Shoulder Impingement and Rotator Cuff Injuries: An Overview

Shoulder impingement is a common problem among athletes, especially those involved in heavy resistance training. As such, today’s topic will focus primarily on shoulder impingement and acute (key word here: acute) partial rotator cuff (RC) tears for younger individuals involved in regular athletic activity.  Shoulder pain, a common injury that affects millions, is the second most common reason an individual will visit their doctor and roughly 65% of shoulder pain is related to the RC tendon.¹ Yikes! However, Charles S. Neer, known for significant contributions surrounding shoulder treatment, claimed that nearly every RC tear injury is brought about by subacromial impingement.¹¹ A diagnosis in the early stages can be difficult since many people can be asymptomatic. When signs of impingement are present, interventions should be applied immediately following a diagnosis. Data as it relates to managing impingement and RC tears comes with conflicting results. There is evidence to support that surgery has a more favorable outcome, and there is also strong evidence that supports non-operative treatments when it comes to RC tears from shoulder impingement.⁵ Initially, age, activity level and degree of injury should be considered. With the techniques presented, positive results can be expected for managing a partial RC tear in a younger athlete. I am not a doctor, but the aim of this post is to provide evidence-based information to cover prehabilitation ideas, tests, diagnosis, pain management and rehabilitation techniques to heal RC tears while addressing shoulder impingement.

 

Epidemiology, Relevant Anatomy, Biomechanics

The role of the RC is to stabilize the shoulder in an effort to prevent excessive humeral head movement. If properly strengthened, the RC should provide exceptional dynamic stability, scapulohumeral rhythm and control. For example, when the arm is being raised, sufficient RC strength will decrease chance of impingement as the humeral head is depressed. As such, when glenohumeral movement is normal and stable, this means the RC is working properly; however, when damage occurs, dysfunction starts to take place.⁴

RC injuries related to shoulder impingement are usually caused by more than one factor. Among these can include poor scapular mechanics, supraspinatus narrowing, posterior capsule tightness, imbalances, capsular laxity, subacromial crowding, RC weakness and instability.¹¹ An RC tear is common among athletes who perform repetitive shoulder motions, especially overhead movements. When shoulder impingement is not addressed, the tendons in the RC will begin to wear. An acute RC tear can be explained as a tear following an injury, when the connective tissues around the joint tear. If wear continues, sometimes, there is permanent thickening and fibrosis of supraspinatus and biceps tendon.⁸

An RC tear can be successfully managed with conservative or surgical treatments. With a non-surgical approach, rehabilitation techniques include modifying current activities, applying appropriate physical therapy with the goal of restoring range of motion (ROM) and strength, combined with anti-inflammatory medications. To resolve the underlying issue of shoulder impingement, this approach successfully relieves symptoms the majority of the time.⁵“Majority” translates to about 70-90% of individuals who have shoulder impingement issues.⁴ This approach is more cost effective than surgery and can fully restore RC functionality and stability.⁹

 

Clinical Presentation

In the early stages, shoulder impingement can cause stiffness, throbbing and increased pain with arm movement. As the injury develops, individuals will generally have weakness and movement restrictions with shoulder elevation and abduction. Swelling may also be present. Common pain complaints include reaching overhead and aching when sleeping at night. Signs of impingement will typically produce pain when the individual is resisting external rotation and/or shoulder abduction.¹ That is because an impinged shoulder occurs when the supraspinatus tendon, subacromial bursa, and long head of biceps tendon become compressed.⁸

 

Diagnostic Evaluation

 When examining the RC, there are a list of options to choose from, including: the lift off test and rotation lag signs that look the teres minor and infraspinatus, the drop arm test that will check the supraspinatus or the belly press test that examines the subscapularis. With over 25 different tests to examine the integrity of a RC, rather than performing every test, it’s important to keep in mind that the goal is to test scapular rotation, capsular laxity, ROM (flexion, abduction, external rotation in neutral and abduction positions) and rotator strength.³ Abduction should be checked at 90 degrees with the elbow extended. External rotation should be examined with the arm at the side. Scapular elevation should be checked with the arm at 90 degrees.⁴ To test specifically for impingement, Neer’s sign can be performed (when the individual is seated and raises the arm overhead into forced flexion).² If pain is produced, impingement would be positive (due to the lack of space between the coracoacromial arch and humeral head).⁸ If a diagnosis is difficult, magnetic resonance imaging (MRI) is useful, which is recommended if the athlete is considering surgery. An MRI diagnosis is also a useful tool as there are so many tests that can be difficult to choose which one is appropriate.¹¹

 

Treatment Options

When it comes to selecting a treatment plan, each case should be examined on an individual basis as it will depend on age, activity level and extent of the injury. Data suggests that younger individuals are generally successful and satisfied with conservative treatment options. Nearly 60% of individuals who followed appropriate rehabilitation programs of stretching and strengthening had significant improvements without surgical interventions.¹Recommendations, especially for those who are younger with fuller RC thickness, usually begin with conservative, non-surgical treatments first and then if conservative treatment fails after 9 months of rehabilitation efforts, the athlete may be a good candidate for surgery.¹¹ Surgery for partial RC tears can be decompressed or repaired with arthroscopic acromioplasty, which is generally a preferred method for better results and an easier recovery.¹¹ Subacromial decompression, although it has had favorable results for severe impingement, can also have a high rate of reoccurrence.¹ It’s also important to note that surgical interventions can be costly for the individual as well as the medical system.⁶

As previously mentioned, the majority of cases for a partial RC tear who follow non-surgical approach, can lead to cessation of symptoms with appropriate techniques.⁵ These can include four phases of manual therapy, rehabilitative exercises, stretching, anti-inflammatory medication and non-operative techniques that enhance RC functions.

 

Part 1: Immediate care procedures

 As part of immediate care, the athlete should rest from any activity that causes pain. The athlete’s approach should first focus on resolving inflammation and only moving the shoulder in a pain free ROM. Early phases may include unweighted scapular neuromuscular movements to build a better scapula foundation for phase 2 exercises. Oral anti-inflammatory medication can be used in the initial stages of recovery to reduce pain and inflammation, especially the first few days after the injury.⁴  Cryotherapy or intermittent icing can also be used immediately following injury as an effort to reduce pain, acute swelling, damage to affected tissues, which can decrease rehabilitation time.⁸

Passive stretching can be done as long as it is kept within a pain free range. Exercises that can facilitate gentle stretching to increase ROM can start off with Codman’s circumduction and sawing motion before progressing to the next stage.⁸ Also, in the beginning stages, joint mobilization techniques can be performed to help reduce tightness restore ROM. An area to concentrate on would be the posterior and inferior glenohumeral joint as tightness is related to subacromial shoulder impingement. According to one study,⁴ posterior capsule stretching can help manage the root cause of shoulder impingement.  Joint mobilization, paired with exercise, should be implemented throughout each phase of rehabilitation. Data shows that exercise paired with manual therapy, including soft tissue mobilization, joint mobilization and massage techniques is more effective than only exercising.⁵ Massage techniques should be introduced more in the second phase after inflammation has subsided.

 

Part II: ROM and Strength Progression

As part of the next phase, activities should be modified to work in a pain free state as the athlete progresses gradually in terms of ROM and strengthening the RC. A combination of proper stretching, therapeutic modalities and isometric exercises has been proven to improve shoulder impingement.² As such, it will be critical for the athlete to introduce exercises to strengthen and assist with external rotation, elevation and abduction of the scapula. A variety of isometrics should be performed to challenge positioning from multiple directions. As shoulder impingement is closely related to shoulder instability, initially, isometric exercises have been shown to improve stability while reducing pain and improving tendon thickness.⁶ Producing force isometrically at weak angles can increase strength but without the pain that comes from joint motion. Because it’s important that centralization of the humeral head is maintained, isometric exercises are a reasonable way to load RC tendons in the beginning stages of strengthening.⁶ Finding a tolerable option is important in this phase, and individuals generally favor isometric or static movements in the earlier phases. Data shows that longer isometric actions (>30 seconds) can result in greater and faster strength increases when compared to shorter isometric actions (~3 seconds), so in this instance it is reasonable to have the athlete perform longer duration isometric actions for faster results.¹⁰

During this phase, isometric exercises should focus on external rotation and internal rotation, elevation and depression as well as upward and downward rotations. Examples of isometric exercises can include: isometric abductions with a band (long hold), isometric abduction to external rotation with a band (long hold), isometric external rotations with a band (long hold) and isometric external rotation with flexion (long hold), deltoid and elbow against wall, pushing fist into wall (standing position).⁴ Another goal of this phase is to increase and restore shoulder ROM. Building upon phase one as an effort to relieve tightness, the individual can progress their stretches to include active shoulder circles, wall slides and wall angels in a seated position.

In conjunction with exercises and stretches, a individual may look to dry needling to increase shoulder mobility. Dry needling has been shown to decrease pain and increase ROM among shoulder impingement individuals.⁷ Dry needling is performed by using a thin needle in specific trigger points of the affected muscle. With positive results and no negative reactions, dry needling may be an effective therapeutic treatment method to improve movement restrictions while providing relief for the individual.

To increase blood flow and circulation, a variety of massage techniques can be introduced during this phase. Friction massage can be used in conjunction with mobilization techniques to relieve stiffness and breakdown adhesions. Such stimulation and manipulation of soft tissue can be used to dilate and drain capillaries, which may facilitate recovery.⁸ As previously mentioned, care should be taken to only perform massage when inflammation has decreased.

Corticosteroid injections can be used during this phase as long as it’s combined with exercise and stretching.² Such injections are effective to reduce pain and inflammation but should not be used as a stand-alone intervention as the problem can recur without proper rehabilitation techniques.

 

Part 3: Advanced Progressions

 The goal of this phase will be to work in a full pain free ROM and the individual should continue with prescribed stretches to full end range. As improvement of neuromuscular control should be focused on, the athlete will relearn control of muscle actions while developing proper firing sequences.⁸ To advance sense of joint position, something to consider is both open and closed kinetic chain exercises.¹¹

During this phase, activities will progress from passive to active exercises and increased resistance and/or reps. These should include concentric activities (first), followed by introduction of eccentric exercises. Elastic bands and light weights can be used as resistance. Light bands can be used as a gentler exercise as the athlete progresses to increased resistance. A low weight high repetition protocol should be strictly followed at first to build muscular endurance.⁴ Plyometric exercises can begin to be implemented with light weighted balls. Plyometric training can improve proprioception and neuromuscular control while focusing on muscle performance and correct shoulder positions. For example, catching a ball (during a chest pass) will load the shoulder eccentrically and then will also include the concentric movement in the throwing phase.¹¹

Resistance should only increase as the individual progresses. If pain is present, the individual should regress to the prescribed program the week prior. Such endurance will provide the foundation to continually improve upon RC strength. With a variety of exercises to choose from, the important thing is to effectively target each area of the RC and deltoid to help with scapula control. Movements should include abduction, extension, elevation/depression, flexion, internal/external rotation.¹¹

Targeted Area	Exercise Examples
Serratus anterior	Wall push up and punches
Scapulothoracic Muscles	Y, W, Ts
Levator Scapulae	Rowing, shoulder elevation and abduction
Rhomboids	Sitting scapular abduction, retraction, elevation, depression
Trapezius	Shrugs, rowing

 

Part IV: Return to Sport

 Returning to play should be a gradual process. During this phase, functional sport-specific activities should be implemented on an individual basis, beginning with low intensity interval training. For example: low level intensity forehand swings that progress to higher level intensity of backhand swings (tennis). It is imperative that any faulty scapular mechanics be corrected prior to the athlete returning to sport. Pain should be non-existent. The athlete should be also be tested to ensure full ROM is restored.⁴

It’s also important to mention that recurrence of shoulder injuries is common. So common that almost half of individuals complain of symptoms after 6 months to a year.⁶ That’s why it is important to continue with home strengthening and stretching routines, even after the initial symptoms subside.

 

Prehabilitation and Injury Prevention

 An effort to prevent injuries before they take place should be an important part of any athlete’s program. Overhead athletes are usually high risk for shoulder injuries (i.e.: swimming, volleyball, baseball, tennis). If an athlete is deemed susceptible to shoulder injuries, it should be advised the athlete perform shoulder health exercises and upper body mobility 2-3 times a week in addition to their regular strength program. During prehabilitation strengthening exercises, the goal is to have the athlete maintain positioning of the humeral head. If the muscles surrounding are strengthened, better scapula positioning and improved stabilization can take place.

Exercise Example	Description
Y-T-W drills	Retraction abduction/flexion or internal/external rotation
Banded pull apart	Scapular retraction using resistance band
Internal/external rotation	Towel under elbow at 90-degree angle

 

Conclusion

In this post, a thorough discussion of RC tears related to shoulder impingement is presented. Such information that includes preventive, diagnosis and treatment may be helpful to an athletic care team, including coaches and athletic trainers when younger athletes are suspected of RC tears and shoulder impingement.

In terms of rehabilitation from a RC injury, an athlete will need an individualized program that progresses appropriately with healing times. Being fully aware of treatment options and programs ahead of time, may help with compliance and expectations. Whichever method of treatment that is chosen, it’s important that the athlete, coach and medical team understand each phase of rehabilitation so recommendations can be followed, and positive results can be achieved.

 

 

Happy training friends!

 

Xo,

Nat

 

 

References:

1. Edwards, P., Ebert, J., Joss, B., Bhabra, G., Ackland, T., Wang, A. Exercise Rehabilitation in The Non-Operative Management of RC Tears: A Review of The Literature. International Journal of Sports Physical Therapy. 2016; 11(2): 279–301
2. Efstratiadis, A., Marangos, S., Kasapakis, E., Georgiadou, P., Ploutarxou, G., Stelicos, G., Stelicou, V., Fousekis, K., Stasinopoulos, D. The Subacromial Impingement Syndrome of The Shoulder: The Role of Physiotherapist in The Evaluation and Treatment of The Syndrome. Biology of Exercise. 2017; 48(16):1202-8. doi: 10.1136/bjsports-2012-091802
3. Jain, N. B., Wilcox, R., Katz, J. N., Higgins, L. D. Clinical Examination of the RC. Journal of Physical Medicine and Rehabilitation. 2013; 5(1): 10.1016/j.pmrj.2012.08.019
4. Kamkar, A., Irrgang, J. J., Whitney, S. L. Nonoperative Shoulder Impingement Syndrome. Journal of Orthopedic and Sports Physical Therapy. 1993; 17(5):212-24
5. Khan, Y. Nagy, T. M., Malal, J., Waseem, M. The Painful Shoulder: Shoulder Impingement Syndrome. Open Orthopedics Journal. 2013; 7: 347–351. doi: 2174/1874325001307010347
6. Kinsella, R., Cowan, S. M., Watson, L., Pizzari, T. A Comparison of Isometric, Isotonic Concentric and Isotonic Eccentric Exercises in The Physiotherapy Management of Subacromial Pain Syndrome/RC Tendinopathy: Study Protocol for A Pilot Randomised Controlled Trial. 2017; 3:45. doi: 1186/s40814-017-0190-3
7. Passigli, S., Plebani, G., Poser, A. Acute Effects of Dry Needling on Posterior Shoulder Tightness. A Case Report. International Journal of Sports Physical Therapy. 2016; 11(2): 254–263
8. Prentice, W. E.Principles of athletic training: A guide to evidence-bashed clinical practice (16th ed.). New York, NY: McGraw-Hill Education; 2017.
9. Sambandam, S. N., Khanna, V., Gul, A., Mounasamy, V. World Journal of Orthopedics. RC Tears: An Evidence-Based Approach. 2015; 6(11): 902–918
10. Scott, J., McCully, K., Rutherford, O. M. The Role of Metabolites in Strength Training. II. Short Versus Long Isometric Contractions. European Journal of Applied Physiology. 1995;71(4):337-41
11. Williams, Gerald R., Kelley, M. Management of RC and Impingement Injuries in the Athlete. Journal of Athletic Training. 2000; 35(3): 300–315