Did you know that the shoulder joint is the most mobile joint in the human body? As wonderful as that is, it sadly places your shoulder at a significantly greater risk of injury. However, I suppose since you are reading this article, you may know that better than anyone else! You may have been told by your physical therapist, doctor, or by doing some thorough research on your own that you may be suffering from a condition called shoulder impingement syndrome (SIS) …Ouch!
This article will help to provide you with a deeper insight about what shoulder impingement syndrome is, effective physical therapy exercises for shoulder impingement, as well as relevant education about what to do to prevent it from re-occurring.
What Is Shoulder Impingement?
Definition & Common Causes
Believe it or not, but the shoulder joint is a very busy area and is home to more than 10 different structures. From your rotator cuff musculature and supportive ligaments, to slipper sacs of fluid (called your bursae) that help to lessen the friction between bodily structures and shock absorbers, there does not really seem to be much room for error. As a result, it would make sense that there are many different shoulder injuries out there that can occur for a variety of reasons. Shoulder impingement syndrome (SIS) is one of the more common injuries that can occur due to many reasons, such as prolonged poor positioning, repetitive overhead motions, as well as rather sudden impacts on the shoulder such as falls. Frequently associated conditions include, but are not limited to rotator cuff tendinitis, rotator cuff strains, shoulder bursitis. Learn all about how to recognize it, what to avoid, as well as physical therapy exercises for shoulder impingement.
Relevant Anatomy
So, at this point you may be wondering what is happening on a structural level within your shoulder joint. Let me give you a brief overview. Your rotator cuff musculature surrounds the tip of your upper arm bone (also called the humerus) and is responsible for keeping your upper arm bone as close to the joint as possible when moving your arm around. The space in between your humerus and the tip of your shoulder (also called your acromion) is called the subacromial space and it is home to a few structures (your supraspinatus muscle, subacromial bursa, long head of the biceps tendon) that are involved in active overhead motions. Due to many different reasons, including poor posture, falls, or rotator cuff weakness, this subacomial space can become narrowed. This can cause repetitive compression of the rotator cuff and results in the pain that you are experiencing.
In order for you to recover most effectively, it is important for you to be aware of what this whole shoulder impingement thing exactly is. The good news is that it is a very common, and typically very manageable condition.
SIS occurs most often in individuals between the ages of 20-40 years and can affect many activities of daily living. The typical recovery time is very dependent on the severity of the condition and can therefore lie anywhere from 1-4 weeks up until 6-12 months.
Generally speaking, the better your adherence to your recommended exercise program and the better you are able to modify your activities according to advice given by your physical therapist, the sooner you should get better. On the contrary, inactivity and neglect of your shoulder injury or “just working through it” can be contributing factors to chronic shoulder pain and prolong your recovery.
Makes sense? Below you can find some common signs (observable manifestations) and symptoms (perceived manifestations) that are worth checking out to see if you may be affected by SIS.
Common Signs
- Elevated Shoulder Height: Mild – moderate elevation of your affected shoulder at rest
- Forward-Rounded Shoulders: Your affected shoulder may be more rounded than your other shoulder
- Tightness: Muscles within your neck, in your chest, surrounding your shoulder blade
- Audible clicking/popping of your affected shoulder joint with elevation and lowering of your arm
- Winging shoulder blade: Your shoulder blade feels as if it want to protrude off your ribcage as you are moving your arm around
Common Symptoms
- Pain (typically sharp and/or throbbing): reaching for your wallet in your back pocket, scratching your back, lowering your arm from an above-shoulder level position, lifting an object at or above shoulder height, reaching for an object, directly sleeping on your shoulder
- Following Activity: feelings of dull achiness in your shoulder/shoulder blade area
- Referral: feelings of achiness/pulling down to your elbow and/or into your shoulder blade
Warning: Some signs and symptoms are also frequently present in other shoulder injuries. We always recommend that you go see a Physiotherapist in-person so that you are provided with the most accurate diagnosis and the best-suited treatment plan for you.
Take-Home-Message #1: Shoulder Impingement Syndrome (SIS) is a common, manageable shoulder injury that most frequently affects individuals aged 20-40. It is most often caused by repetitive overhead activity, prolonged poor sitting postures, or falls. Common signs and symptoms include, but are not limited to audible clicking/popping of the affected shoulder with arm movement, forward-rounded shoulders and sharp/throbbing pain with weighted arm movements.
How Is It Diagnosed?
A) Analysis of Signs & Symptoms
If you can relate well with the above-mentioned signs and symptoms, you may be suffering from shoulder impingement syndrome. Diagnoses are usually made based on subjective (“the story”), as well as objective data gathered from assessments of your presenting range of motion, upper body strength, special testing and movement observation. Your local physical therapist will be able to safely guide you through this in person.
B) Active Range Of Motion Assessment
During your active range of motion assessment, your physical therapist will likely find that you will have difficulty with lifting your arm above shoulder level without significant discomfort, either when straightening your arm out in front of your body or when lifting it out to the side.
About halfway of your full shoulder range, you may be experiencing a lag (a “slowing of your movement”) and your shoulder feels like it “catches”. As you are lowering your arm back down, you may experience some clicking & popping.
Outward rotations of your arm (performed by bending your elbows to 90 degrees, while tucked against your body and moving your hands out to the side as far as possible) may be tolerable, however reaching your hand behind your back (resulting in inward rotation) is associated with pain. Beside shoulder range of motion, your provider may also assess your neck and elbow range of motion, as joints above and below the level of injury may be limited as well.
C) Resisted Testing
As with any other injury testing discussed in this article, I highly recommend that you go and see a physical therapist in-person to appropriately evaluate your muscle strength. During your assessment, your physical therapist may assess your shoulder flexors (the muscle group that is responsible for elevating your arm out straight in front of you) and your shoulder abductors (your muscle group that is responsible for elevating your arm out straight to the side). Typically, both your shoulder flexors and abductors will appear to be weak and painful when compared to your unaffected side.
Assessments of your shoulder external rotators (your muscle group that is responsible for rotating your arm out to the side and stabilizing it as your are lifting your arm) and internal rotators (responsible for rotating your arm in and stabilizing your arm with elevation) is likely going to be weak and painful and may cause you to experience pain up in through your neck and shoulder blade.
D) Special Testing
Special tests are used in practice to attempt to find the structures at fault. Your health care provider may get you to move or test your strength in a specific position. Out of many hundred’s of special tests, there are a few that are frequently used to help with the diagnosis of shoulder impingement. As mentioned before, your health care provider should be the person performing these, as the purpose of special tests is frequently to provoke pain and you may be at risk for worsen your condition if it is performed incorrectly.
E) Other
Although we do not recommend it unless your health care provider thinks it is required, there are a few imaging techniques available that can provide you with more information in regards to the health of your shoulder’s soft tissues. Preferred imaging choices for suspected SIS are X-ray and MRI scans.
X-ray’s will identify how much narrowing of your bony structures (humerus and acromion) has occurred, whereas an MRI scan can provide you with details about the health of your soft tissues (tendons, muscle, ligaments, bone), which can be used to exclude more serious injuries, such as a rotator cuff tear. Signs of a rotator cuff tear include (but are not limited to) pain with laying on the affected shoulder, pain with active rotation of your arms, shoulder weakness). For more information on rotator cuff tears read more here.
Take-Home-Message #2: During your assessment, your physiotherapist will be able to diagnose your shoulder pain through a detailed analysis of your story, as well as objective data such as assessments of range of motion, strength testing and special testing.
Physical Therapy Exercises For Shoulder Impingement
Important Considerations
Before starting any shoulder exercise program, ensure to confirm with your health care provider that you are truly suffering from shoulder impingement, as exercise prescription for other shoulder injuries will likely differ in terms of their parameters (repetitions, sets, rest periods, frequency, etc.)
During the initial stages of the program, our goal is to achieve good sitting and standing postures by training the shoulder stabilizers conservatively until they adopt appropriate levels of endurance and strength. In stage two you will perform these exercises through full range and with greater resistance. Stage three will be the fine-tuning and maintenance stage, where we would continue to strengthen the shoulder girdle musculature involved with shoulder activity.
As you are watching the videos, pay attention to the starting positions, end positions, speed and body posture. If at any point you get a sharp, throbbing pain or significant (non-muscular) discomfort with these exercises that does not ease up within 10-15 minutes following the termination of these exercises, I advise you to decrease the intensity of the exercise by about 50% or seek help from your physical therapist. If it persists, please stop and seek professional advice.
Below you can find a list of shoulder impingement exercises that may help your recovery and you can discuss with your physical therapist.
Suggested equipment: resistance bands, 2-5 lb dumbbells, athletic wear, mirror
Physical Therapy Exercises: Phase I
Start with the following exercises if you are just starting out. Isometric exercises are exercises where your limb is not moving through space and tends to be the safer option during initial stages of injury rehabilitation, particularly when you do not have pain-free, full range of motion. These exercises will help to keep your muscles active, reduce the detrimental effects of muscular atrophy from underuse and keep your joint moving to enhance your shoulder mobility.
Talk to your physical therapist about parameters (repetitions, sets, rest, frequency, etc.) that are right for you before starting Phase I of your exercise program.
1. Isometric Internal & External Rotation
https://www.youtube.com/watch?v=xZKlQlkAeZA
https://www.youtube.com/watch?v=0d8OPH6aeo8
2. Isometric Abduction Against Wall
3. Wall Crawls
4. Retractions With Band
https://www.youtube.com/watch?v=WklUZWulQao
5. Deep Neck Flexor Hold
Physical Therapy Exercises: Phase II
The second phase of the exercise program will help you to strengthen your shoulder girdle musculature throughout your available range. In order to advance to the second phase of shoulder impingement rehabilitation your active shoulder range of motion should be full and pain-free. Muscles that support the proper mechanics of shoulder movement include: rotator cuff, trapezius (lower, middle and upper fibers), serratus anterior and your deltoid. Ensure to meet with your physical therapist to agree on the right parameters prior to execution of phase II of your program.
1. Active Internal & External Rotation
https://www.youtube.com/watch?v=dFkD9rK5OaA
https://www.youtube.com/watch?v=B1-r0yQRZn0
2. Isometric External Rotation Through Flexion
3. Prone Shoulder Blade Retractions
https://www.youtube.com/watch?v=zunB3DKuJi0
4. Weighted Protractions
5. Biceps Curl With Band
6. Deep Neck Flexor Hold
Physical Therapy Exercises: Phase III
Phase III is the last phase of the shoulder impingement rehabilitation program. Here, we are gradually preparing you to transition general shoulder movements to more functional rehabilitation to prepare you to engage in activities of daily living. Your physical therapist may add further individualized exercises into this phase of your rehab program. In order to advance to phase III of the rehabilitation program, you will need to be able to perform phase II exercises without pain and you should be able to feel a significant progress compared to the start of your exercise program. Again, ensure to talk to your physical therapy provider to talk about appropriate exercise parameters for you.
1. Mid- and Lower Trapezius Strengthening
2. External Rotation Strengthening with Arm Overhead
https://www.youtube.com/watch?v=yDOigJEe07M
3. Isometric Shoulder External Rotation Through Flexion
4. Shoulder Abduction Strengthening with Weight
5. Shoulder Flexion Eccentric Strengthening with Weight
6. Deep Neck Flexor Strengthening with Band
Stretches For Surrounding Musculature
Neck Stretches
The muscles of the neck are an important group of muscles to consider when it comes to good posture. As a general rule, wherever the head goes, the shoulders will follow. In order to be able to maintain a good posture, we need the head to be in a neutral position. This can get difficult when we have different muscles pulling our head in different directions at rest.
Below you can find five great stretches to help you loosen up your neck.
1. Upper Trapezius Stretch
2. Levator Scapulae Stretch
https://www.youtube.com/watch?v=imLiEN0Kf14
3. Scalene Stretch
https://www.youtube.com/watch?v=qrMB_a6Yxjg
4. Neck Extensor Stretch
Chest Stretches
Pectoral (chest) muscles are often overlooked when it comes to addressing shoulder pain. There are two main muscles of the chest. The pectoralis major is the thicker, more superficial muscle, and is responsible for bringing your arms and hands in closer towards your chest and are most active when you are performing pushing activities, such as a push-up. Below that, sits the pectoralis minor, a smaller muscle responsible for protruding your shoulders forward and stabilizing your shoulder blade. When attempting to bring the shoulders into a more neutral posture, we want to focus on stretching the pectoralis minor. Below you can find two stretches that will help loosen it up.
Warning: some chest stretches can temporarily worsen the pain you are experiencing. Carefully try them out with your physical therapist and see which one work best for you.
Wall Stretch
Shoulder & Elbow Stretches
Take-Home-Message #3: Neck, chest, shoulder and elbow stretches are great at reducing muscle tension and can alleviate feelings of tightness, as well as improve your posture and flexibility. They contribute positively towards your rehabilitation, particularly if performed regularly.
How Else Can Physiotherapy Help?
Injury Education
During the healing phase of your recovery, it is important to avoid activities and positions that caused your condition in the first place. Talk to your physical therapy provider about activities that require modification and about motions and positions to avoid as you are healing from your injury. Below you can find some general activities and positions to avoid during the healing phase of shoulder impingement.
- Avoid Excessive Overhead and Reaching Motions: Excessive overhead arm movements in combination with a weak rotator cuff are a common cause of shoulder pain. During the initial stages, try to avoid all overhead and reaching arm motions that are causing you pain. If you have to lift your arm, rotating your arm so that your thumb faces up as you lift can make it more tolerable.
- Switch up Your Posture: Poor posture is a common contributor to shoulder pain. Pay attention to your overall posture. Instead of leaning forward while you are resting, carefully pull your shoulders back and retract your head slightly. Switch up your positioning every 10-15 minutes to keep your muscles moving and preventing them from stiffening up.
- Use It or Lose It: Try to use your affected arm as much as you can tolerate. If you stop using your affected arm for too long, you are at risk of worsening your condition by further weakening your rotator cuff. Continue to stay as active as possible within your own limitations
- Take Breaks as Necessary: On days where your shoulder pain is higher than usual, try taking more breaks to recover from episodes of pain.
Ask your physical therapist about other useful advice that will help you better manage your lifestyle. This may include deeper pain education and/or individualized activity modification.
Manual Therapy
Your physical therapist may use specialized joint-gliding and/or soft tissue relaxation techniques to help relax your muscles, manage your pain and further improve your joint range of motion and improve your overall function. Ask your physical therapy provider which manual therapy techniques are right for you!
Modalities
In physical therapy practice, modalities are frequently used as a pain management tool, to speed up the healing process through varying mechanisms, or to prepare bodily structures (such as tight musculature) for treatment. Your therapist may use ice packs, heat packs, therapeutic ultrasound, low-level laser therapy, shockwave therapy or other modalities as adjunct therapy tools to help you recover faster.
Take-Home-Message #4: Beside providing you with an individualized exercise program, physical therapy providers can help improve your condition through proper injury-specific education, through the use of manual therapy and the use of adjunct modalities.
How Can I Ease The Pain?
Some days you the shoulder impingement pain can be a bit overwhelming, so it is a good idea to inform yourself about a few short-term solutions for pain management
Follow The “PRICE” Acronym
The PRICE acronym stands for Protection, Rest, Ice, Compression and Elevation.
Protect the affected area by not exposing it to painful stimuli and by avoiding putting excessive pressure on it. During the acute stages of the injury, you will want to avoid engaging in activities that aggravate the pain. Give it some rest when it is acting up, however still use it during activities that do not bother it.
Ice can help decrease inflammation in the area by reducing the local blood flow. It constricts the blood vessels and helps decrease any swelling that may be present as a result of inflammation. Place ice on the affected area for about 15-20 minutes at a time and ensure to place a small towel between your skin and the ice pack. You can wet the towel a bit to aid with conduction of the cold. You can use ice frequently throughout the day, however ensure to give your tissues enough time to rest in between ice applications.
Gentle Exercising
Perform some gentle exercising from Phase I of the physical therapy exercise program to increase the activity of the muscles responsible for proper shoulder posture. As a result of the body’s pain response, muscles frequently decrease in activity and need to be activated repeatedly through conservative strengthening exercises. Try your best to continue daily activities that you are able to perform without significant discomfort.
Boost Your Endorphins
Perform activities that boost the production of your body’s natural happiness hormones – endorphins. There are many different ways to increase their production, including high-intensity exercise, aromatherapy, foods high in vitamin D, and many more. Make sure to check out our article What Are Endorphins – Exploiting Joy’s Best Sources to get the full list!
TENS
TENS stands for transcutaneous electrical nerve stimulation and works by overriding the pain stimulus in the area of application. It is a way of reducing your symptoms in the short-term. Be careful not
to rely on your TENS unit, as you will want to participate in a corrective exercise program to help you heal and get rid of the pain in the long-term.
Take-Home-Message #5: When the shoulder pain becomes too overbearing, try to alleviate your pain by following the “PRICE” acronym, engaging in some light exercising, or if the pain becomes chronic it may be beneficial to acquire a TENS machine as a temporary pain solution.
How To Prevent Future Shoulder Pain
A) Continue To Stay Active
By staying active and engaging your upper body in regular exercise, your rotator cuff musculature will continuously be challenged and get used to functioning well when exposed to higher loads.
B) Maintain Proper Sitting and Lifting Postures
Your body likes to move. Break up prolonged positioning by changing your posture. When you have been sitting 15+ minutes, try to stand up and move around. Pay attention to your posture, whether you are walking, sitting or lying down, prolonged forward positioning can tighten musculature and cause wear on your shoulder structures. By keeping your shoulders back, your ears in line with your shoulders when sitting or standing, you are decompressing the affected structures and allowing them to work better.
C) Gradual Progression Of Activities
When introducing a new exercise or activity to your regular routine, ensure that you are doing so gradually. If, for example, you are planning on painting your house, do it in small increments. Work on one wall and then rest for a bit. Listen to your body and try not to overexert yourself too quickly.
Take-Home-Message #6: Ensure to stay as active as possible, switch up your positioning throughout the day and gradually progress new activities to prevent future pain from shoulder impingement.