Shoulder Impingement Syndrome: Rehabilitation Protocol

This protocol provides a comprehensive guideline for the physical therapy management of shoulder impingement syndrome. It is designed to be adaptable and should be modified based on individual patient needs, progress, and symptom presentation. Regular communication with the referring physician is crucial throughout the rehabilitation process.

Pathophysiology

Shoulder impingement, also known as subacromial impingement syndrome (SAIS), is a common condition characterized by compression of structures within the subacromial space, primarily the rotator cuff tendons (supraspinatus, infraspinatus, teres minor, and subscapularis), the long head of the biceps tendon, and the subacromial bursa. This compression often occurs during overhead activities or internal rotation and adduction of the arm. Contributing factors can include:

• Anatomical Variations: Acromial shape (e.g., hooked acromion), presence of bone spurs.
• Rotator Cuff Weakness or Imbalance: Weakness of the rotator cuff muscles, especially the external rotators, can lead to superior migration of the humeral head and impingement.
• Scapular Dyskinesis: Abnormal scapular movement alters the mechanics of the shoulder complex, contributing to impingement.
• Poor Posture: Forward head and rounded shoulders can narrow the subacromial space.
• Capsular Tightness: Posterior capsule tightness can limit internal rotation and contribute to anterior humeral head glide during elevation.
• Overuse: Repetitive overhead activities can irritate the tendons and bursa.

Common Special Tests

• Neer Impingement Test: The examiner passively flexes the patient's arm in forward flexion while internally rotating the humerus. A positive test elicits pain.
• Hawkins-Kennedy Test: The examiner flexes the patient's shoulder to 90 degrees and then forcefully internally rotates the arm. Pain indicates a positive test.
• Empty Can Test (Jobe Test): The patient abducts the arm to 90 degrees, internally rotates the arm (thumb pointing down), and the examiner applies downward resistance. Weakness or pain suggests supraspinatus involvement.
• Painful Arc: Pain experienced between 60 and 120 degrees of abduction is suggestive of impingement.
• Scapular Assistance Test (SAT): The therapist manually assists the scapula into upward rotation and posterior tilt during arm elevation. Improvement in pain with assistance suggests scapular dyskinesis.

Phase I: Protection (Week 1-3)

Goals: Reduce pain and inflammation, protect injured tissues, restore pain-free range of motion, and initiate gentle muscle activation.

• Pain Management:
  • Rest and activity modification: Avoid aggravating activities and overhead motions.
  • Ice packs: Apply for 15-20 minutes, several times per day.
  • Pain medication: As prescribed by the physician (NSAIDs).
  • Modalities: Consider ultrasound, electrical stimulation (TENS), or phonophoresis to manage pain and inflammation.
• Range of Motion (ROM):
  • Pendulum exercises: Promote gentle ROM in all planes without stressing the shoulder.
  • Supine shoulder flexion with a cane or dowel rod.
  • Wall walks: Gradual increase in shoulder flexion and abduction.
  • Gentle external rotation stretches: Supine with a towel roll under the humerus.
  • Cross-body adduction stretch.
• Muscle Activation:
  • Isometric exercises: Perform pain-free isometric contractions of the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis) and scapular stabilizers (rhomboids, trapezius, serratus anterior). Hold for 5-10 seconds, repeat 10-15 times.
  • Scapular retractions: Focus on proper scapular positioning and movement.
  • Low row with theraband, focusing on scapular adduction.
• Patient Education:
  • Proper posture and body mechanics.
  • Activity modification and avoidance of aggravating factors.
  • Importance of adhering to the rehabilitation program.
• Progression Criteria:
  • Decreased pain and inflammation.
  • Improved pain-free ROM.
  • Tolerance to isometric exercises.

Phase II: Loading (Week 4-8)

Goals: Restore strength and endurance of the rotator cuff and scapular stabilizers, improve neuromuscular control, and gradually increase functional activities.

• Strengthening:
  • Theraband exercises: External rotation, internal rotation, scaption, horizontal abduction. Progress resistance as tolerated.
  • Prone shoulder extension.
  • Prone horizontal abduction with external rotation.
  • Rows with dumbbells or resistance bands.
  • Scapular protraction with serratus punch.
  • Weight shifting on hands and knees.
  • Bicep curls and tricep extensions with light weights.
• Proprioception and Neuromuscular Control:
  • Weight bearing exercises on a stable surface.
  • Rhythmic stabilization exercises: Manual perturbations in various shoulder positions.
  • Use of a wobble board or BAPS board to improve balance and coordination.
• ROM:
  • Continue stretching exercises from Phase I, gradually increasing the intensity.
  • Joint mobilization: Address any capsular restrictions, particularly posterior capsule tightness.
• Functional Activities:
  • Gradually introduce light functional activities that mimic daily tasks or sport-specific movements.
  • Avoid overhead activities until pain-free and strong.
• Progression Criteria:
  • Pain-free ROM.
  • Good strength and endurance of the rotator cuff and scapular stabilizers.
  • Improved neuromuscular control.
  • Tolerance to light functional activities.

Phase III: Return to Function (Week 9+)

Goals: Restore full functional capacity, return to sport or work activities, and prevent recurrence of symptoms.

• Advanced Strengthening:
  • Plyometric exercises: Medicine ball tosses, wall dribbles.
  • Progressive weight lifting: Increase weight and repetitions as tolerated.
  • Closed kinetic chain exercises: Push-ups, pull-ups (modified if necessary).
• Sport-Specific Training:
  • Gradually introduce sport-specific drills and activities.
  • Focus on proper technique and biomechanics.
  • Progress intensity and duration of training sessions gradually.
• Maintenance Program:
  • Continue strengthening and stretching exercises to maintain strength and flexibility.
  • Maintain proper posture and body mechanics.
  • Avoid overtraining and overuse.
• Return to Activity Criteria:
  • Full pain-free ROM.
  • Strength and endurance comparable to the unaffected side.
  • Ability to perform sport-specific or work-related activities without pain or discomfort.

Important Considerations:

• This protocol is a guideline and should be adapted to individual patient needs.
• Regularly assess the patient's progress and adjust the treatment plan accordingly.
• Educate the patient on the importance of adherence to the rehabilitation program.
• Communicate with the referring physician regarding the patient's progress and any concerns.