Version May 2024
INTRODUCTION — Shoulder impingement syndrome (SIS) refers to a combination of shoulder symptoms, examination findings, and radiologic signs attributable to the compression of structures around the glenohumeral (shoulder) joint that can occur during shoulder elevation, abduction, or abduction and internal rotation. Such compression can be external (subacromial impingement) or internal (undersurface cuff and posterior superior labrum) and may lead to persistent pain and dysfunction. SIS is a common cause of shoulder pain among patients presenting to primary care clinics.
The principles of rehabilitation and a physical therapy program for the treatment of SIS are discussed here and should target the anatomic site of impingement. The rehabilitation program for SIS may be used to manage other patients with rotator cuff injuries (eg, tendinopathy) or glenohumeral instability. The assessment of the patient with shoulder complaints and the risk factors, pathophysiology, diagnosis, and general management of SIS and other shoulder problems are reviewed separately. (See "Subacromial (shoulder) impingement syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears" and "Multidirectional instability of the shoulder" and "Superior labrum anterior to posterior (SLAP) tears" and "Evaluation of the adult with shoulder complaints" and "Physical examination of the shoulder".)
DEFINITION AND CLASSIFICATION — Shoulder impingement syndrome (SIS) is a chronic condition that develops when soft tissues are repeatedly compressed between the humeral head and acromion or the humeral head and posterior glenoid when the arm is actively placed into forward elevation, abduction, or abduction and internal rotation. It refers to a combination of shoulder symptoms, examination findings, and radiologic signs rather than injuries to specific structures that are uniformly present.
The classic form of impingement involves the superior surface of the rotator cuff and subacromial bursa getting pinched between the undersurface of the acromion or clavicle during shoulder elevation. Certain effects of chronic shoulder impingement, such as acromial spurring and acromioclavicular hypertrophy, can predispose to rotator cuff tendinopathy and tears. SIS most commonly presents in middle-aged and older adults and is often related to chronic repetitive overuse and overhead positioning. (See "Subacromial (shoulder) impingement syndrome", section on 'Pathophysiology' and "Rotator cuff tendinopathy", section on 'Pathophysiology and mechanism of injury'.)
Throwing athletes can suffer from a unique form of SIS called internal impingement where the undersurface of the rotator cuff and the superior and posterior labrum are compressed when the arm is placed into external rotation, extension, and abduction of the shoulder (ie, the cocking phase of throwing). The different types of SIS and their pathophysiology are reviewed separately. (See "Throwing injuries: Biomechanics and mechanism of injury".)
ANATOMY AND BASIC BIOMECHANICS — The anatomy and basic biomechanics of the shoulder are reviewed separately (figure 1 and figure 2 and figure 3 and picture 1). (See "Evaluation of the adult with shoulder complaints", section on 'Anatomy and biomechanics'.)
PATHOPHYSIOLOGY — Given the nature of contemporary life in resource-rich nations, the pervasiveness of shoulder pain is not surprising. Many of us sit for most of the day, and many of our activities (eg, working at a computer) require spending significant periods in a posture that predisposes us to shoulder impingement: head forward, thoracic spine flexed, shoulders rounded and internally rotated, and scapula protracted (picture 2). In addition, the average person has relatively tight and strong muscles in the anterior torso and upper extremities (pectoralis major and minor, anterior deltoid, subscapularis, and biceps) and relatively weak muscles in the back and posterior shoulder (rhomboids, mid trapezius, shoulder external rotators, and posterior deltoid), which further contribute to this problematic posture.
In addressing shoulder impingement syndrome (SIS), rotator cuff pathology, and many other shoulder problems, we must take into account the effects of this posture upon shoulder function [1-5]. Indeed, careful attention to the contributions of the entire kinetic chain is essential for proper rehabilitation of SIS. For most sports and some daily activities, the lower extremity and torso must be effective in both the creation and transfer of power beginning with push-off from the ground, while proper scapular function and positioning are essential for the effective transfer of force to the upper extremity. If the scapular stabilizing muscles are weak or scapular motion is limited or dysfunctional, there is an increased risk for shoulder impingement.
PRINCIPLES OF REHABILITATION
Guiding principles — The normal biomechanics of any joint can be disrupted by problems intrinsic to the joint or in related structures. Muscles, tendons, or ligaments that are relatively tight/loose or weak/strong can contribute to such problems. To understand and rehabilitate injuries properly, we need to understand the requirements of the involved joint complex and how imbalances in strength and flexibility affect its function. Once the fundamental problems are recognized, a progressive program can be designed to address them.
Proper rehabilitation makes use of several important principles. One is the overload principle, which involves providing a progressive stimulus (or stress) to which the body must adapt [6]. According to this principle, a muscle will only become stronger if resistance is increased. Each exercise program starts with simple movements involving light resistance. Over time, depending upon the muscle group involved, more complex exercises using greater resistance are added as the patient can tolerate them. In other words, as soon as the patient can perform an exercise without difficulty, the amount of weight or the tube tension being used should be increased. Such increases in resistance should be gradual but steady.
Balance is another key principle. Rehabilitation requires that the patient achieve appropriate mobility around the joint in all orientations and balance strength in agonist and antagonist muscle groups (eg, shoulder internal and external rotators). Chronic imbalances in mobility or strength lead to suboptimal outcomes and potential recurrence of injury.
Rarely do joints move in isolation, and successful rehabilitation addresses deficits in mobility and strength along the entire chain of related movement (ie, kinetic chain) that may contribute to the condition at hand. As an example, a throwing athlete needs strong, stable lower extremities to create powerful ground reaction forces that can be transferred to the upper extremity and ultimately the object being thrown. This requires adequate, balanced strength and coordinated movement among the muscles of the lower extremities, hip, and trunk and a stable scapula to serve as the foundation for glenohumeral motion.
It is important to maintain the patient's confidence during rehabilitation. If a program is too easy and provides little benefit, patient compliance may fall; if a program is too difficult, pain may increase and the patient may quit rehabilitation. Increasing the stimulus by an appropriate amount and at an appropriate rate leads to steady improvement.
All therapeutic exercise programs follow the basic steps of rehabilitation:
●Decrease pain and inflammation
●Restore normal range of motion
●Improve individual muscle function
●Restore overall functional capacity
●Educate and direct injury prevention exercises to avoid re-injury
Managing pain — Basic interventions to reduce pain unrelated to rehabilitation are discussed separately. (See "Subacromial (shoulder) impingement syndrome", section on 'Acute treatment'.)
Often, the pace of recovery is determined by pain and inflammation. As an example, shoulder pain can inhibit the primary movers of the shoulder (ie, the rotator cuff). When the rotator cuff is not working properly, the head of the humerus migrates superiorly, impinging on structures in the subacromial space [7,8]. Therefore, decreasing pain and inflammation must be the first step in treating shoulder dysfunction. With shoulder impingement syndrome (SIS), this is accomplished in part by improving scapular stability. Improved scapular stability contributes to better rotator cuff function, and as the rotator cuff becomes better able to hold the head of the humerus against the glenoid fossa during arm elevation, impingement decreases and overall shoulder function improves [9]. In addition, exercises specifically for improving rotator cuff function are necessary to treat SIS.
More generally, pain causes psychological and emotional responses that deter recovery and rehabilitation from shoulder injury [10,11]. Therefore, it is important to acknowledge these stressors and to explain to the patient how their rehabilitation program will proceed. This includes explaining each phase of the program and how some exercises may sometimes exacerbate pain but will ultimately lead to improvements in function and recovery. No exercise should cause severe pain.
Exercise selection and programming — Each muscle group performs specific actions in a particular manner, and rehabilitation of each muscle group involves different exercises and workout volumes (ie, number of exercises, sets, and repetitions). In general, we prefer to use several different exercises to ensure that every major movement for each involved muscle is appropriately trained. Another benefit of using a range of exercises is the ability to modify a program based upon the patient's abilities and limitations; for example, when a patient is unable to perform a particular exercise. For the rotator cuff (figure 4), the major movements are internal rotation (subscapularis), external rotation (teres minor, infraspinatus), and abduction (supraspinatus); and for the muscles that provide scapular stability (figure 5), the major movements are retraction, elevation, and depression-rotation (or protraction) of the scapula.
In addition, researchers in rehabilitation have identified the need to create specific training regimens for postural muscles versus phasic muscles [12]. Postural, or tonic, muscles are primarily involved in endurance functions and contract over longer periods while phasic muscles primarily perform in short bursts of activity and exert greater power. The number of repetitions used for a particular exercise will vary depending upon the muscle type. As an example, a high number of repetitions (50 to 100) is necessary to improve the endurance of postural muscles, while phasic muscles become stronger when performing fewer repetitions (10 to 20) using greater resistance.
Exercise technique — Proper exercise technique and posture are essential for effective physical therapy. During rehabilitation, exercises for the shoulder complex should be performed in a deliberate, controlled manner; patients must avoid using momentum to make exercises easier. The muscles involved in executing a particular movement should move smoothly. If a patient is unable to complete the prescribed number of repetitions in a controlled manner, it is better to stop as soon as the form starts to break down, rather than risk injury, and build up to the desired number over time. Our goal is to improve muscle function, not just to complete the sets and repetitions.
Appropriate exercise technique depends in part on whether a muscle is contracting concentrically or eccentrically. When a muscle is contracting and the lever arm is shortening, this is called a concentric contraction. One example is the biceps muscle when a person is pulling their body up to the bar during a chin up. Concentric exercises during physical therapy are generally performed to a two-second count. When a muscle is contracting and the lever arm is lengthening, this is called an eccentric contraction (sometimes referred to as a "negative" repetition by weightlifters). An example would be the biceps muscle when a person is lowering their body down from the bar to the ground during a chin up. Eccentric exercises during physical therapy are generally performed to a four-second count.
These second counts reflect the importance of using controlled, deliberate movements to perform resisted rehabilitation exercises and the relative strength of eccentric movement generally. This approach ensures that the appropriate muscles are doing the work and the role of momentum is minimized. In addition, an eccentric contraction can generate forces up to one and one-third times that of a concentric contraction involving the same muscle. By increasing the duration of the eccentric contraction, a suitable challenge is created for the muscle without changing the load.
Of note, eccentric contraction involves the breaking of actin-myosin cross-bonds in muscle sarcomeres, while concentric contraction involves the creation of such cross-bonds. The breaking of cross-bonds is associated with the delayed-onset muscle soreness resulting from weight lifting and other intense athletic activities involving significant eccentric contraction under a load [13].
Posture and ergonomics — Posture has a large effect on muscles and movement, and this is particularly true of the shoulder. If exercises are performed with slumped, internally rotated shoulders and poor spinal posture, anterior muscles such as the pectoralis major (which in most patients are too tight and too strong relative to the muscles of the upper back and rotator cuff) can overcompensate for deficiencies elsewhere, and physical therapy will be ineffective. Optimal rehabilitation for shoulder impingement includes careful assessment of deficiencies in posture and links along the entire kinetic chain, especially deficiencies in scapular strength and mobility.
Once rehabilitation is completed and healthy shoulder function is achieved, it is crucial that patients not resume the postures and practices that predispose to disability. Therefore, it is important that patients continue to perform a few times each week a subset of exercises prescribed by the physical therapist that will maintain the strength of the scapular stabilizers and rotator cuff muscles and overall shoulder function. In addition, proper posture and ergonomics at home, work, and play are essential to avoiding a recurrence of shoulder impingement (table 1). Techniques for improving and maintaining proper posture and ergonomics are reviewed separately. (See "Overview of joint protection", section on 'The principles of joint protection'.)
REHABILITATION PROGRAM
Overview — Rehabilitation of any injury requires a specific plan and exercise progression. With shoulder impingement syndrome (SIS), there are four primary goals of rehabilitation [3,14-16]:
●Strengthen the muscles that stabilize the scapula: By strengthening the scapular stabilizers, greater stability is provided for the rotator cuff muscles, which originate on the scapula. This stability allows for greater efficiency and muscular endurance of the rotator cuff and improved overall shoulder function. This is a critical first step in rehabilitation. A subset of patients with deficiencies in scapular motion may need these addressed.
●Correct imbalances in strength and flexibility about the glenohumeral joint, including optimizing rotator cuff strength and ensuring mobility of the posterior shoulder capsule: Typically, before rehabilitation, the muscles at the front of the shoulder complex (anterior deltoid, internal rotator [ie, subscapularis]) are 1.5 to 2 times stronger than those at the posterior (posterior deltoid, external rotators).
●Stabilize the secondary movers of the shoulder complex: Once the primary muscles of the shoulder are strong and functional, the next step is to rehabilitate the secondary shoulder muscles in order to improve coordination of the entire shoulder complex.
●Correct imbalances, weaknesses, or dysfunction at any segment along the kinetic chain (ankle, knee, hip, torso, etc).
In addition to these four primary goals, a fifth goal for many athletes is to improve sport-specific biomechanics and function. This may entail performing exercises that simulate key movements in their sport using resistance or other techniques to improve performance. Proper technique is an essential component of this phase.
Patients should be made aware that successful completion of such a program generally requires 8 to 16 weeks, but some improvement is usually noted within the first three to four weeks. A patient who has successfully completed a rehabilitation program for SIS should have complete, pain-free motion of the glenohumeral joint and should be able to perform all functional movements and exercises in the program without pain. Several months following the completion of rehabilitation may be needed before pain during sleep completely resolves.
It is important to maintain the patient's confidence during rehabilitation. If a program is too easy and provides little benefit, patient compliance may fall; if a program is too difficult, pain may increase and the patient may quit rehabilitation. To avoid such problems when rehabilitating patients with shoulder pain, it is important to distinguish between SIS and rotator cuff tears at the outset and to refer patients back to their primary care or sports medicine clinician to discuss possible surgical evaluation as soon as the need is recognized (eg, patient demonstrates significant weakness consistent with a substantial rotator cuff tear). A discussion of how to work through the differential diagnosis of the adult with shoulder pain and specific discussions of how to diagnose a rotator cuff tear are provided separately. (See "Evaluation of the adult with shoulder complaints" and "Presentation and diagnosis of rotator cuff tears".)
Step one: Improve scapular stability — Scapular instability is common in patients with SIS, and improving the stability of the scapula is the first goal in rehabilitating these patients. The scapula is the origin for the rotator cuff muscles, and thus, if it is unstable, rotator cuff contractions are weaker and less efficient. Strengthening the muscles that stabilize the scapula allows for better rotator cuff function [1-4,16-21]. The muscles targeted in this phase of physical therapy are, in order of importance, the rhomboid and mid-trapezius, lower trapezius, upper trapezius and levator scapulae, and the serratus anterior.
The key to success in this step is getting the patient to focus on the scapula. This is often accomplished by having the patient exaggerate squeezing the shoulder blades together. Initially, it may help for the clinician or therapist to place a finger or object in the space between the scapulae while this is done. The most common mistakes that patients make when performing these exercises are overemphasizing arm movement and neglecting scapular movement.
The muscles providing scapular stability contract continuously during the day to help maintain posture. Thus, the patient must perform exercises using relatively low resistance but many repetitions in order to improve the endurance of these muscles. In one randomized trial of patients with chronic SIS, the group assigned to rehabilitation involving exercises performed with high repetitions (three sets of 30) demonstrated significantly greater improvements in pain and function than the group treated with low repetitions (two sets of 10) [22].
The author's preferred exercises for scapular stabilization include:
●Row – Use tubing anchored to a doorknob, table leg, or sturdy stair banister. While standing, hold the tubing in each hand at about waist height. Pull the tubing back by letting the elbows bend and squeezing the shoulder blades together as much as possible, as if you are trying to hold a pencil between your shoulder blades (picture 3 and movie 1). Pull back while slowly counting to two, and then return to the starting position while slowly counting to four. Perform two sets of 20 to 25 repetitions with 30 seconds of rest between sets.
●Shoulder extension – Use tubing anchored to a doorknob, table leg, or sturdy stair banister. While standing, hold the tubing in each hand at about waist height. Keeping the elbows straight, pull the tubing back and squeeze the shoulder blades together as much as possible, like you are trying to hold a pencil between your shoulder blades (picture 4 and movie 2). Pull back while slowly counting to two, and then return to the starting position while slowly counting to four. Perform two sets of 20 to 25 repetitions with 30 seconds of rest between sets.
●Scapular downward rotation and depression ("Supermans") ‒ Lay on your stomach with your arms straight and directly overhead. Lift your arms off the floor and hold the position while slowly counting to two, and then slowly lower your arms while counting to four (movie 3). Perform two sets of 20 to 25 repetitions with 30 seconds of rest between sets.
●Horizontal shoulder abduction – Use tubing anchored to a doorknob, table leg, or sturdy stair banister. While standing, hold the tubing in each hand at about shoulder height. Keeping the elbows straight, pull the tubing back and squeeze the shoulder blades together as much as possible (movie 4). Your arms and body will form a T shape. Pull back while slowly counting to two, and then return to the starting position while slowly counting to four. Perform two sets of 20 to 25 repetitions with 30 seconds of rest between sets. The exercise can be performed from a prone position, using dumbbells if added resistance is desired (picture 5 and movie 5).
The authors prefer to have patients begin performing these exercises using rubber tubing for resistance and performing a moderate number of repetitions (eg, 15 to 20). Gradually, the patient works up to three sets of 50 to 100 repetitions [3]. For most patients, it is reasonable to increase the number of repetitions by five each session. It is generally safe for the patient to increase the resistance of an exercise (eg, use tubing with greater tension) when they can successfully perform two to three sets of 50 repetitions without an increase in pain. For each group of exercises, it usually takes two to three weeks for a patient to achieve the full number of repetitions and progress to more difficult tubing.
Tubing is made by a number of manufacturers, and different tubes or bands have variable resistance. As an example, Thera-Band tubing has resistance as follows: yellow tubing 2.4 to 3.4 lbs (1.1 to 1.5 kg), red 3.7 to 5.5 lbs (1.7 to 2.5 kg), green 4.6 to 6.7 lbs (2.1 to 3 kg), blue 5.8 to 8.6 lbs (2.6 to 3.9 kg), black 7.3 to 10.2 lbs (3.3 to 4.6 kg), silver 10.2 to 15.3 lbs (4.6 to 6.9 kg).
Once an appropriate number of repetitions can be performed for each exercise above using more difficult tubing, patients begin using weighted resistance. Suitable exercises to perform once this stage is reached include:
●Seated rows ‒ While seated, grasp the handle of a pulley bar directly in front of you and, while maintaining an erect posture, gradually pull the bar straight to your belly, hold for one second, and then return the bar to the starting position (picture 6). Do three sets of 15 repetitions with a weight that does not cause pain but challenges the muscles. Work up to three sets of 20 repetitions without pain, while maintaining proper form, before increasing the weight. Each time the weight is increased, begin with three sets of 15 repetitions and work up to 20 repetitions.
●Close-grip pull-downs ‒ While seated, grasp the handle of an overhead pulley bar and, while maintaining good posture, gradually pull the bar straight to your chest, hold for one second, and then return the bar to the starting position (picture 7). Do three sets of 15 repetitions with a weight that does not cause pain but challenges the muscles. The progression is identical to that for seated rows.
●I-T-Ys with dumbbells ‒ I-T-Ys can be performed in different positions, and one or both arms can be used; the authors' preferred approach is described here. Begin by lying prone with your upper torso extended beyond the edge of a stable, flat surface. An examination table, bed, weight bench, or stability ball can be used. Initially, perform each exercise without weight for two sets of 15 to 20 repetitions. As the exercises become easier, add resistance in one-pound (0.45-kg) increments until the exercises can be performed using 8- to 10-pound (3.6- to 4.5-kg) dumbbells.
"I" exercises begin with the involved arm hanging straight down from the shoulder. Keeping the elbows straight, extend your shoulders until the arms are pointing straight down and are adjacent to your torso (picture 8). Hold this position for one second, and then slowly return the arms to the starting position. When performed with resistance, the exercise can done prone with dumbbells (movie 6) or standing with tubing (movie 7).
"T" exercises begin from the same starting position. Keeping the elbows extended, raise your arms straight to the side (combination of shoulder extension and abduction) until they are perpendicular to the torso (if both arms are used, the arms and torso form a T) and in line with the body (picture 9 and picture 10). Hold the position for one second, and then slowly return the arms to the starting position. When performed with resistance, the exercise can done prone with dumbbells (movie 8) or standing with tubing (movie 9).
"Y" exercises begin from the same starting position. With the elbows extended and the thumbs pointing up, flex your shoulders in a plane approximately at a 45-degree angle from the body until the arms are in line with the body (if both arms are used, the arms and torso form a Y) (picture 11). Hold the position for one second, and then slowly return the arms to the starting position. When performed with resistance, the exercise can done prone with dumbbells (movie 10) or standing with tubing (movie 11).
●Shoulder shrugs – Holding a dumbbell in each hand, gradually shrug your shoulders completely, hold the top of the shrug for one second, and then gradually lower them to the starting position (movie 12). Do three sets of 15 repetitions with a weight that does not cause pain but challenges the muscle. The progression is identical to that for seated rows.
In the final stages of rehabilitation, more complex exercises are performed. These exercises may involve the use of suspension training (eg, TRX), free weights, or other equipment. However, regardless of the complexity of the movement or the equipment used, the exercises should involve relatively low resistance but steadily build to a high number of repetitions (50 to 100). With each new group of more challenging exercises, the patient should begin with lighter resistance and perform two to three sets of 15 repetitions. Gradually, the number of sets and repetitions are increased until the patient can perform three sets of 50 to 100 repetitions. Then, resistance is gradually increased, and the process begins anew. Repetitions can be increased for as long as there is no shoulder pain.
Stretching — Many patients with SIS have inadequate flexibility in the muscles of their anterior shoulder and chest and tightness in the posterior capsule of their glenohumeral joint. These problems contribute to shoulder impingement, and thus an important part of rehabilitation for SIS is a stretching program [23]. Stretching exercises are performed throughout rehabilitation.
The authors prefer the following stretching exercises:
●Corner stretch (for chest and anterior deltoid) (movie 13 and picture 12)
●Posterior capsule (cross-body) stretch (movie 14 and picture 13)
●Sleeper stretch (movie 15 and picture 14)
●Pectoralis minor stretch (movie 16 and picture 15)
The sleeper stretch and posterior capsule stretch can place some patients in positions of impingement, especially during the acute inflammatory phase of SIS. Modified versions of the sleeper and posterior capsule stretches can be used to avoid such positions; we instruct patients not to extend these stretches to the point that they cause pain [23-26].
Each stretch is held for 30 seconds and repeated three times. A rest interval of about 60 seconds between sets is generally adequate. For exercises that involve one extremity at a time, both sides should be stretched.
During the initial stages of rehabilitation, pain may limit the patient's ability to perform stretches. Thus, early on, patients stretch once a day to the extent that they can without causing pain. However, improving flexibility generally requires more frequent training than improving strength. Therefore, as pain subsides and patients are able to perform physical therapy exercises, we tell patients to stretch twice daily. When patients reach the final phase of shoulder rehabilitation and are preparing to resume their usual activities, we tell patients to stretch two to three times daily and have them continue this regimen until they achieve full, pain-free shoulder movement. Thereafter, they can stretch following exercise to maintain flexibility.
Step two: Strengthen the rotator cuff — There are four rotator cuff muscles involved in three distinct shoulder movements (although the coordinated action of all four muscles is essential for healthy shoulder function). To address strength imbalances among the rotator cuff muscles, it is necessary for patients to perform exercises that isolate particular muscles.
Although rotator cuff muscles perform postural functions during some activities of daily living, the rotator cuff muscles are primarily phasic and most often perform short bursts of activity. Phasic muscles become stronger when performing exercises with 10 to 20 repetitions. Thus, the best rehabilitation volume consists of two to three sets of 10 to 20 repetitions. As soon as the patient can perform a workout without difficulty, the amount of weight or the tube tension being used should be increased. Increases in resistance should be gradual but steady. (See 'Principles of rehabilitation' above.)
It is important that the patient perform the rotational exercises described below in a deliberate, controlled manner, thereby forcing the muscles involved to rotate the arm and stabilize the glenohumeral joint simultaneously.
Supraspinatus — SIS often involves weakness or dysfunction of the supraspinatus muscle, which is involved in abduction of the arm. Therefore, exercises to strengthen this muscle are generally included in the rehabilitation program.
Abduction exercises performed with the thumbs pointed upwards are the safest way to train the supraspinatus, according to a systematic review of biomechanical and clinical studies performed to identify the most effective rehabilitation exercises for rotator cuff and scapulothoracic muscles [14,27]. These exercises are sometimes referred to as "full can" exercises because the patient's hands are positioned as if they are holding a full can of liquid they do not want to spill. Exercises that isolate the supraspinatus but are performed with alternative positioning have been found to compress subacromial structures.
The progression of exercises used to strengthen the supraspinatus consists of the following:
●Isometric holds in the mid-range of abduction using the "full can" position (picture 16 and movie 17) ‒ Start with your arms hanging straight down from your body. With your arm in a thumbs-up position, lift your arm in a plane at approximately 45 degrees of shoulder external rotation (ie, arm in front of your body) to waist height so that it engages the counter or a wall and then maintain it at this height for five seconds. Perform two sets of 10 to 15 repetitions. When this exercise can be performed without pain, progress to the next exercise.
●Active abduction using the "full can" position (movie 18) ‒ Start with your arms hanging straight down from your body. With your arm in a thumbs-up position, lift your arm in the plane of the scapula, approximately 45 degrees anterior to the frontal plane, hold this position for one second, and then slowly return to the starting position (picture 17). Perform three sets of 15 repetitions.
●Active abduction using the "full can" position against resistance (tubing or free weights) (picture 18 and movie 19) ‒ Start with your arms hanging straight down from your body while holding a 1-lb (0.45-kg) dumbbell. Alternatively, you can use light resistance tubing attached at about waist height to a fixed object behind you. With your arm in a thumbs-up position, lift your arm in a plane at approximately 45 degrees of shoulder external rotation to shoulder height. Perform three sets of 15 repetitions. Each time you are able to perform three sets of 20 repetitions without pain, add 1 lb (0.45 kg) to the load being raised. A reasonable goal for the average patient is to perform the exercise with 10 to 12 lbs (4.5 to 5.5 kg) for three sets of 20 repetitions.
Avoid elevating the arm too much in these exercises.
External rotators (infraspinatus and teres minor) — The infraspinatus and the teres minor are the rotator cuff muscles responsible for external rotation of the shoulder. In addition, the external rotators decelerate the humerus during overhand throwing and racquet sports. These muscles are trained together during rehabilitation.
Several exercises can be used to strengthen the external rotators, and selection is sometimes based upon the specific activities in which the patient participates. The author prefers to begin with isolated movements and then progress to more complex movements designed to help the patient improve performance in their chosen activity.
A typical progression of exercises used to strengthen the external rotators consists of the following:
●Isometric holds in neutral position (picture 19 and movie 20) ‒ Standing with your body perpendicular to a wall, flex your elbow to 90 degrees and make sure that your posture is erect. While keeping your elbow tight to your side throughout the exercise, push your forearm into the wall by externally rotating your shoulder. Maintain the contraction for five seconds and then relax for two to five seconds. Perform two sets of 10 to 15 repetitions. When this can be done without pain, progress to the next exercise.
●Active external rotation with the arm held in neutral position ‒ While standing or sitting, flex your elbow to 90 degrees. Keeping your elbow tight to your side throughout the exercise, externally rotate your shoulder so your forearm travels approximately 90 degrees; your forearm will move from touching your abdomen until it points directly in front of your torso. Perform three sets of 15 repetitions.
●Active external rotation while lying on the side ‒ While lying on the uninvolved side, rest your affected arm on the side of your torso and flex the elbow to 90 degrees, allowing your forearm to rest against your abdomen. Keeping your elbow tight to your side throughout the exercise, externally rotate your shoulder such that your forearm moves a little beyond 90 degrees (ie, forearm is just beyond parallel to the floor). Perform three sets of 15 repetitions.
●Active external rotation against resistance, using either tubing or free weights (movie 21 and movie 22) ‒ Stand with your body perpendicular to the wall or to the site to which the tubing is anchored. Hold the weight or tubing in the hand furthest from the wall or anchor site and flex your elbow to 90 degrees. If you are using tubing, move away from the site to which the tubing is anchored until there is no slack and your forearm is resting against your abdomen (picture 20). Keeping your elbow tight to your side throughout the exercise, externally rotate your shoulder until the forearm is slightly more than 90 degrees from your body. The goal is to perform three sets of 20 repetitions with 10 to 15 lbs (4.5 to 6.8 kg), or at least 50 percent of the resistance used for internal rotation exercises.
In order to isolate the rotational component of these exercises, it is often helpful to have the patient pinch a towel between their body and the arm involved in performing the exercise.
Subscapularis — Internal rotation of the shoulder is performed by the subscapularis, a relatively large muscle that originates on the undersurface of the scapula. The subscapularis is generally quite responsive to exercise and rarely limits the rehabilitation potential of the patient with SIS or other shoulder problems. Therefore, beginning isometric exercises are usually unnecessary unless the shoulder has sustained acute trauma involving an anterior glenohumeral force moment (eg, anterior glenohumeral dislocation). In such circumstances, rehabilitation would begin with isometric holds in a neutral position, with the patient performing two sets of 15 repetitions with five-second holds for each repetition (movie 23).
In most circumstances, a typical progression of exercises used to strengthen the subscapularis consists of the following:
●Active internal rotation with the arm held in neutral position ‒ Stand or sit and flex the elbow of your involved arm to 90 degrees. Keeping your elbow tight to your side throughout the exercise, begin with your forearm pointing straight in front of your body and then internally rotate your shoulder, moving your forearm until it rests against your abdomen. Perform three sets of 15 repetitions.
●Active internal rotation while lying on the side (picture 21 and movie 24) ‒ While lying on your involved side, position your bottom (ie, affected) arm under your body and flex the elbow to 90 degrees, allowing your forearm to rest against the floor or table. Keeping your elbow tight to your side throughout the exercise, internally rotate your shoulder until your forearm touches your abdomen. Perform three sets of 15 repetitions.
●Active internal rotation against resistance, using either tubing or free weights (movie 25 and movie 26) ‒ Stand with your body perpendicular to the wall or to the site to which the tubing is anchored with the affected arm closest to the wall. Hold the weight or tubing in the hand closest to the wall or anchor site and flex your elbow to 90 degrees. If you are using tubing, move away from the site to which the tubing is anchored until there is no slack and the forearm arm is rotated a little more than 100 degrees from your body (picture 22). Keeping your elbow tight to your side throughout the exercise, internally rotate your shoulder until the forearm touches your abdomen. The goal is to perform three sets of 20 repetitions with 15 to 25 lbs (6.8 to 11.3 kg).
Step three: Improve overall strength and coordination of shoulder complex — Gaining strength in isolated movements is essential for proper rehabilitation, but exercises to improve coordinated shoulder movement are a critical and often overlooked final step in treatment that is necessary to attain maximal function.
As symptoms and shoulder function improve, patients gradually resume their usual daily activities. These activities often include manipulating an object overhead at arm's length (eg, removing or replacing a dish from a high shelf). Thus, the final stages of SIS rehabilitation should include more challenging functional exercises that develop the scapular stability and rotator cuff strength necessary to counteract the torque created at the end of the lever arm when they perform such activities. Incorporating more complex movements, like combined internal and external rotation or diagonal pulls across the body, and more difficult exercises, such as plyometric and closed kinetic chain exercises, helps to achieve these functional goals.
Two exercises suitable for the general patient population that help to improve overall shoulder strength and coordination are the following:
●Active internal rotation against resistance in a "90-90" position (movie 27) ‒ Attach appropriate tubing to a stationary object at about waist height. Stand facing away from the object while holding the tubing at head height with the arm in a "90-90" position (90 degrees of elbow flexion and 90 degrees of arm abduction). Internally rotate the shoulder until the forearm is parallel to the ground (picture 23). The goal is to perform three sets of 20 repetitions with blue or black tubing (or 20 to 30 lbs [9.0 to 13.6 kg] of resistance).
●Active external rotation against resistance in a "90-90" position (movie 28) ‒ Attach appropriate tubing to a stationary object at about waist height. Stand facing the object while holding the tubing at head height with the arm in a "90-90" position (90 degrees of elbow flexion and 90 degrees of arm abduction). Externally rotate the shoulder until the forearm is perpendicular to the ground (picture 24). The goal is to perform three sets of 20 repetitions with blue or black tubing (or 10 to 15 lbs [4.5 to 6.8 kg]) or 50 percent of internal rotation resistance.
An overhead press, either during this step or step four below, is another important type of exercise to include, as it helps to restore normal coordinated overhead shoulder movement. When recovering from injury, patients sometimes persist in using abnormal movement patterns that avoid previously painful positions or motions. Therefore, as the patient progresses toward the final phase of rehabilitation, it is important that they maintain proper scapulothoracic posture and that the scapular stabilizers and rotator cuff muscles work in a smooth, coordinated manner while moving the shoulder. Overhead press exercises help to achieve such movement (picture 25 and picture 26 and picture 27). In addition, such coordinated movement helps to reduce the compressive forces generated by the deltoid muscle as it regains strength during rehabilitation.
Exercises involving more complex movements are used for patients with specific needs, such as athletes preparing for a particular sport, but these are beyond the scope of this topic.
Step four: Improve strength, mobility, and coordination throughout kinetic chain — This final step is largely beyond the scope of this discussion but consists of carefully assessing the entire kinetic chain involved in shoulder function; identifying deficits in strength, mobility, and coordination; and implementing a program to address any such deficits. The goal is to ensure adequate, balanced strength and coordinated movement among the muscles of the lower extremities, hip, and trunk muscles and a stable scapula to serve as the foundation for glenohumeral motion. If deficits in the kinetic chain persist, the risk of injury remains.
WHERE TO BEGIN — When deciding how to begin a rehabilitation program for the patient with shoulder impingement syndrome (SIS), it is important to determine the type and stage of their shoulder pathology. Is the problem acute inflammation or chronic overuse? Is there a history of shoulder problems in the affected extremity? Is a significant rotator cuff tear suspected?
Whenever SIS is suspected but there is doubt about the precise nature of the problem, it is best to begin treatment with simple isometric exercises. The patient can then progress to active range of motion exercises as tolerated, and finally to resisted exercises. (See 'Principles of rehabilitation' above.)
The management of rotator cuff tears is debated, and most patients with a suspected tear can be assessed by any physician experienced in the management of shoulder disorders. Active patients with a suspected rotator cuff tear associated with significant shoulder weakness or instability who present acutely following an injury should be referred immediately to an orthopedic surgeon. (See "Management of rotator cuff tears".)
A discussion of how to work through the differential diagnosis of the adult with shoulder pain and specific discussions of how to diagnose rotator cuff tendinopathy and rotator cuff tear are provided separately. (See "Evaluation of the adult with shoulder complaints" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)
EVIDENCE SUPPORTING THIS APPROACH — Much of the evidence supporting the approach to physical therapy for shoulder impingement syndrome (SIS) described in this topic consists of clinical experience, biomechanical studies, and observational data [3,14,28-30]. However, further support can be found in a small number of clinical trials. A broad study of systematic reviews assessing non-surgical treatments for subacromial shoulder pain noted the variable quality of available evidence but concluded that a strong recommendation can be made for exercise therapy as first-line treatment to reduce pain and improve shoulder mobility and function [31].
In an important, controlled trial of 102 patients with chronic SIS (symptoms >6 months), the group randomly assigned to treatment with a physical therapy program designed specifically for SIS showed significantly greater improvements in shoulder function and patient satisfaction than the group managed with general exercises for the shoulder and neck [15]. The mean change in the Constant-Murley shoulder assessment score was 24 points for patients in the specific program (95% CI 19-28) and 9 points in the general exercise group (95% CI 5-13). The specific program consisted of eccentric strengthening exercises for the rotator cuff and both concentric and eccentric exercises for the scapula stabilizers performed with progressive resistance, along with manual mobilization. At five-year follow-up, the intervention group continued to show significant improvements in all outcomes compared with the control group [32].
In addition to the exercise-based rehabilitation program described in this topic, manual manipulation of the involved shoulder to improve mobility (ie, manual therapy), when performed by experienced physical therapists, appears to improve outcomes in patients with SIS [31,33-36].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Shoulder soft tissue injuries (including rotator cuff)".)
SUMMARY AND RECOMMENDATIONS
●Definitions of shoulder impingement – Classic shoulder impingement syndrome (SIS) is a chronic condition that develops when soft tissues are repeatedly compressed between the humeral head and the acromion when the arm is actively raised overhead. A specific subtype of SIS called internal impingement is seen in overhead athletes (eg, pitchers, tennis players) and involves impingement of the posterior superior glenoid labrum and undersurface rotator cuff by the humeral head and posterior superior glenoid. (See "Subacromial (shoulder) impingement syndrome".)
●Goals of rehabilitation – Rehabilitation of SIS requires a specific plan that includes appropriate exercises and progressions. Our suggested plan for general rehabilitation of SIS is described in the text. This plan is organized around four primary goals of rehabilitation (see 'Principles of rehabilitation' above and 'Rehabilitation program' above):
•Strengthen the muscles that stabilize the scapula ‒ By strengthening the scapular stabilizers, greater stability is also provided for the rotator cuff muscles, which originate on the scapula. This stability allows for greater efficiency and muscular endurance of the rotator cuff and improved overall shoulder function. (See 'Step one: Improve scapular stability' above.)
•Correct imbalances in strength and mobility about the glenohumeral joint, focusing on the rotator cuff muscles and posterior shoulder capsule tightness ‒ Typically, before rehabilitation, the muscles at the anterior of the shoulder complex (anterior deltoid, internal rotator [ie, subscapularis]) are disproportionately stronger than those at the posterior (posterior deltoid, external rotators). (See 'Step two: Strengthen the rotator cuff' above.)
•Stabilize the secondary movers of the shoulder complex ‒ Once the primary muscles of the shoulder are strong and functional, the next step is to rehabilitate the secondary shoulder muscles in order to improve coordination of the entire shoulder complex. (See 'Step three: Improve overall strength and coordination of shoulder complex' above.)
•Correct imbalances, weakness, and dysfunction at any segment along the kinetic chain. (See 'Step four: Improve strength, mobility, and coordination throughout kinetic chain' above.)
●Completion of rehabilitation – Successful completion of the SIS rehabilitation program generally requires from 8 to 16 weeks, but some improvement is usually noted within the first three to four weeks. A patient who has successfully completed a rehabilitation program for SIS should have complete, pain-free motion of the glenohumeral joint and should be able to perform all functional movements and exercises in the program without pain. It is important to instruct patients about proper posture, movement, and ergonomics to reduce the risk of recurrence (table 1).
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