Impingement Syndrome, Rotator Cuff, Bursitis

with Rehab

Impingement syndrome is a condition that involves inflammation of the tendons of the rotator cuff and the subacromial bursa, that causes pain in the shoulder. The rotator cuff consists of four tendons and muscles that control much of the shoulder and upper arm function. The subacromial bursa is a fluid filled sac that helps reduce friction between the rotator cuff and one of the bones of the shoulder (acromion). Impingement syndrome is usually an overuse injury that causes swelling of the bursa (bursitis), swelling of the tendon (tendonitis), and/or a tear of the tendon (strain). Strains are classified into three categories. Grade 1 strains cause pain, but the tendon is not lengthened. Grade 2 strains include a lengthened ligament, due to the ligament being stretched or partially ruptured. With grade 2 strains there is still function, although the function may be decreased. Grade 3 strains include a complete tear of the tendon or muscle, and function is usually impaired.

SYMPTOMS

  • Pain around the shoulder, often at the outer portion of the upper arm.

  • Pain that gets worse with shoulder function, especially when reaching overhead or lifting.

  • Sometimes, aching when not using the arm.

  • Pain that wakes you up at night.

  • Sometimes, tenderness, swelling, warmth, or redness over the affected area.

  • Loss of strength.

  • Limited motion of the shoulder, especially reaching behind the back (to the back pocket or to unhook bra) or across your body.

  • Crackling sound (crepitation) when moving the arm.

  • Biceps tendon pain and inflammation (in the front of the shoulder). Worse when bending the elbow or lifting.

CAUSES

Impingement syndrome is often an overuse injury, in which chronic (repetitive) motions cause the tendons or bursa to become inflamed. A strain occurs when a force is paced on the tendon or muscle that is greater than it can withstand. Common mechanisms of injury include:

Stress from sudden increase in duration, frequency, or intensity of training.

  • Direct hit (trauma) to the shoulder.

  • Aging, erosion of the tendon with normal use.

  • Bony bump on shoulder (acromial spur).

RISK INCREASES WITH:

  • Contact sports (football, wrestling, boxing).

  • Throwing sports (baseball, tennis, volleyball).

  • Weightlifting and bodybuilding.

  • Heavy labor.

  • Previous injury to the rotator cuff, including impingement.

  • Poor shoulder strength and flexibility.

  • Failure to warm up properly before activity.

  • Inadequate protective equipment.

  • Old age.

  • Bony bump on shoulder (acromial spur).

PREVENTION

  • Warm up and stretch properly before activity.

  • Allow for adequate recovery between workouts.

  • Maintain physical fitness:

  • Strength, flexibility, and endurance.

  • Cardiovascular fitness.

  • Learn and use proper exercise technique.

PROGNOSIS

If treated properly, impingement syndrome usually goes away within 6 weeks. Sometimes surgery is required.

RELATED COMPLICATIONS

  • Longer healing time if not properly treated, or if not given enough time to heal.

  • Recurring symptoms, that result in a chronic condition.

  • Shoulder stiffness, frozen shoulder, or loss of motion.

  • Rotator cuff tendon tear.

  • Recurring symptoms, especially if activity is resumed too soon, with overuse, with a direct blow, or when using poor technique.

TREATMENT

Treatment first involves the use of ice and medicine, to reduce pain and inflammation. The use of strengthening and stretching exercises may help reduce pain with activity. These exercises may be performed at home or with a therapist. If non-surgical treatment is unsuccessful after more than 6 months, surgery may be advised. After surgery and rehabilitation, activity is usually possible in 3 months.

MEDICATION

  • If pain medicine is needed, nonsteroidal anti-inflammatory medicines (aspirin and ibuprofen), or other minor pain relievers (acetaminophen), are often advised.

  • Do not take pain medicine for 7 days before surgery.

  • Prescription pain relievers may be given, if your caregiver thinks they are needed. Use only as directed and only as much as you need.

  • Corticosteroid injections may be given by your caregiver. These injections should be reserved for the most serious cases, because they may only be given a certain number of times.

HEAT AND COLD

  • Cold treatment (icing) should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain, and immediately after activity that aggravates your symptoms. Use ice packs or an ice massage.

  • Heat treatment may be used before performing stretching and strengthening activities prescribed by your caregiver, physical therapist, or athletic trainer. Use a heat pack or a warm water soak.

SEEK MEDICAL CARE IF:

  • Symptoms get worse or do not improve in 4 to 6 weeks, despite treatment.

  • New, unexplained symptoms develop. (Drugs used in treatment may produce side effects.)

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Impingement Syndrome (Rotator Cuff

Tendinitis, Bursitis)

These exercises may help you when beginning to rehabilitate your injury. Your symptoms may go away with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

STRETCH – Flexion, Standing

  • Stand with good posture. With an underhand grip on your right / left hand, and an overhand grip on the opposite hand, grasp a broomstick or cane so that your hands are a little more than shoulder width apart.

  • Keeping your right / left elbow straight and shoulder muscles relaxed, push the stick with your opposite hand, to raise your right / left arm in front of your body and then overhead. Raise your arm until you feel a stretch in your right / left shoulder, but before you have increased shoulder pain.

  • Try to avoid shrugging your right / left shoulder as your arm rises, by keeping your shoulder blade tucked down and toward your mid-back spine. Hold for __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRETCH – Abduction, Supine

  • Lie on your back. With an underhand grip on your right / left hand and an overhand grip on the opposite hand, grasp a broomstick or cane so that your hands are a little more than shoulder width apart.

  • Keeping your right / left elbow straight and your shoulder muscles relaxed, push the stick with your opposite hand, to raise your right / left arm out to the side of your body and then overhead. Raise your arm until you feel a stretch in your right / left shoulder, but before you have increased shoulder pain.

  • Try to avoid shrugging your right / left shoulder as your arm rises, by keeping your shoulder blade tucked down and toward your mid-back spine. Hold for __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ROM – Flexion, Active-Assisted

  • Lie on your back. You may bend your knees for comfort.

  • Grasp a broomstick or cane so your hands are about shoulder width apart. Your right / left hand should grip the end of the stick, so that your hand is positioned "thumbs-up," as if you were about to shake hands.

  • Using your healthy arm to lead, raise your right / left arm overhead, until you feel a gentle stretch in your shoulder. Hold for __________ seconds.

  • Use the stick to assist in returning your right / left arm to its starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ROM - Internal Rotation, Supine

  • Lie on your back on a firm surface. Place your right / left elbow about 60 degrees away from your side. Elevate your elbow with a folded towel, so that the elbow and shoulder are the same height.

  • Using a broomstick or cane and your strong arm, pull your right / left hand toward your body until you feel a gentle stretch, but no increase in your shoulder pain. Keep your shoulder and elbow in place throughout the exercise.

  • Hold for __________ seconds. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRETCH - Internal Rotation

  • Place your right / left hand behind your back, palm up.

  • Throw a towel or belt over your opposite shoulder. Grasp the towel with your right / left hand.

  • While keeping an upright posture, gently pull up on the towel, until you feel a stretch in the front of your right / left shoulder.

  • Avoid shrugging your right / left shoulder as your arm rises, by keeping your shoulder blade tucked down and toward your mid-back spine.

  • Hold for __________ seconds. Release the stretch, by lowering your healthy hand.

Repeat __________ times. Complete this exercise __________ times per day.

ROM - Internal Rotation

  • Using an underhand grip, grasp a stick behind your back with both hands.

  • While standing upright with good posture, slide the stick up your back until you feel a mild stretch in the front of your shoulder.

  • Hold for __________ seconds. Slowly return to your starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRETCH – Posterior Shoulder Capsule

  • Stand or sit with good posture. Grasp your right / left elbow and draw it across your chest, keeping it at the same height as your shoulder.

  • Pull your elbow, so your upper arm comes in closer to your chest. Pull until you feel a gentle stretch in the back of your shoulder.

  • Hold for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTHENING EXERCISES - Impingement Syndrome (Rotator Cuff Tendinitis, Bursitis)

These exercises may help you when beginning to rehabilitate your injury. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Increase the resistance and repetitions only as guided.

  • You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does get worse, stop and make sure you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician.

  • During your recovery, avoid activity or exercises which involve actions that place your injured hand or elbow above your head or behind your back or head. These positions stress the tissues which you are trying to heal.

STRENGTH - Scapular Depression and Adduction

  • With good posture, sit on a firm chair. Support your arms in front of you, with pillows, arm rests, or on a table top. Have your elbows in line with the sides of your body.

  • Gently draw your shoulder blades down and toward your mid-back spine. Gradually increase the tension, without tensing the muscles along the top of your shoulders and the back of your neck.

  • Hold for __________ seconds. Slowly release the tension and relax your muscles completely before starting the next repetition.

  • After you have practiced this exercise, remove the arm support and complete the exercise in standing as well as sitting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Shoulder Abductors, Isometric

  • With good posture, stand or sit about 4-6 inches from a wall, with your right / left side facing the wall.

  • Bend your right / left elbow. Gently press your right / left elbow into the wall. Increase the pressure gradually, until you are pressing as hard as you can, without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold for __________ seconds.

  • Release the tension slowly. Relax your shoulder muscles completely before you begin the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - External Rotators, Isometric

  • Keep your right / left elbow at your side and bend it 90 degrees.

  • Step into a door frame so that the outside of your right / left wrist can press against the door frame without your upper arm leaving your side.

  • Gently press your right / left wrist into the door frame, as if you were trying to swing the back of your hand away from your stomach. Gradually increase the tension, until you are pressing as hard as you can, without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold for __________ seconds.

  • Release the tension slowly. Relax your shoulder muscles completely before you begin the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Supraspinatus

  • Stand or sit with good posture. Grasp a __________ weight, or an exercise band or tubing, so that your hand is "thumbs-up," like you are shaking hands.

  • Slowly lift your right / left arm in a "V" away from your thigh, diagonally into the space between your side and straight ahead. Lift your hand to shoulder height or as far as you can, without increasing any shoulder pain. At first, many people do not lift their hands above shoulder height.

  • Avoid shrugging your right / left shoulder as your arm rises, by keeping your shoulder blade tucked down and toward your mid-back spine.

  • Hold for __________ seconds. Control the descent of your hand, as you slowly return to your starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - External Rotators

  • Secure a rubber exercise band or tubing to a fixed object (table, pole) so that it is at the same height as your right / left elbow when you are standing or sitting on a firm surface.

  • Stand or sit so that the secured exercise band is at your uninjured side.

  • Bend your right / left elbow 90 degrees. Place a folded towel or small pillow under your right / left arm, so that your elbow is a few inches away from your side.

  • Keeping the tension on the exercise band, pull it away from your body, as if pivoting on your elbow. Be sure to keep your body steady, so that the movement is coming only from your rotating shoulder.

  • Hold for __________ seconds. Release the tension in a controlled manner, as you return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Internal Rotators

  • Secure a rubber exercise band or tubing to a fixed object (table, pole) so that it is at the same height as your right / left elbow when you are standing or sitting on a firm surface.

  • Stand or sit so that the secured exercise band is at your right / left side.

  • Bend your elbow 90 degrees. Place a folded towel or small pillow under your right / left arm so that your elbow is a few inches away from your side.

  • Keeping the tension on the exercise band, pull it across your body, toward your stomach. Be sure to keep your body steady, so that the movement is coming only from your rotating shoulder.

  • Hold for __________ seconds. Release the tension in a controlled manner, as you return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Scapular Protractors, Standing

  • Stand arms length away from a wall. Place your hands on the wall, keeping your elbows straight.

  • Begin by dropping your shoulder blades down and toward your mid-back spine.

  • To strengthen your protractors, keep your shoulder blades down, but slide them forward on your rib cage. It will feel as if you are lifting the back of your rib cage away from the wall. This is a subtle motion and can be challenging to complete. Ask your caregiver for further instruction, if you are not sure you are doing the exercise correctly.

  • Hold for __________ seconds. Slowly return to the starting position, resting the muscles completely before starting the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Scapular Protractors, Supine

  • Lie on your back on a firm surface. Extend your right / left arm straight into the air while holding a __________ weight in your hand.

  • Keeping your head and back in place, lift your shoulder off the floor.

  • Hold for __________ seconds. Slowly return to the starting position, and allow your muscles to relax completely before starting the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Scapular Protractors, Quadruped

  • Get onto your hands and knees, with your shoulders directly over your hands (or as close as you can be, comfortably).

  • Keeping your elbows locked, lift the back of your rib cage up into your shoulder blades, so your mid-back rounds out. Keep your neck muscles relaxed.

  • Hold this position for __________ seconds. Slowly return to the starting position and allow your muscles to relax completely before starting the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Scapular Retractors

  • Secure a rubber exercise band or tubing to a fixed object (table, pole), so that it is at the height of your shoulders when you are either standing, or sitting on a firm armless chair.

  • With a palm down grip, grasp an end of the band in each hand. Straighten your elbows and lift your hands straight in front of you, at shoulder height. Step back, away from the secured end of the band, until it becomes tense.

  • Squeezing your shoulder blades together, draw your elbows back toward your sides, as you bend them. Keep your upper arms lifted away from your body throughout the exercise.

  • Hold for __________ seconds. Slowly ease the tension on the band, as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Shoulder Extensors

  • Secure a rubber exercise band or tubing to a fixed object (table, pole) so that it is at the height of your shoulders when you are either standing, or sitting on a firm armless chair.

  • With a thumbs-up grip, grasp an end of the band in each hand. Straighten your elbows and lift your hands straight in front of you, at shoulder height. Step back, away from the secured end of the band, until it becomes tense.

  • Squeezing your shoulder blades together, pull your hands down to the sides of your thighs. Do not allow your hands to go behind you.

  • Hold for __________ seconds. Slowly ease the tension on the band, as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Scapular Retractors and External Rotators

  • Secure a rubber exercise band or tubing to a fixed object (table, pole) so that it is at the height as your shoulders, when you are either standing, or sitting on a firm armless chair.

  • With a palm down grip, grasp an end of the band in each hand. Bend your elbows 90 degrees and lift your elbows to shoulder height, at your sides. Step back, away from the secured end of the band, until it becomes tense.

  • Squeezing your shoulder blades together, rotate your shoulders so that your upper arms and elbows remain stationary, but your fists travel upward to head height.

  • Hold for __________ seconds. Slowly ease the tension on the band, as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Scapular Retractors and External Rotators, Rowing

  • Secure a rubber exercise band or tubing to a fixed object (table, pole) so that it is at the height of your shoulders, when you are either standing, or sitting on a firm armless chair.

  • With a palm down grip, grasp an end of the band in each hand. Straighten your elbows and lift your hands straight in front of you, at shoulder height. Step back, away from the secured end of the band, until it becomes tense.

  • Step 1: Squeeze your shoulder blades together. Bending your elbows, draw your hands to your chest, as if you are rowing a boat. At the end of this motion, your hands and elbow should be at shoulder height and your elbows should be out to your sides.

  • Step 2: Rotate your shoulders, to raise your hands above your head. Your forearms should be vertical and your upper arms should be horizontal.

  • Hold for __________ seconds. Slowly ease the tension on the band, as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Scapular Depressors

  • Find a sturdy chair without wheels, such as a dining room chair.

  • Keeping your feet on the floor, and your hands on the chair arms, lift your bottom up from the seat, and lock your elbows.

  • Keeping your elbows straight, allow gravity to pull your body weight down. Your shoulders will rise toward your ears.

  • Raise your body against gravity by drawing your shoulder blades down your back, shortening the distance between your shoulders and ears. Although your feet should always maintain contact with the floor, your feet should progressively support less body weight, as you get stronger.

  • Hold for __________ seconds. In a controlled and slow manner, lower your body weight to begin the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.