Shoulder Impingement Part 7: Stages of Rehabilitation

If this is the first time you’ve read been reading this article series I recommend going back to part 1 and starting there.  A lot of the topics build...

overhead pressIf this is the first time you’ve read been reading this article series I recommend going back to part 1 and starting there.  A lot of the topics build on top of each other.  I don’t want anyone to be confused if they start here!

Part 1  Part 2  Part 3 Part 4 Part 5 Part 6

As discussed in part 1 of the series, acromion type is associated with excessive shoulder impingement and rotator cuff tears (1,2).  This is a boney structural problem.  Unfortunately this can’t be changed without surgery.

However, we do have a great deal of control over the amount of impingement we have at the shoulder.  The elements we have control over are called functional causes of impingement.  We’ve systematically broken down each of these elements in prior articles.  In the upcoming articles we’ll address specifics treatment ideas for these issues.

Remember: Always consult a qualified medical professional before you begin any type of exercise program.  Getting a professional to do a thorough evaluation of your shoulder and creating a program specific to your needs will always be the best option.  

Before we start addressing these aspects of rehabilitation we need to address where you are with your injury.  Everyone is an individual and should be treated according to their specific needs.  This means that certain individuals may need more of some treatment and less of another.  It also means we’ll have to figure out how bad the injury is and where you are along your journey of healing.

If we jump into the wrong phase of rehabilitation we’ll  be setting ourselves up for failure.

Shoulder impingement is a vicious cycle.  Exercise is the cure but also the culprit.  If we add too much exercise or the wrong exercises at the start of a rehabilitation program it creates more impingement and can make your shoulder worse.  Our job is to break this cycle.

I realize that most meatheads and fitness buffs out there (myself included) have a really difficult time cutting back on their current activities.  Getting your shoulder better will absolutely require us to scale back on our program with the removal of offending activities and exercises.

Common offenders (ooh, it hurts to hear this):

  • Bench press
  • Overhead press
  • Dips
  • Pull-ups (especially kipping)
  • Most pressing variations

Bench Press

“You may take my pride but you’ll never take my bench presss!!”

The ideas is to set yourself up for healing.  We need to take out the offensive exercises in order to do this.  On top of that we also have to be careful with our rehab exercises.  Just because they are therapy exercises doesn’t mean we can go willy-nilly with them.

I had a professor that used to say that prescribing physical therapy exercises  is like making soup.  If you add too much spice to the soup all at once, you ruin the soup.  Ideally you want to add a small bit of spice at a time and taste it frequently.

The same goes for shoulder exercises.  Too much exercise increases pain and impingement, worsening your condition.  In the beginning keep in mind that less is more.   Enough exercise and we progress forward, too much we go back.  We’re trying to make delicious soup, not a rotator cuff tear.

It’s vital to have patience.  You won’t be able to rush your body.  It’s going to heal on its own terms.

Food for thought: If you’ve been having shoulder impingement for some time now (especially if you’re an older individual) you might have some tendon degeneration or what we like to call in the medical world a tendinopathy.  This is a condition where the tendon becomes enlarged, weakened and more likely to tear.  This takes a significant period of time to fix and up to 4-6 weeks just to decrease pain. (3)  Unfortunately we don’t always have pain when tissue degeneration is occurring so by the time we start getting pain things could already be fairly damaged (3).

Now that we’ve got that underway, let’s get down to business.  The next step is to classify what phase of rehabilitation we’re in at the moment.  An excellent resource is the chapter on non-operative treatment of shoulder impingement in the text, “The Athlete’s Shoulder.”  Keirns and Whitman have outlined clear cut phases of rehab for subacromial impingement to help guide us through the rehab process (4).

Note: The authors concluded that approximately 70% of people will fit the categories of the upcoming phases.  15% of patients will need to be progressed faster, and 15% slowed down (4).  Don’t rush this process, no matter how tempted you might be.

1. Phase I – Acute Inflammatory Phase (4) – How do we know if this is the phase we’re in?

  • Inability to sleep on shoulder
  • Discomfort at rest
  • Warmth to touch of shoulder
  • Pain and weakness with muscle strength testing
  • Pain with overhead motion
  • Positive impingement signs
  • Diffuse tenderness with palpation of the shoulder

What is the purpose of this phase?

  • Decrease Pain
  • Reduce Inflammation
  • Prevent Atrophy (Muscle wasting from inactivity)

What do we need to do in this Phase?

  • Rest and avoid offending exercises and activities
  • Promote pain free mobility of adjacent joints including our cervical spine (neck), thoracic spine and ribcage.
  • Prevent atrophy through isometrics
  • Soft tissue work to aggravated shoulder structures
  • Stay mobile – pain free stretches only
  • Ice massage and electric stimulation
  • Isometrics at 45 degrees of shoulder abduction for 3 sets of 12 to 20 repetition (3 second holds at about 20-50% of your maximal strength)
  • Fix your posture
  • Find a sleeping posture that does not aggravate your shoulder and promotes healing

  • Modify your daily routine as not to aggravate your symptoms
  • Don’t offend impingement symptoms in this phase!

How long will I be in this phase? You can progress to stage II when you:

  • Have no discomfort at rest
  • No warmth with shoulder joint palpation
  • Tolerate the exercises in phase one
  • Takes about 1 week

Food for thought: Cortisone shots are commonly used in patients with subacromial impingement syndrome.  Although effective for reducing inflammation and subsequently pain, these injections can produce tendon atrophy and decrease the ability of the tendon to heal itself (The opposite of what we want).  Also, several control studies have shown minimal effectiveness of cortisone injections to the shoulder in the absense of therapy (4).  On top of that the use of NSAIDs such as ibu profen have been shown to slow the tissue healing process of a tendon (3).

2. Phase II – Subacute Stage (4): 

What is the purpose of this phase?

  • This is a continuation of phase 1 and emphasizes circulation to damaged tissues to help promote healing

What do we need to do in this phase?

  • Continue and progress all parts of phase I
  • Promote blood flow to healing tissues
  • Ultrasound, ice and soft tissue work to the tissues to promote blood flow
  • Advance ROM as tolerated (Don’t progress impingement!)
  • Continue isometrics as shown in the phase above
  • Begin scapular stabilization exercises
  • Begin addressing the joints above and below the shoulder (thoracic spine, ribcage, AC joint, cervical spine)

How long will I be in this phase? You can progress to stage III when you:

  • Can show normal range of motion at the shoulder 

  • No pain during your normal daily activities (Not what you do in the gym)
  • Improved muscular performance

Food for thought: Impingement leads to tendinopathy of the rotator cuff tendons.  When rehabbing a shoulder we’ll have to think about not only decreasing impingement but treating a pathological (diseased) tissue.  In a healthy tendon the collagen fibers that make up the tissue run parallel to each other and line up in an efficient position to help transmit force.  In tendinopathy the fibers don’t line up properly and do not transmit forces normally.  A pathological tendon is more likely to tear.  Also keep in mind that a resolution of pain does not equate to a completely healed tendon (3,4).

3. Phase 3 – Progressive Exercise Stage (4):  Finally the good stuff!

What is the purpose of this phase?

  • Here’s where we can really start addressing all of the abnormalities that we discussed in the other parts of this series
  • Restore normal functioning of the rotator cuff musculature
  • Restore normal motion of the shoulder blades
  • Restore alignment of the ribs and thoracic spine
  • Begin introducing a specific strength and conditioning program to return to your normal lifting/fitness/sporting activities.

What do we need to do in this phase?

  • Continue to normalize shoulder motion more aggressively (Shoulder, T-spine, ribs etc.)
  • More aggressive joint mobilizations guided by a physical therapist
  • Advance rotator cuff endurance exercises to all planes.
  • Advance scapular stability exercises.
  • Sports specific strength training program.  Here’s where we begin preparing for what we’re trying to get back to.  For most this will probably be pressing and overhead activities.  We’re taking into account proper programming for these activities.

Here are some of my favorite closed chain exercise progressions to help return to exercises like pushups, pull-ups and handstand work

Here are some of my favorite open chain exercise progressions to progress back to dumbbell and barbell work like push press, push jerk and split jerk.

  • Begin plyometric activity.
  • Promote normal motion.

How long will I be in this phase? You can progress to stage IV (Return to Activity) when you have:

  • Full and non-painful range of motion
  • No tenderness to any shoulder structures upon palpation (when pressing into the shoulder)
  • Full strength in all ranges of motion

4. Phase IV – Return to sport or activity (4):

At this point we’ve addressed everything we need to in order to get back to what it is we love doing.  There’s still a few things to keep in mind.

  • Fix your programming – Too much pressing might have gotten you into this problem in the first place.  Adjust what needs to be adjusted.  We want to balance pressing with rowing both in the horizontal plane (bench press vs. rowing) and frontal plane (overhead press vs. pull-ups)  Click HERE if you want to try my online programming
  • Fix your technique – Poor technique is another reason for shoulder impingement.  Make correcting this a priority.  It might be a problem with your mobility or stability.  Maybe you just go too heavy on your exercises.  Remember that your shoulders attach to the rest of your body.  You might need to address other joints and muscles above or below your shoulder in order to fix these issues.  That’s an article for another day (Isn’t this series already long enough?).
  • Maintenance – I’m a big fan of adding additional mobility, scapular stability, rotator cuff and shoulder proprioceptive activity into your warm-up and at the end of workouts to help keep those shoulders healthy.   Hopefully I’ll get a video up of the exercises I like the most sometime in the near future.

cat benchThis article is going to form the backbone of your progress through shoulder rehabilitation.

Want to learn more about how to assess your own and your athlete’s shoulder motion during common exercises and find the best exercises to optimize it so you don’t get back in pain again?  Check out Dr. Dave Tilley and my product:

Monkey Method – Movement Essentials

The Ultimate Guide to Understanding and Fixing Technical Flaws in the Handstand, Muscle-up and Olympic Lifts

Rotator cuffs of steel,

Dan Pope

References:

  1. Bigliani LU, Morrison DS, April EW: The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 10:228, 1986.
  2. Morrison DS, Bigliani LU: The clinical significance of variations in acromial morphology. Orthop Trans 11:234, 1987.
  3. Cook , J., & Purdam, C. (2013). Is tendon pathology a continuum? a pathology model to explain the clinical presentation of load-induced tendinopathy.British Journal of Sports Medicine43, 409-416.
  4. Wilk, K. E., Reinold, M. M., & Andrews, J. R. (2009). The Athlete’s Shoulder . (2 ed.). Philadelphia, PA: Churchhill Livingstone.
Categories
rehabilitationShoulderUncategorized
19 Comments on this post.
  • John
    26 July 2013 at 10:26
    Leave a Reply

    Hi Dan,
    Do you have any post regarding the progressive exercise for rehabilitation?
    It would be greatly appreciated of any exercise recommendation from you!!

    • djpope
      26 July 2013 at 10:26
      Leave a Reply

      Hey John! I’ve been doing a lot of research lately for shoulder rehab and in the process of making a book. I’ll try and get some posts out soon with specific progressive exercises for these issues!

    • Carrie J
      4 August 2013 at 10:26
      Leave a Reply

      Hello,

      I have just rec’d the impingement diagnosis and had my 1st PT visit, so I am trying to gain the big picture on how I got here and how I will get out. I had my 2nd SLAP tear repair + bicep tendonesis on 12/28/2012. It was my 2nd shoulder surg. (initial SLAP tear repair 3/2004). I felt so relieved of the accrued pain from living w/ the torn tendon post surgically. I was only able to do 5 PT visits to regain ROM following the 8 week immobilization period due, to a high Medical deductible coupled w/ surgery expenses…terrible insurance. Over the next 8-12 weeks the pain ans clicking with shoulder movement, pec pain,trap tightness, upper cervical locking the whole nasty pattern. So back to the surgeon and onto therapy.

      Finally my Q? at my age 52, female w/ shoulder pathology and a recruited negative compensation pattern, what can I expect for a rehab period? This is ingrained in muscle memory despite numerous stints in PT and personally attempting to negate the pattern that creates the problem.
      Any comments, I would describe myself as significantly deconditioned currently but, willing to work into and through pain to regain my shoulder , rib and thoracic function and then move into peaker condition for me.

      thank you, Carrie

      • djpope
        5 August 2013 at 10:26
        Leave a Reply

        Hey Carrie! Thanks for the question. Have you spoken to your doc about this? Usually they send a protocol for rehab to your therapist to follow. That will give you a better idea of how long it will take to rehab.

        I also think its going to depend on what you want to get back to. Are you trying to get back to some high intensity fitness ala crossfit? The protocols usually give you an idea of when you can get back to certain activities but I don’t think they always tell the full story of when you’ll be able to get back to intense exercise. Get back to me with those questions and we can troubleshoot further.

  • casino
    28 July 2013 at 10:26
    Leave a Reply

    I like it when individuals come together and share ideas.
    Great site, stick with it!

    • djpope
      28 July 2013 at 10:26
      Leave a Reply

      Appreciate it, thank you.

  • shadam
    1 August 2013 at 10:26
    Leave a Reply

    all these shoulder posts are great…rife with practical knowledge and written w/humility. do you have a private practice?
    thanks!

    • djpope
      1 August 2013 at 10:26
      Leave a Reply

      Thanks for the kind words Shawn. No, I actually just moved to Denver Colorado and am looking for a place to work!

  • Steve
    10 January 2014 at 10:26
    Leave a Reply

    Hi Dan.
    Just wanted to pass on my sincere thanks for a highly informative mountain of great information that has answered in full all of my questions. I’m in shoulder rehab right now but language barriers with the Doc here make things difficult to understand. However your info has made the translation between Doc and patient (or not so patient at times) easy and clear.
    Thanks again.
    Steve.

    • djpope
      18 January 2014 at 10:26
      Leave a Reply

      Thank you Steve, I really appreciate it.

  • Ryan
    6 May 2014 at 10:26
    Leave a Reply

    Hi there!

    Great reading!

    I am currently awaiting surgery in July for my right shoulder after an initial disclocation 20 years ago (I’m 40) and maybe 2 or 3 since. I had a Bankart repair on my left shoulder in 2004 which stabalized it nicely. I damaged my right shoulder on 31 st March this year and I was wearing a sling on this arm. I have a toddler at home that I was carrying around with just my left arm. Around the 5th April I had to strain to carry my daughter just using my left arm for around 40secs (whilst she was unhappy and I wanted to get her back to the car) My bicep throbbed afterward and on following Monday shoulder started to feel unstable, to the point of slightly subluxing. I have seen my personal PT and await an X-Ray as the initial process from the NHS here. Then I should get referred to an NHS physiotherapist and possibly and MRi scan. My own PT beleives it may be impingement and would know more with a scan. What it feels like to me is like there is a bubble of air toward the front of my shoulder, my arm feels light and sometimes my thumb and fingers close up. Then it will back off but still feel unstable. I’m concerned about with I have done to it and the fact it’s unstable due to the straining to lift my daughter up. If I let it swing freely infront (like picking something up from the floor) of me I’m quite it would disslocate to the front.
    I am just hopefull it’s stronger before I get my right arm repaired in July!
    Thank you!

    • djpope
      26 May 2014 at 10:26
      Leave a Reply

      Hey Ryan thanks for the kind words. Let me know the results of the imaging.

  • ben
    13 August 2014 at 10:26
    Leave a Reply

    Hi, absolutely love the articles. I have suffered from shoulder pain for two years. Ive seen every kind of professional but none have been able to explain why as well as you.
    Doing the rehab now and hope to b back surfing & crossfitting in a month or two.
    Wish U were based in Sydney. Many thanks again.

    • djpope
      7 September 2014 at 10:26
      Leave a Reply

      Thanks a million Ben, let me know how rehab goes.

  • Anne
    2 April 2015 at 10:26
    Leave a Reply

    Hi Dan,
    Your article is excellent!
    Could you please shed some light on a question I have?
    I am 3 years into shoulder impingement syndrome, I had a corticosteroid injection 6 weeks ago into my subacromial bursa, the injection needle also hacked away some calcification on the acromion.
    I have been pain free since and have full ROM. I have tried to start working on stabilising my shoulder but am having pain in my traps going up my neck.
    Do you think that is because my trapezius is over compensating for a weakness elsewhere?
    Also, I was not referred for any physio rehab after the injection, I’m just trying to figure out as much as I can on my own.
    I’m 38 and would like to get back to training as soon as!
    Thanks,
    Anne

  • Sean Wilson
    22 October 2015 at 10:26
    Leave a Reply

    Hi Dan.

    Brilliant articles (I have read all 1-7).

    I am currently undergoing rehab for a subacromial impingement that I have had for months. I have been doing the rehab work for weeks now but it does not seem to be getting any better.

    Rehab work includes:

    – Laser therapy and soft tissue work
    – posture correction exercises
    – rotator cuff strengthening exercises aswell as lower lat and serratus anterior strengthening exercises.
    – Shoulder stability and mobility work, and thoracic spine mobility work.

    My main concern is that I have a hard tendon/ligament that is very prominent under my armpit (on the injured side, nothing like this on the good side). I feel like this is the main reason that I am still getting impingement and that it does not seem to be getting any better.

    Could you shed and light on this please and what I can do to sort it?
    I am trying to get back to weight training and have been out for months (I will of course be keeping all of the shoulder work that I have learned in my program going forward as maintenance)

    Thanks in advance and keep up the great work.

    • djpope
      1 November 2015 at 10:26
      Leave a Reply

      Sean, it honestly looks like you’re on the right track. I’d continue with what you’re doing. It isn’t a fast journey. I’d definitely continue listening to the therapist. Have the therapist look at it and see what they think. It could just be a common attachment of several muscles in that area.

  • Mike Asara
    8 May 2016 at 10:26
    Leave a Reply

    Nice article. I should of seen this before doing tricep dip. Now the impingement is worse than before.

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