Shoulder Impingement Part 7: Stages of Rehabilitation

Updated November 2017

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 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. (Also keep in mind that many people actually have rotator cuff tears and are asymptomatic)

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 goal is to start adding exercises slowly and progressively while carefully monitoring for symptoms over time.

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

“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 months to really start feeling better (5).

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 (If needed) 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): Get back at it!

Want to learn more about how to rehabilitate and prevent future shoulder injury? Check out my latest shoulder course with Dr. Dave Tilley.

Just a few things covered in the course…

Functional Shoulder Anatomy: What parts of the shoulder are most relevant to your understanding of injury and performance?
The Most Common Shoulder Injuries Seen in the Gym: Shoulder impingement, rotator cuff tears, biceps tendonitis, AC joint injuries, bursitis and labral tears
Technical Errors: Advice on where injuries occur in the major lifts and how to fix this
Advanced Rehabilitation Strategies: Learn how to bridge the gap between basic rehabilitation and high level performance
Progressive Return to Exercise Programs – Specific exercise protocols to help you return back to pull-ups, bench press, muscle-ups, snatching, jerks and overhead pressing

Click HERE to Learn More about Peak Shoulder Performance

Cuff Jacked,

Dan Pope DPT, OCS, CSCS

References:

Bigliani LU, Morrison DS, April EW: The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 10:228, 1986.
Morrison DS, Bigliani LU: The clinical significance of variations in acromial morphology. Orthop Trans 11:234, 1987.
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 Medicine, 43, 409-416.
Wilk, K. E., Reinold, M. M., & Andrews, J. R. (2009). The Athlete’s Shoulder . (2 ed.). Philadelphia, PA: Churchhill Livingstone.
Rotator Cuff Tendinopathy with Dr. Chris Littlewood https://www.clinicaledge.co/podcast/physio-edge-podcast/physio-edge-047-rotator-cuff-tendinopathy-with-dr-chris-littlewood

Shoulder Impingement Part 7: Stages of Rehabilitation

Click HERE to Learn More about Peak Shoulder Performance

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