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What is Shoulder Impingement?

Shoulder Impingement is the compression of the following structures in the shoulder:

Subacromial bursa

Supraspinatus tendon

As a result – this can lead to painful conditions such as:

1. Subacromial bursitis

Let’s break it down into simpler terms:

a) Subacromial = “underneath the acromion”.

(The acromion is a bony process of the shoulder blade.)

b) Bursitis = “inflammation of the bursa”.

(A bursa is a fluid-filled sac within the shoulder complex.)

Summary: It is the inflammation of the fluid-filled sac structure (Bursa) in the area of your shoulder that is underneath the acromion (Subacromial).

2. Supraspinatus tendinopathy

The Supraspinatus is part of a group of shoulder muscles called the rotator cuff.

It has the important role of stabilising and moving the shoulder joint.

As the Supraspinatus tendon is located in the area directly underneath the acromion, it is susceptible to getting compressed.

This can lead issues in the tendon such as: Inflammation (“Rotator cuff Tendinitis”)

Degeneration (“Rotator cuff Tendinosis”)

Tear (“Rotator cuff tear”)

Calcification

What causes Shoulder Impingement?

Poor posture (Eg. Rounded shoulders, Thoracic Kyphosis)

Repetitive use of shoulder (especially over head)

Poor scapulohumeral rhythm

Acromial spurs

Poor joint centration of the humeral head

The content presented on this blog post is not medical advice and should not be treated as such. It is not intended to be used as a substitute for professional advice, diagnosis or treatment. For more information: Medical disclaimer.

Tests for Shoulder Impingement

Note: These tests give a general guide line in diagnosing your shoulder problem.

Many other structures in your shoulder can also make these tests reproduce pain as well.

a) Nature of pain

The area of pain is usually felt deep within the point of the shoulder.

In many cases, pain can also refer down the side of your upper arm. (see above)

Pain is often aggravated in certain positions of shoulder such as over head movements.

b) Painful arc

Instructions:

Raise your arm out to the side and over your head. (Also known as Shoulder abduction)



Findings : Unable to lift arm into full range.

Pain between 60-120 degrees of abduction.

degrees of abduction. Nil or reduced pain at early (0-60 degrees) and late (120-180 degrees) shoulder abduction.

b) Hawkins Kennedy test

Instructions:

Bring your bent arm to 90 degrees of shoulder flexion in front of you. (see above)

Crank your hand down with the help of your other hand. (Shoulder Internal rotation) Do not let your shoulder hitch upwards.



Findings: Reproduction of your shoulder symptoms with the movement.

c) Neer’s test

Instructions:

Raise your arm a) in front of you and b) to the side with your thumb pointing downwards.

Findings: Reproduction of your shoulder symptoms with the movement.

Shoulder Impingement exercises

Note: These Shoulder Impingement exercises must be comfortable and performed gently. Listen to your body!

Step 1 : Stop aLL activities that cause pain

How can you expect your shoulder to get better if you keep exposing it the activities that make it worse?

It may sound really straightforward, but I’ve seen so many people get this first simple step wrong.

… STOP aggravating your pain!

The body can not (…and will not) heal itself if you don’t allow enough time for it to do so.

“… If it hurts, don’t do it!

If feels fine, keep at it!”

Avoid aggravating positions such as over head movements, lifting and sleeping on the painful shoulder!

Quick tip: When you do use your shoulder, try to keep your elbows as close to the side of your body as possible.

Step 2 : Reduce inflammation

If there is excessive inflammation in the area, everything will be painful!

Once the inflammation levels have subsided, we can then start the Shoulder Impingement exercises without aggravating the shoulder again.

a) Anti-inflammatory gel

Apply the anti-inflammatory gel to the whole shoulder.

Do this 2-3/day.

I prefer products with natural active ingredients like arnica, calendula or hypericum.

b) Non-steroidal anti-inflammatory drugs (NSAIDs)

It is recommended that you take a strong anti-inflammatory medication for at least 7-10 days.

(Please consult your general practitioner before taking any new medication)

c) Ice/Cold therapy

Apply an ice pack to your shoulder for at least 10-15 minutes.

Do this 3-5 times per day.

d) Shoulder sling

If the pain is severe, you can temporarily immobilize your shoulder for a short period of time.

(… do NOT wear it for longer than 1-2 days!)

e) Try natural products

Taking turmeric and/or fish oil capsules are natural ways to help reduce the inflammation.

Step 3 : Reduce pressure on painful structures

a) Shoulder release

This will help decompress the shoulder joint.

Place your shoulder muscles into a massage ball onto the floor.

Target muscles: Deltoid

Continue for 2-3 minutes to cover the entire area.

b) Shoulder traction (with a resistance band)

Instructions:

Anchor a strong resistance band underneath your foot.

Whilst holding onto the end of the resistance band, start to lean away from the band.

Aim to feel a downward pulling sensation in your shoulder.

Keep your shoulder as relaxed as possible.

Apply more tension to the band if you would like to increase the stretch.

Hold for 30 seconds .

. Repeat 3-5 times.

Note: Do NOT pull into sharp pain. (… especially if you have a tear!)

Step 4 : Release tight muscles

The following tight muscles can limit how much you can raise your arm.

Instructions: Place target area on top of a massage ball or a foam roller.

Apply an appropriate amount of your body weight on to the ball

Continue for 1 minute on each area.

on each area. Make sure that you cover the whole muscle.

(I strongly recommend looking up the exact location of these muscles on Google.)

a) Pec minor

b) Latissimus Dorsi

c) Teres Major

d) Triceps

Step 5 : Initial Shoulder Impingement exercises

The goal here is to keep the shoulder as mobile as possible.

Do what you can.

Don’t do more than you can’t…

Overprotecting your shoulder may predispose you developing frozen shoulder. (… and that’s way worse!

a) Pendulum

Instructions:

Lean over a chair and allow your arm to hang underneath you.

Using the momentum of your arm, gently sway your arm side ways/forwards/backwards/circles.

Allow the shoulder to move as much as you can without reproducing any pain.

reproducing any pain. Repeat each movement for 10 repetitions each.

Alternative : Roll a ball on a table top in a circular motion.

: Progression : Generate more tension throughout the whole arm as you move the arm.

b) Forward leans

Instructions:

Place your hand on the back of a chair.

Lean forward as to bring your arm in an upwards direction. Do this as much as you can without reproducing any pain.

Repeat 20 times.

Alternative : Roll a ball forwards/backwards on a table top. Roll a ball up/down the wall.

:

c) Rotations

Instructions:

Bend your elbows to 90 degrees.

Keep your elbows in contact with the side of your body.

Proceed to rotated your arm outwards/inwards.

Allow the shoulder to move as much as you can without reproducing any pain.

reproducing any pain. Repeat 20 times.

Progression : Generate more tension throughout the whole arm as you move the arm.

d) Shoulder flexion with band

Instructions:

Lie on your back.

Hold a resistance band between your hands.

Gently pull the band apart.

Keep your elbows bent at 90 degrees.

Raise your arms as far as possible without reproducing any pain.

Repeat 20 times.

Step 6 : Encourage joint centration

If the shoulder bone (… also known as the humeral head) is not centered within the shoulder socket, it can often move into a forwards and upwards direction.

This may increase the chance of impingement in the shoulder.

a) Posterior shoulder release

A tight posterior capsule can push the humeral head forward in the shoulder socket.

Instructions:

Place the back portion of your shoulder on top of a massage ball.

Apply an appropriate amount of your body weight into the area.

Continue for 1 minute.

b) Posterior shoulder stretch

Instructions:

Gently pull your shoulder blades backwards.

Without moving your shoulder blades, bring your arm across the body.

Pull the arm further with your other hand.

Aim to feel a stretch at the back of your shoulder.

Hold for 30 seconds.

c) Anti-impingement exercises

Humeral head depression: You need to get familiar with the sensation of depressing your humeral head in your shoulder socket. Imagine your shoulder bone is constantly being sucked in a downwards AND inwards direction into the socket whilst you move your arm. (This may take some time to understand and perform correctly… and that’s fine. Keep at it!)

Extension:

Instructions:

Anchor resistance band on top of the door.

Face the door.

Starting at shoulder height, pull the resistance band down towards your body.

Keep constant tension through resistance band throughout movement.

Hold for 3-5 seconds .

. Slowly return the hand back to shoulder height If this hurts, you may want to start at a lower height

Repeat 10-30 times. 3 sets.

times. sets. Progression : Start from a higher position. Apply more tension to the band

:

Adduction:

Instructions

Anchor resistance band on top of the door.

Stand side on to the door. The affected shoulder should be closer to the door.

Starting at shoulder height, pull the resistance band down towards your body.

Make sure your palms are facing forward.

Keep constant tension through resistance band throughout movement.

Hold for 3-5 seconds.

seconds. Slowly return the hand back to shoulder height If this hurts, you may want to start at a lower height

Repeat 10-30 times.

times. Perform 3 sets.

sets. Progression : Start from a higher position. Apply more tension to the band

:

Step 7 : Ideal scapula position

By optimizing the scapula position, this will help reduce impingement in the subacromial space.

This is a quick and easy way to reset your shoulders into a more neutral position.

If you ever forget where your shoulder should be, do this:

Instructions:

Keep your shoulders “long and wide” : Reach and stretch out your hands as far to opposite sides as possible. (see above)

: Reach and stretch out your hands as far to opposite sides as possible. (see above) Retraction : Slightly bring your arms backwards. Make sure you can feel a gentle contraction between your shoulder blades. Do not over squeeze your shoulder blades together!

: Slightly bring your arms backwards. Posterior Tilt : Turn your palms upwards so that your thumbs are angled towards the floor. Imagine the inferior angle (“the pointy part of lower scapula”) is digging into the back of your rib cage.

Turn your palms upwards so that your thumbs are angled towards the floor.

Take note of your new shoulder position.

Keep this position and slowly lower your arms down by your side.

Now that you know how your scapula should ideally sit, it is just as important to understand how it should MOVE as you use your arm.

[See video]

Main points: It is VITAL that your scapula moves properly when you lift your arm up. (especially over head)

As the arm is raised, the scapula should laterally rotate so that the inferior angle reaches the side of your ribs. This will promote more space in the subacromial space where compression occurs.

so that the inferior angle reaches the It can help if you visualize how the scapula should be moving as you use your arm.

The scapula should sit flat on the rib cage throughout movement.

This is achieved by learning how to…

Step 8 : Activate your Serratus anterior

This muscle is responsible for moving your shoulder blade more effectively as you use your arm.

It is important that you can feel the Serratus Anterior muscle contracting as you perform the following strengthening exercises.

Activating the Serratus anterior: Instructions: Assume the wall plank position. (see above)

Assume the Ideal scapula position. (See step 6)

Activate the Serratus Anterior by pushing your forearms into the wall: Pull your shoulder blades DOWN and AROUND the ribs. Keep your shoulders long/wide.

Aim to feel the contraction in the lower and side region of the scapula. (… This is where the Serratus Anterior muscle is!)

the contraction in the lower and side region of the scapula. There should be a balance between the muscles that are pulling backwards and the muscles that are pulling down/around.

Hold for 30 seconds.

seconds. Repeat 5 times.

times. Progression : Whilst maintaining the activation of the Serratus Anterior, slide your forearms up/down the wall. For more exercises like this: Serratus Anterior strengthening exercises.

Step 9 : Strengthening

Maintain the Ideal scapula positioning throughout all of these Shoulder Impingement exercises.

Remember:

Tilt the shoulder blades BACKWARDS .

. Pull your shoulder blades DOWN and AROUND the ribs.

and the ribs. Keep your shoulders long/wide.

… This is CRUCIAL!

1. Isometric training

This involves strengthening your shoulder muscles without moving.

This is to make sure that you do not aggravate the symptoms in your shoulder.

You can perform an isometric contraction in ANY shoulder position and in ANY direction.

Example: External rotation (with flexion)

Instructions:

Keep your elbows tucked to the side of your body.

Gently pull your shoulders back.

Hold a resistance band between your hands.

Pull the resistance band away from each other. (External rotation)

Whilst maintaining the tension on the band, lift your arms up as high as you can with nil pain. (Flexion)

Hold this position for 30-45 seconds .

. Repeat 3 times.

Note: Only push yourself as far as you are comfortable!

2. Dynamic exercises

Progress to these Shoulder Impingement exercises only if you are able to conduct the previous Shoulder Extension, Adduction and Internal rotation exercises easily.

Remember to: Depress the humeral head throughout movement.

Maintain the Ideal scapula position.

Engage the Serratus Anterior.

a) External rotation

Instructions:

Anchor the resistance band at elbow height.

Stand sideways with the affected arm further from the door

Pull the band away from your body.

Aim to keep your elbow in contact with the side of your body at all times. Think about squeezing a piece of paper between your elbow and the side of your body

Repeat 10-30 times

times Perform 3 sets

b) Internal rotation

Instructions:

Anchor the resistance band at elbow height.

Stand sideways with the affected arm closer to the door.

Pull the band towards your body.

Aim to keep your elbow in contact with the side of your body. Think about squeezing a piece of paper between your elbow and the side of your body

Repeat 10-30 times

times Perform 3 sets

c) Flexion

Instructions

Stand on the end of a resistance band.

Pull the resistance band as high as you can comfortable go without pain.

Keep constant tension on the resistance band throughout movement.

Hold for 3-5 seconds.

seconds. Slowly return the hand back to the body.

Repeat 10-30 times.

times. Perform 3 sets.

d) Abduction

Instructions:

Stand on the end of a resistance band.

Pull the resistance band towards the side as high as you can comfortably go without pain.

Keep constant tension on the resistance band throughout movement.

Hold for 3-5 seconds at end range.

seconds at end range. Slowly return the hand back to the body.

Repeat 10-30 times.

times. Perform 3 sets.

3. Weight bear exercises

a) Rock back

Instructions:

Assume the plank position with your knees on the floor.

Assume the Ideal Scapula Position.

Push your forearms into the floor.

Rock your body backwards as far back as possible.

Return to starting position.

Repeat 30 times.

times. Progression : Increased the amount of weight going through your shoulder by performing the exercise whilst on your hands and feet.

4. Strengthening in functional positions

What exact activity can’t you do because of your painful shoulder?

You need to find an exercise that will mimic the motion of doing this SPECIFIC movement/activity.

For example:

If you have difficulty hanging out your clothes on the clothes line… you can do the following exercise:

Instructions

Stand on the end of a resistance band.

Assume the Ideal Scapula Position. (See Step 6) This is to prevent you starting from a slouched shoulder position.

(See Step 6) Aim to pull the resistance band as high as you can go without causing any pain. (Experiencing a small amount of discomfort is fine!)

Keep constant tension on the resistance band throughout movement.

Hold for 3-5 seconds.

seconds. Slowly return the hand back to the body.

Repeat 10-30 times.

times. Perform 3 sets.

Step 10 : Address Posture

If you have been persistent with these shoulder impingement exercises and are still experiencing symptoms, consider addressing the following postural issues:

a) Rounded shoulders

Having Rounded Shoulders is when the resting shoulder position is in front of the mid line of the torso.

Do you have it?

For more information, check out this blog post:

b) Thoracic Kyphosis

A curved spine will place the shoulders in an ineffective position to function.

Do you have it?

For more information, check out this blog post:

c) Winged Scapula

A Winged Scapula is when the inner border of the shoulder blade protrudes off the rib cage.

The scapula is in a position of anterior tilt and downward rotation which can increase the chance of compression occurring in the subacromial space.

Do you have it?

For more information, check out this blog post:

Common questions :

1. How often should I do Shoulder impingement exercises?

Aim for 3/week.

Start with 1/week.

Monitor and assess how the shoulder responds.

Adjust frequency accordingly.

2. How long does it take to recover?

… It really depends!

There are many factors that will influence the time it will take for a full recovery.

Try to focus on consistent improvements.

3. Does the Cortisone injection help?

If you have already been to your doctor, then the chances are that they have already suggested that you get the cortisone injection.

This injection consists of a steroid (cortisone) and an analgesic substance.

The aim of the injection is to:

a) Reduce inflammation

Reduce inflammation b) Reduce pain

Reduce pain c) Create a “window of opportunity” to progress the exercises.

Sounds great in theory… right?

Yes, it does…

BUT – The problem is that it does absolutely nothing to address the underlying cause of the shoulder impingement.

More often than not – the injection may provide some short term relief, but only to have the pain come back at a later date (… and usually with a vengeance!).

My recommendation: Persist with these shoulder impingement exercises for about 4-6 weeks .

. If there is absolutely no improvement (… or if it’s getting worse), then it might be the next step to take.

It should NEVER be the first thing that you do.

4. Do I need surgery?

My immediate answer: NO.

The reason behind this is that I have a strong belief in healing the body via conservative means.

Please give these exercises a chance before even considering surgery for Shoulder Impingement.

(Keep in mind – not all surgeries are successful!)