Rehabilitation principles and practice for shoulder impingement and related problems
- Craig Parsons, MS, PT
Craig Parsons, MS, PT
- The Physical Therapy Network
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
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 joint that occurs during shoulder elevation. Such compression causes 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. The risk factors, pathophysiology, diagnosis, and general management of SIS and other shoulder problems are reviewed separately. (See "Shoulder impingement syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears" and "Frozen shoulder (adhesive capsulitis)" and "Evaluation of the patient with shoulder complaints" and "Physical examination of the shoulder".)
DEFINITION AND CLASSIFICATION
Glenohumeral or 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. SIS refers to a combination of shoulder symptoms, examination findings, and radiologic signs, rather than injury to a specific structure. However, shoulder impingement predisposes to rotator cuff tendinopathy and tears.
Most often SIS results from overuse in middle-aged adults. Throwing athletes suffer from a unique form of SIS: Impingement of the superior and posterior labrum and rotator cuff occurs with 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 "Shoulder impingement syndrome", section on 'Pathophysiology'.)
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 patient with shoulder complaints", section on 'Anatomy and biomechanics'.)
- Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med 2007; 35:1744.
- Cools AM, Declercq GA, Cambier DC, et al. Trapezius activity and intramuscular balance during isokinetic exercise in overhead athletes with impingement symptoms. Scand J Med Sci Sports 2007; 17:25.
- Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med 2010; 44:319.
- Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg 2003; 11:142.
- Warner JJ, Micheli LJ, Arslanian LE, et al. Scapulothoracic motion in normal shoulders and shoulders with glenohumeral instability and impingement syndrome. A study using Moiré topographic analysis. Clin Orthop Relat Res 1992; :191.
- Dirix A, Knuttgen HG, Tittle K. Strength and power. In: The Olympic Book of Sports Medicine, Wiley-Blackwell, Chicago 1991. p.181.
- Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972; 54:41.
- American Academy of Orthopaedic Surgeons. Shoulder Pain. OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=a00065 (Accessed on May 13, 2012).
- Levangie P, Norkin CC. Joint Structure and Function: A Comprehensive Analysis, 3rd, F.A. Davis, Philadelphia 2001.
- Knuttgen HG. Strength training and aerobic exercise: comparison and contrast. J Strength Cond Res 2007; 21:973.
- Hackney KJ, Engels HJ, Gretebeck RJ. Resting energy expenditure and delayed-onset muscle soreness after full-body resistance training with an eccentric concentration. J Strength Cond Res 2008; 22:1602.
- Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther 2009; 39:105.
- Holmgren T, Björnsson Hallgren H, Öberg B, et al. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ 2012; 344:e787.
- Kibler WB, Ludewig PM, McClure PW, et al. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'Scapular Summit'. Br J Sports Med 2013; 47:877.
- Pluim BM, van Cingel REH, Kibler WB. Shoulder to shoulder: stablilising instability, re-establishing rhythm, and rescuing the rotators! Br J Sports Med 2010; 44:299. http://bjsportmed.com/content/44/5/299.full.pdf+html (Accessed on May 21, 2012).
- Cools AM, Struyf F, De Mey K, et al. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med 2014; 48:692.
- Østerås H, Torstensen TA, Østerås B. High-dosage medical exercise therapy in patients with long-term subacromial shoulder pain: a randomized controlled trial. Physiother Res Int 2010; 15:232.
- Poppen NK, Walker PS. Forces at the glenohumeral joint in abduction. Clin Orthop Relat Res 1978; :165.
- McClure PW, Bialker J, Neff N, et al. Shoulder function and 3-dimensional kinematics in people with shoulder impingement syndrome before and after a 6-week exercise program. Phys Ther 2004; 84:832.
- Bernhardsson S, Klintberg IH, Wendt GK. Evaluation of an exercise concept focusing on eccentric strength training of the rotator cuff for patients with subacromial impingement syndrome. Clin Rehabil 2011; 25:69.
- Başkurt Z, Başkurt F, Gelecek N, Özkan MH. The effectiveness of scapular stabilization exercise in the patients with subacromial impingement syndrome. J Back Musculoskelet Rehabil 2011; 24:173.
- Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2007; 15:915.
- Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000; 30:126.
- DEFINITION AND CLASSIFICATION
- ANATOMY AND BASIC BIOMECHANICS
- PRINCIPLES OF REHABILITATION
- REHABILITATION PROGRAM
- Step one: Improve scapular stability
- Step two: Strengthen the rotator cuff
- - Supraspinatus
- - External rotators (infraspinatus and teres minor)
- - Subscapularis
- Step three: Improve overall strength and coordination of shoulder complex
- WHERE TO BEGIN
- EVIDENCE SUPPORTING THIS APPROACH
- SUMMARY AND RECOMMENDATIONS