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 on top of each other.  I don’t want anyone to be confused if they start here!

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

“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 (see video below) 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.
• 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)
• 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.

This article is going to form the backbone of your progress through shoulder rehabilitation.  In the next articles we’ll be discussing specific ways to address the problems you’ll have with shoulder impingement.  Get pumped.

Rotator cuffs of steel,

Dan Pope

P.S. If you enjoyed this article then sign up for the newsletter to receive the FREE guide - 10 Idiot Proof Principles to Crossfit Performance and Injury Prevention as well as to keep up to date with new information as it comes out via weekly emails.

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 Medicine, 43, 409-416.
4. Wilk, K. E., Reinold, M. M., & Andrews, J. R. (2009). The Athlete’s Shoulder . (2 ed.). Philadelphia, PA: Churchhill Livingstone.