Summary of the Condition
Shoulder Impingement Syndrome (SIS) is shoulder pain that is exacerbated with overhead activities. Shoulder impingement has been classified into two main categories: structural and functional. The subacromial space can become impinged from a narrowing of the subacromial space resulting from bony grown or soft-tissue inflammation (structural impingement), or superior migration of the humeral head caused by weak rotator cuff muscles (functional).1 Overhead athletes are at greater risk of developing SIS due to the biomechanics of throwing that may cause tissues below the coracoacromial arch to be subjected to subtle microtrauma, leading to inflammation and tendinitis.1
Guide to Physical Therapy Practice and Suggested Management2
The Guide to Physical Therapy Practice provides clinicians with general treatment guidelines for a variety of diagnoses. Since SIS has several different causes, the Guide provides three main practice patterns that SIS falls under.
- Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
- Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation
- Pattern 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery
Suggested management from the Guide to Physical Therapy Practice are simply addressing the problems listed in each pattern: improving ROM, decreasing pain, and improving strength of the shoulder.
Patients who present with SIS will have shoulder pain that is exacerbated with overhead activities. Pain will be the patients' chief complaint and thus relieving pain will initially be the primary goal of physical therapy. Patients with SIS will present with a painful arc of motion (shown to the right). This arc is from 60-120 degrees of shoulder abduction (ABD). Working outside of this painful arc is optimal. Educating the patient on avoiding this painful ROM with repetitive tasks is key to the initial stages of decreasing pain in the shoulder.
NSAIDs and Ice
Physicians may prescribe non-steroidal anti-inflammatory (NSAIDs) and/or recommend icing the shoulder to decrease inflammation and pain within the shoulder.
Joint mobilizations can also be utilized to address pain. Specific glenohumeral (GH) joint mobilization techniques discussed in research that have shown significant effects on pain reduction include: GH joint anterior, posterior, and inferior glides, and long-axis distraction passive accessory motions (PAM).3
Research suggests that SIS results from a characteristic pattern of muscle imbalance including weakness of the lower and middle trapezius, serratus anterior, infraspinatus, and deltoid, coupled with tightness of the upper trapezius, pectoralis and levator scapula.1
Exercises that strengthen these weakened muscles include but are not limited to: resisted scapular retraction (shown to the left), resisted internal rotation (shown to the right), serratus punches, scapular depression, and resisted horizontal extension (posterior deltoid).
Strengthening the RTC will allow the humeral head to be pulled inferiorly as the arm is moved into abduction (ABD). Exercises that focus on strengthening the RTC are: shoulder external rotation (ER), internal rotation (IR), and first 15 degrees of shoulder ABD.
Proprioceptive Neuromuscular Facilitation (PNF) is a manual therapy technique that may provide benefits in more functional patterns. A trained PT can work within a pain free ROM in the two different patterns to facilitate functional movements. Manual resistance throughout these patterns can be provided by the PT and will enhance the patients strength throughout each functional pattern.
- D1 Flexion pattern: shoulder flexion, elbow flexion, forearm supination, wrist flexion, finger flexion (should end with hand within fist-width from opposite ear in a "bowling position")
- D1 Extension pattern: shoulder extension, elbow extension, forearm pronation, wrist and finger extension (should end with hand within fist-width from same hip as "reaching for a baton")
- D2 pattern: shoulder flexion, elbow extension, forearm supination, wrist extension, finger extension (should end with arm within fist-width from head, palm facing toward body, shoulder ER) Note: work within pain free ROM in this pattern
- D2 pattern: shoulder extension, elbow flexion, forearm pronation, wrist and finger flexion (should end with thumb on opposite ASIS/hip bone) Note: work with eccentric control in this pattern to strengthen shoulder stabilizers.
Improving Range of Motion
In patients with SIS an imbalance in glenohumeral ROM existis and may contriube to altered shoulder kinematics. Excessive external rotation (ER) ROM coupled with limited internal rotation (IR) ROM leads to increased anterior and inferior translation of the humerus which can lead to anterior instability and tightness of the posterior capsule.
Performing stretches into IR will allow patients to regain full ROM into IR. The image to the left indicates a patient using a towel to pull his right arm into more IR. This is a good stretch for younger more athletic patients who do not have any cervical pathologies due to the postural stability it requires to perform this stretch. This exercise can also be prescribed as a part of the patients home exercise program (HEP). An alternative position to perform this same stretch is called the "sleeper stretch". The patient is side-lying on involved side in 90 degrees shoulder abduction (ABD) and 90 degrees elbow flexion, the patient then grabs their wrist of the involved side with the uninvolved arm and gently stretches into IR. This exercise is demonstrated in the image to the right and may also be incorporated into a HEP.
Joint mobilizations are another means of improving ROM. Patients with SIS may present with the humeral head sitting more anteriorly in the glenoid fossa. Stretching the posterior joint capsule with PA grade III/IV joint mobilizations will aid in not only pain reduction as stated above, but also improving pain free ROM. The image to the right shows the positioning for PA joint mobilization. The PT provides slight distraction of the humeral head while applying pressure on the anterior surface of the humeral head in a posterior direction, feeling for resistance. Applying this rhythmically for 30 seconds 2-3 times will allow the posterior capsule to stretch and the humeral head to rest more posteriorly than its previous resting position. Research indicates that joint mobilizations combined with movement (Mulligan mobilization with movement MWM) and regular joint mobilizations are more effective than exercises alone at increasing ROM.3
Regaining functional movement in the involved shoulder is very important. PTs do not want their patients to lose ground in the strengthening and stretching exercises they provided them if patients begin compensating their movements with functional activities.
- Reaching for anything above 90 degrees, or above shoulder height, is one functional activity that will have to progress within a pain free ROM.
- Putting on clothing or jackets require a certain amount of IR and is another functional activity that a patient may initially have trouble with. Throughout the stretching program, the patient will regain IR ROM and may have an easier time donning and doffing their jackets or button-up shirts.
- Washing the back with the involved arm again requires a certain amount of IR of the shoulder which can be compromised by SIS.
- Overhead athletes may begin a throwing program similar to the one listed on the home page of SIS by Kirchhoff and Imhoff to regain the functional mobility required by their sport.
- Postural education may be a part of functional activity if the patients' occupation requires them to sit at a desk or drive for extended periods of time.
|Stretches||Reps & Sets||Strengthening Exercises||Reps & Sets|
|Towel Stretch - Increase IR ROM||5 stretches hold 20s each||Resisted IR ROM with tubing||2 sets 15 reps|
|Sleeper Stretch - Increase IR ROM||2 times for 30s hold||Scapular Retraction + hold 5 seconds||Repeat 10 times|
|Pectoral "Doorway" Stretch||2 times for 30s hold||Resisted ER ROM with tubing||2 sets 15 reps|
Note: This is not a complete list of exercises for patients with SIS. Progress the home exercise program (HEP) as patient tolerates. Adjusting the color of resistance tubing and incorporating other functional exercises are two ways to progress your HEP. Another way to change the exercises (to minimize possibility of boredom) use light free weights and place patient supine or prone on an exercise ball to perform internal and external rotation or scapular retraction. Be sure to provide pictures and written instructions on how to specifically perform the exercises and how many repetitions and sets to complete.
Several different approaches exist when discussing modalities. Electrical stimulation, ultrasound, kinesio-taping, and acupuncture are discussed most throughout literature.
- There is no convincing evidence that electromagnetic therapy is of additional benefit in acute phase rehabilitation program of SIS.4 Studies involving electrical stimulation, however, are not very reliable since the experimental group is the only group receiving the electrical stimulation and the control group is receiving "sham electrical stimulation" and that is hard to convince the patient of.
- Ultrasound is also prevalent in research. Studies have used ultrasound in concert with therapeutic exercise to treat SIS and have concluded that pain scores improved in both groups and thus findings suggest that intermittent ultrasound added to conservative treatment of SIS does not provide an additional benefit to the patients.5
- Kinesio-taping gained popularity during the Beijing 2008 Olympics with Kerry Walsh sporting kinesio-tape on her shoulder throughout some of her matches. Research has compared kinesio-tape with physical therapy and the effect on pain at rest, at night, and with movement. Kinesio tape has been found to be more effective than the local modalities at the first week however were equally as effective as the physical therapy group after two weeks. Kinesio tape may provide an alternative treatment option for immediate pain relief in SIS.6
- Acupuncture is another alternative modality to treat SIS. Research shows that single-point acupuncture associated with physiotherapy, is more effective than when physiotherapy is associated mock TENS. This study used the Constant-Murley Score shoulder function. [The CMS combines 35% subjective parameters (pain 15%, tasks of daily living 20%) and 65% objective parameters (range of motion 40%, strength 25%) with a maximum of 100 points, indicating a shoulder with mobility completely free from pain and with normal functioning.] 7 This study revealed statistically significant results 3, 6, and 12 months post-intervention and can provide physical therapists who practice using holistic methods an alternative means of treating SIS conservatively.
Most importantly with patients who are experiencing SIS, avoiding painful activities is the most important instruction. Aggravating the already inflamed, irritated shoulder joint is what must be avoided. Examples of potentially painful positions are:
- Instruct the patient to avoid sleeping on the involved shoulder as this will place compressive forces through their shoulder and will exacerbate their pain.
- Instruct the patient to avoid repetitive overhead activities outside their pain-free ROM. (i.e. putting groceries away over head, reaching for items in taller closets, hammering nails into the wall above head, lifting children up above their heads).
1. Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes. International Journal of Sports Physical Therapy 6(1)2011: 51-56.
3. Kachingwe AF, Phillips B, Sletten E, Plunkett SW. Comparison of manual therapy techniques with therapeutic exercise in the treatment of shoulder impingement: a randomized controlled pilot clinical trial. Journal of Manual and Manipulative Therapy. 2008;16(4):238-247
4.Aktas I, Akgun K, Cakmak B. Therapeutic effect of pulsed electromagnetic field in conservative treatment of subacromial impingement syndrome. Clin Rheumatol.(8) 2007: 1234-1239.
5. Celik DD, Atalar ACAC, Sahinkaya SS, Demirhan MM. [The value of intermittent ultrasound treatment in subacromial impingement syndrome]. Acta orthopaedica et traumatologica turcica. 2009;43(3):243-247.
6. Kaya EE, Zinnuroglu MM, Tugcu II. Kinesio taping compared to physical therapy modalities for the treatment of shoulder impingement syndrome. Clin Rheumatol. 2011;30(2):201-207
7. Vas J, Ortega C, Olmo V, Perez-Fernandez F, Hernandez L, Mdeina I, Seminario JM, Herrera A, Luna F, Perea-Milla E, Mendez C, Madrazo F, Jimenez C, Ruiz MA, Aguilar I. Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial. Rheumatology 2008;47:887-893.