Secondary Impingement Syndrome

with Rehab

The rotator cuff consists of four muscles that are responsible for much of the function of the shoulder joint. The subacromial bursa is a fluid filled sac that reduces friction between part of the shoulder (acromion) and the rotator cuff tendons. Secondary impingement syndrome is a condition in which the subacromial bursa or tendons of the rotator cuff become inflamed. Inflammation of either of these tendons causes pain and weakness in the shoulder.

SYMPTOMS

  • Pain, weakness, and/or loss of motion in the shoulder.

  • Pain that worsens with shoulder function.

  • Tenderness, swelling, warmth, or redness may occasionally be present over the outer aspect of the shoulder.

  • A crackling sound (crepitation) when the shoulder is moved.

CAUSES

Secondary impingement syndrome is caused by inflammation of the rotator cuff tendons or subacromial bursa. Common mechanisms of injury include:

  • Repetitive and/or strenuous shoulder movements, especially those above shoulder height.

  • Direct trauma to the shoulder (uncommon).

RISK INCREASES WITH:

  • Contact sports (football, wrestling, or boxing).

  • Activities involving arm movement above shoulder height (baseball, volleyball, or racquet sports).

  • Swimming

  • Weightlifting.

  • Heavy labor.

  • Previous shoulder injury.

  • Poor strength and flexibility.

  • Loose shoulder ligaments.

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 technique. When possible, have coach correct improper technique.

PROGNOSIS

If treated properly, then secondary shoulder impingement normally resolves with conservative treatment.

RELATED COMPLICATIONS

  • Prolonged healing time, if improperly treated or re-injured.

  • Recurrent symptoms that result in a chronic problem.

  • Other shoulder conditions, such as frozen shoulder or a rotator cuff tear.

TREATMENT

Treatment initially involves the use of ice and medication to help reduce pain and inflammation. The use of strengthening and stretching exercises may help reduce pain with activity, especially those exercises focused on stabilizing the shoulder blade (scapula). These exercises may be performed at home or with referral to a therapist. If symptoms persist for greater than 6 months despite non-surgical (conservative) treatment, then surgery may be recommended.

MEDICATION

  • If pain medication is necessary, then nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

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

  • Prescription pain relievers may be given if deemed necessary by your caregiver. Use only as directed and only as much as you need.

COLD THERAPY

Cold treatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or massage the area with a piece of ice (ice massage).

SEEK MEDICAL CARE IF:

  • Treatment seems to offer no benefit, or the condition worsens.

  • Any medications produce adverse side effects.

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - SECONDARY IMPINGEMENT SYNDROME

These exercises may help you when beginning to rehabilitate your injury. Your symptoms may resolve 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.

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 __________. 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/belt with your right / left hand.

  • While keeping an upright posture, gently pull up on the towel/belt 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 __________. Release the stretch by lowering your opposite hand.

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

ROM - Internal Rotation

  • Using underhand grips, 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 __________ seconds. Slowly return to your starting position.

  • Grasp a stick behind your back with both hands.

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

STRETCH - External Rotation and Abduction

  • Stagger your stance through a doorframe. It does not matter which foot is forward.

  • As instructed by your physician, physical therapist or athletic trainer, place your hands:

  • And forearms above your head and on the door frame.

  • And forearms at head-height and on the door frame.

  • At elbow-height and on the door frame.

  • Keeping your head and chest upright and your stomach muscles tight to prevent over-extending your low-back, slowly shift your weight onto your front foot until you feel a stretch across your chest and/or in the front of your shoulders.

  • Hold __________ seconds. Shift your weight to your back foot to release the stretch.

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

STRETCH - Posterior Shoulder Capsule

  • Stand or sit with good posture. Grasp your right / left elbow and draw it across your chest. Keep it 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 __________.

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

STRENGTHENING EXERCISES - Secondary Impingement Syndrome

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. Progress with the resistance and repetition exercises only as your caregiver advises.

  • 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 worsen, stop and make certain 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 right / left hand or elbow above your head or behind your back or head. These positions stress the tissues which 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 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 completing the next repetition.

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

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 __________ seconds.

  • Release the tension slowly. Relax your shoulder muscles completely before you do 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 abdomen. Gradually increase the tension until you are pressing as hard as you can without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold __________ seconds.

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

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

STRENGTH - Internal Rotators, Isometric

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

  • Step into a door frame so that the inside 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 draw the palm of your hand to your abdomen. Gradually increase the tension until you are pressing as hard as you can without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold __________ seconds.

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

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 clinician 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 completing 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 __________ seconds. Slowly return to the starting position and allow your muscles to relax completely before completing 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 comfortably can be).

  • 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 completing the next repetition.

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

STRENGTH - Scapular Depressors

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

  • Keeping your feet on the floor, lift your bottom 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 __________ seconds. In a controlled and slow manner, lower your body weight to begin the next repetition.

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

STRENGTH - Scapular Retractors

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a palm-down grip, grasp an end of the band/tubing 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 band/tubing until it becomes tense.

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

  • Hold __________ seconds. Slowly ease the tension on the band/tubing 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/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a thumbs-up grip, grasp an end of the band/tubing 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 band/tubing 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/tubing 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/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a palm-down grip, grasp an end of the band/tubing 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 band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, rotate your shoulder so that your upper arm and elbow remain stationary, but your fists travel upward to head-height.

  • Hold __________ for seconds. Slowly ease the tension on the band/tubing 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/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a palm-down grip, grasp an end of the band/tubing 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 band/tubing 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 shoulder 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/tubing as you reverse the directions and return to the starting position.

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

STRENGTH - Internal Rotators

  • Secure a rubber exercise band/tubing to a fixed object 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/tubing 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/tubing, pull it across your body toward your abdomen. Be sure to keep your body steady so that the movement is only coming from your shoulder rotating.

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

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

STRENGTH - External Rotators

  • Secure a rubber exercise band/tubing to a fixed object 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/tubing is at your side that is not injured.

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

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

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

STRENGTH - Supraspinatus

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

  • Slowly lift your right / left hand from your thigh into the air, traveling about 30 degrees from straight out at your side. Lift your hand to shoulder height or as far as you can without increasing any shoulder pain. Initially, 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 - Shoulder Abductors

  • Stand or sit with good posture. Place your right / left arm at your side.

  • With a thumbs-up grasp, hold a __________ weight or a secure rubber exercise band/tubing in your right / left hand. Slowly lift your arm from your side as far as you can without reproducing any of your shoulder pain. Do not lift your hand above shoulder-height unless you have been instructed to do so by your physician, physical therapist or athletic trainer. If this motion causes pain or increased discomfort, discuss this with your physician, physical therapist, or athletic trainer.

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

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

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