If you are experiencing pain in the front of your shoulder that may radiate down towards your elbow and worsen with overhead activities, you may be suffering from Shoulder Impingement.
This condition is an umbrella term for two main conditions that occur in the anterior shoulder and it is caused by overuse and/or repeated movement of the shoulder in positions of internal rotation and flexion.
Some common examples of activities associated with shoulder impingement include painting, swimming, tennis, and cleaning.
Repeated and overuse of these movements at work or in your daily habits can lead to a decrease in the sub-acromial space of the shoulder. This is located between the coracoacromial arch and the humeral head and the greater tuberosity of the humerus below. As a result, the shoulder bursa or rotator cuff (RC) tendon (supraspinatus tendon) may become impinged or trapped in the gradually decreasing space.
This leads to inflammation of the area and associated pain. Commonly, the bursa (fluid-filled sac of connective tissue) becomes impinged in the sub-acromial space when the individual also presents with bursitis (inflammation of the bursa). This is due to the changes that occur with bursitis, which can result in fragments of the bursa becoming impinged.
When an individual presents with anterior shoulder pain that worsens with overhead movements, there are a few steps I would take to ensure the correct exercise rehabilitation approach.
1. Complete Objective Tests
Painful Arch Test:
This test is conducted with the client standing in the anatomical position and is instructed to abduct their shoulder slowly through a full range of motion. A position test indicative of shoulder impingement is when pain presents between 60-120 degrees of shoulder abduction. During this test and with shoulder impingement, it is common for the client to experience no pain until 60 degrees of shoulder abduction and pain subsiding at greater than 120 degrees
Hawkins Kennedy Test:
During this test, the clinician would passively put the client’s arm into a 90-degree shoulder flexion and then internally rotate the shoulder. this passive movement causes the greater tuberosity to impinge the supraspinatus tendon under the coracoacromial arch. A positive test would occur when pain is present during this movement. indicating shoulder impingement.
2. Investigate the client’s activities of daily living:
Discussing the client’s daily habits will allow you to investigate what activities the client is engaging in that might be contributing to their shoulder impingement. This is likely caused by a regular upper limb movement that is regularly engaged in, resulting in overuse. This will lead the clinician to prescribe activity modification and adjustments in movement technique in the treatment phase.
3. Educate the Client:
Educating the client on the anatomy, physiology, and movement associated with their injury will foster trust between the client and clinician. This allows for a better understanding of their pain experience and positively influences their treatment and adherence.
Exercise Treatment Approach:
The goal of treating shoulder impingement should be to address the underlying cause not just the symptoms. Since shoulder impingement’s cause is the overuse and repeated movement of the upper limb, with the shoulder repeatedly moving into shoulder flexion and internal rotation, the first step should be to modify the activity that is contributing to the impingement.
Discuss with the client how they are completing the task in their daily life or work and see if they can make any adjustments.
For example:
- Can the client approach the task from a different body position that allows for less shoulder flexion and internal rotation?
- Are they able to complete the task without internally rotating their shoulder but rather externally rotating their shoulder?
- Can they complete the task using a piece of equipment or aid to avoid shoulder internal rotation?
If modification is not possible, I would recommend that the client refrain from completing the activity for a few weeks while beginning their exercise rehab program aimed at building strength in specific areas of their shoulder and improving biomechanics.
The exercise prescription should aim to strengthen the muscles that externally rotate the shoulder (infraspinatus, teres minor). The goal is to retrain the movements that are causing the impingement, by focusing on external rotation and avoiding internal rotation of the shoulder so the sub-acromial space can be opened up.
Exercise rehab should also aim to stabilize the humeral head within the glenoid to prevent it from rising and impinging the bursa. Client can achieve this by exercising the rotator cuff muscles. Poor scapular rhythm may also be contributing to the shoulder impingement, so prescribing exercises that promote scapula protraction and upward rotation such as serratus anterior exercises, can improve scapular rhythm.
Throughout the treatment process, it is important to continue monitoring pain and symptoms of the injury, discuss how the client’s activities of daily living are influencing these symptoms, and determine if avoiding specific movements has helped decrease pain.
For an acute shoulder impingement injury, clients can typically see full improvement following these guidelines within 6 weeks. However, in chronic cases this timeframe can significantly increase.
For some beginner exercises to assist with shoulder impingement, you can visit my Instagram page @kadezur_exercisephysiology_.
