuming that every painful overhead shoulder represents the same condition.
1. Ask what phase of activity provokes the pain. Internal impingement is associated with the late cocking phase of throwing and other overhead activity.
2. Check internal rotation. Loss of glenohumeral internal rotation (GIRD) is associated with internal impingement, and posterior capsular thickening can limit internal rotation.
3. Don’t assume every painful throwing shoulder is impingement. Instability, labral pathology and rotator cuff tendinitis can present differently. A sensation that the shoulder is going to come out — particularly with abduction and external rotation — should raise concern for instability.
4. Consider multidirectional instability when instability occurs without significant trauma. Patients with MDI may have generalized hypermobility and may be able to subluxate the shoulder without a specific injury.
5. Look beyond the glenohumeral joint. Periscapular strength, core movement, hip rotation and overall mechanics contribute to overhead movement and may need to be addressed during rehabilitation.