What the pain pattern suggests

The most recognisable sign is a band of pain that appears as you raise your arm out to the side, then eases again once your arm is fully overhead or drops back to your side. This window — roughly between 60° and 120° of shoulder abduction — is called the painful arc, and it is the symptom that most reliably points toward supraspinatus tendinopathy or shoulder impingement rather than another shoulder condition.

Day to day, the discomfort tends to sit at the outer shoulder or into the upper arm. Reaching overhead, tucking your arm behind your back, or lifting something away from the body can all reproduce it. Night pain is another common feature: lying on the affected shoulder compresses the already-irritated tendon, and disturbed sleep is often what prompts a first GP appointment.

Some weakness alongside pain is typical — an inflamed tendon has less capacity to generate force. But a sudden inability to lift the arm at all, or weakness that is markedly disproportionate to the pain, points more toward a tendon tear than simple tendinopathy and warrants earlier specialist review rather than a period of watchful waiting.

Stiffness that limits movement in every direction — not just a painful range — is a different picture altogether. That pattern is more consistent with frozen shoulder (adhesive capsulitis), which follows a distinct clinical pathway and requires separate assessment.

Symptoms build a strong working suspicion, but clinical examination and imaging are what confirm whether the tendon is the source.

Tendinopathy and impingement — what the terms actually mean

Two terms appear on referral letters and GP correspondence so often they seem interchangeable — they are not.

Impingement describes a mechanical event: each time the arm is raised, the supraspinatus tendon gets compressed between the head of the humerus and the underside of the acromion above it. Think of it as the cause, or the recurring insult.

Tendinopathy is what happens to the tendon tissue as a result. It is an umbrella term covering tendinitis (an acute inflammatory response), tendinosis (degenerative change in the tendon's collagen structure without active inflammation), and partial-thickness tears. The damage varies in severity and character — two patients with the same impingement mechanism may present with quite different tissue-level findings on imaging.

What drives impingement also varies. Extrinsic causes include a structurally narrowed subacromial space — a hooked acromion shape, a bone spur, or acromioclavicular joint arthritis pressing down on the tendon. Secondary impingement arises not from bony crowding but from muscle imbalance or poor scapular mechanics, which allow the humeral head to ride upward during arm elevation and compress the tendon from below.

The same patient can carry both labels simultaneously. Treatment may need to target both the mechanism and the tissue damage, and the two do not always respond to the same approach.

Which specialist to see, and when

For most people in the UK, the pathway begins with a GP or physiotherapist — either can make the initial diagnosis based on history and clinical examination, arrange early imaging where it is needed, and refer on to specialist care if the picture warrants it.

Physiotherapist

Once supraspinatus tendinopathy is the working diagnosis, a physiotherapist is the primary treatment clinician. The focus is progressive rotator cuff strengthening, scapular control, and restoring range of motion. Physiotherapy does not require a GP referral in most NHS and private settings, and self-referral is increasingly available across the UK.

Sports medicine physician or physiatrist

Where medical coordination sits alongside rehabilitation — for example when a diagnosis remains uncertain before committing to a rehabilitation programme, or when an image-guided injection is under discussion — a sports medicine physician or physiatrist (PM&R specialist) offers a non-surgical route to specialist assessment and load-management advice.

Orthopaedic shoulder surgeon

An orthopaedic surgeon with a shoulder or sports medicine focus is the appropriate referral when conservative care has not produced meaningful improvement, when a full-thickness rotator cuff tear is suspected, or when there is significant functional loss. Subacromial decompression is within the orthopaedic surgeon's remit, though only once conservative management has been given a fair trial. Acromioplasty alone is no longer recommended as a standalone procedure.

The threshold for orthopaedic referral is not precisely fixed in current UK guidelines — the relevant question is whether a sustained, structured course of conservative care has had a genuine opportunity to work. Search MSK allows you to filter by specialty and region to identify physiotherapists, sports medicine physicians, or orthopaedic shoulder surgeons suited to your current stage.

What a clinical examination involves

Before any physical test begins, the clinician will take a short history. They will ask how the pain started — a sudden traumatic event reads differently from an ache that crept in over weeks — as well as your occupation, any overhead or repetitive arm work, which arm is dominant, and whether rest or movement tends to make things better or worse. This context shapes how the tests that follow are interpreted.

A cervical spine screen typically comes next. Neck pathology can produce shoulder-region pain that mimics rotator cuff symptoms closely, so ruling out a cervical contribution is a standard step before focusing the examination on the shoulder itself.

Four provocation tests are most commonly used:

• Neer Impingement Test — the clinician passively lifts your arm forward while stabilising your shoulder blade. Pain during this movement suggests the supraspinatus tendon is being compressed under the acromion.
• Hawkins-Kennedy Test — your arm is held at 90° in front of you and then rotated inward. A positive result produces pain as the tendon is driven into the subacromial space.
• Jobe Empty Can Test — with your arm out to the side and your thumb pointing downward, you resist downward pressure. Pain or weakness here points to a problem with supraspinatus integrity rather than simple compression.
• Painful Arc Test — you actively raise your arm out to the side through a full arc. Pain that appears roughly between 60° and 120° of lift, then eases beyond that range, is a classic supraspinatus impingement sign.

No single test confirms the diagnosis on its own. The clinician is assembling a picture across all four findings, the history, and any imaging — a positive Hawkins-Kennedy with a normal Empty Can and no arc pain tells a different story from a positive result on all three.

Imaging: X-ray, ultrasound, and MRI

Three imaging modalities are typically used in a supraspinatus tendinopathy pathway, and understanding what each one is looking for explains why more than one scan is often requested.

X-ray does not visualise soft tissue, so it will not show the tendon directly. Its value is structural: an early X-ray can identify subacromial bone spurs, confirm acromion morphology, and detect acromioclavicular joint arthritis — all bony factors that may be narrowing the subacromial space and contributing to mechanical impingement.

Ultrasound is the frontline soft-tissue imaging tool across most UK musculoskeletal pathways. It identifies the hypoechoic lesion patterns associated with tendinopathy, can assess how the tendon moves dynamically as the arm is elevated, and — critically — allows accurate guidance of injections into the subacromial space or directly into a tendon lesion. It is lower cost and avoids the contraindications associated with MRI.

MRI is the reference standard for characterising rotator cuff disorders. It grades supraspinatus tendinopathy severity (broadly Grade I through IV, from mild signal change to full-thickness tear) and provides a complete soft-tissue picture that includes the biceps tendon, labrum, and AC joint — context that ultrasound alone may not capture. MRI and ultrasound are best understood as complementary rather than competing tools.

Sonoelastography — strain ratio imaging — is an emerging adjunct that correlates with MRI-graded tendinosis and may have future utility for monitoring rehabilitation progress, though it is not yet part of routine clinical practice.

One important principle applies across all three modalities: a scan showing tendinopathy is not, by itself, a mandate for intervention. Asymptomatic imaging findings are common, and clinical context — symptom severity, functional impact, and how the condition is progressing — determines the management pathway, not the scan result alone.

When to escalate and how to find the right specialist

Knowing when to step up from self-management can be harder than recognising the original injury. A useful starting point is duration: if shoulder pain has not improved meaningfully after six to twelve weeks of rest and over-the-counter analgesia, a formal clinical assessment is warranted rather than continued waiting.

Certain presentations call for earlier review. A sudden loss of strength, an inability to lift the arm away from the body, or a sharp change in symptoms following a fall or heavy lift should not be left to resolve on their own — these patterns raise the possibility of a rotator cuff tear that requires imaging to rule in or out promptly. Left untreated, progressive tendinopathy can advance to partial or full-thickness tears that require more complex management.

Within a structured physiotherapy programme, the clearest trigger for onward referral is a lack of meaningful progress after a reasonable course of treatment. Persistent night pain that consistently disrupts sleep, or pain that is actively worsening rather than plateauing, also justifies moving to the next stage of assessment sooner rather than later.

Once the decision to seek specialist input is made, Search MSK allows patients to filter by specialty and region across the UK — making it straightforward to identify a physiotherapist, sports medicine physician, or orthopaedic shoulder surgeon suited to the current stage of care.