Shoulder Impingement & Exercise

Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. Recently I wrote a lengthy series of blogs about the pros and cons of physiotherapy for shoulder pain versus surgery and in those blogs (which can be found here shoulder surgery vs physiotherapy 1; shoulder surgery vs physiotherapy 2; shoulder surgery vs physiotherapy 3)  I looked at how effective surgery was, how effective imaging was and at what point you should consider having surgery. Just recently I read an interesting review about the effectiveness of a series of interventions for shoulder impingement, so I thought this would be a nice thing to continue with as our next blog and have a look at shoulder impingement, what it is, who it affects and some recent research about the effectiveness of exercise in treating it.

What is Shoulder Impingement?

Well there is actually a fair amount of debate about whether or not shoulder impingement is actually a valid description of what is happening inside a painful shoulder, however rather than get into that I think it is better to simply describe what has traditionally been called shoulder impingement. Basically, shoulder impingement is when one of the tendons or potentially bursa in your shoulder rubs and gets impinged by part of the scapula and causes pain. To understand a bit more about shoulder impingement we need to have a look at the anatomy of the shoulder joint.

The Anatomy of the Shoulder

The shoulder joint is a truly amazing piece of anatomy and allows the arm to move through an enormous range and lift weights up from all angles. It is a ball and socket joint which is made up of the bones of the humerus (upper arm bone) and scapula (shoulder blade). The head of the humerus forms the ball part of the joint and articulates with the scapula at the glenoid fossa (this is the socket part of the joint). Although not physically part of the actual shoulder joint the clavicle (collar bone) has an important role in attaching the scapula to the thorax (rib cage) and sternum (breast plate).

So, now we have a decent idea of the bones that make up the shoulder joint we now need to have a look at the muscles that move the shoulder itself and the tendons that attach those muscles to the bones and the ligaments that provide stability. For anyone wondering “what’s the difference between a tendon and a ligament?” It is fairly easy to understand:  "a ligament is a piece of connective tissue that connects a bone to a bone" and "a tendon is a piece of connective tissue that connects muscle to bone". Simply put the tendons connect the muscles to the bones but do not do any of the pulling themselves (all of that is done by the muscles), ligaments are just bits of tissue stabilising and securing bone to bone.

The most important of the muscles of the shoulder are the 4 rotator cuff muscles: subscapularis, supraspinatus, infraspinatus and teres minor. All of these insert directly into the head of humerus via their associated tendons. These are the most commonly injured structures in the shoulder and some studies say that over 90% of shoulder pain can be attributed to a problem with one of these tendons. As suggested by the name "rotator cuff" these muscles are heavily involved with rotation of the arm and shoulder. One of their major roles is that of a stabiliser of the head of humerus (ball part of the joint) - they act as guy lines and suck the head of humerus into the socket and keep it stable and moving well and securely.

One of these muscles in particular – supraspinatus has a tendon that is the most commonly injured of the rotator cuff tendons, this is thought to be because it passes through a small gap in the scapula (the subacromial arch) and it can sometimes become compressed and irritated here. Finally, we have the subacromial bursa - a bursa is a fluid/jelly filled sac that reduces friction and in this case it sits in between the supraspinatus tendon and the scapula in the subacromial space. A large number of studies have shown it to be heavily innervated (it has lots of nerve endings) and to be a source of shoulder pain. The compression of either (or both) the bursa and the tendon of supraspinatus in this subacromial space is thought to be the source of pain in shoulder impingement.

 

What are the Symptoms of Shoulder Impingement?

Unlike the anatomy of the shoulder, the actual symptoms of shoulder impingement are fairly easy to know and are generally a combination of the following:

• Pain in the outside of the shoulder or outside of the arm, which will usually stop above the elbow.
• Pain on lifting or raising the arm above shoulder height.
• Pain on putting your arm behind your back.
• A painful arc when you take your arm out to the side and above your head, this often becomes painful at about 60 degrees but then eases off after about 120 degrees.

Obviously, it is important to note that having these symptoms does not mean you definitely have shoulder impingement and in fact they can often be the sign of other conditions. As such if you are concerned that you have shoulder impingement you need an assessment to get a clear diagnosis.

What Causes Shoulder Impingement?

The space through which the supraspinatus tendon moves – the subacromial space is very tight and it only needs either a small growth in the bone above or a swelling in the tendon itself to make that space even tighter and compress either the tendon or the bursa. Once irritated it can then set up a cycle of swelling in the tendon which causes compression of the bursa and the tendon itself which further irritates the tendon through compression.

This initial swelling or compression of the bursa can happen through trauma (i.e. a fall) but usually happens gradually and is generally a symptom of overload and repetitive movement over shoulder height. Sometimes there is an underlying weakness in one of the other muscles of the shoulder or a general weakness in the rotator cuff itself that causes the tendon to be overloaded and for shoulder impingement to start. As such it is always worth having a full assessment to determine what the cause of your shoulder impingement is.

Who is at Risk of Getting Shoulder Impingement?

Pretty much anyone can get shoulder impingement but it usually affects people who do a lot of overhead activity such as painters and decorators or people who do a lot of repetitive movement of their shoulders such as swimmers. Anyone who has recently started doing a lot of work with their arms such as someone who has decided to paint the whole house will also be at risk of developing shoulder impingement through overload.

How is Shoulder Impingement Diagnosed?

Shoulder impingement is generally diagnosed clinically by a physiotherapist from a series of tests and taking a history of the patient’s symptoms and pain. There is in general very little need for any imaging such as an ultrasound scan or MRI of the shoulder to diagnose shoulder impingement. If after a program of rehabilitation things are not improving a scan can then be warranted as a way of determining the next step in treatment and making sure that the diagnosis of shoulder impingement is correct.

Treatments for Shoulder Impingement

There are a range of treatment options available for shoulder impingement with physiotherapy and rehab work being usually the first option:

• Physiotherapy: an assessment by a physiotherapist and a programme of exercises can help in making an accurate initial diagnosis and ensuring that you are doing the right things in terms of exercises and rehab work. In general physiotherapy has a very high success rate with shoulder impingement and should in almost all circumstances be the starting place for anyone with shoulder impingement. We have a series of blogs available here discussing the pros and cons of surgery vs physiotherapy for shoulder pain.
• Steroid Injection: a cortico-steroid injection into the shoulder capsule can sometimes be an effective treatment option for patients with large amount of pain and inflammation and who have either not responded to physiotherapy or are unable to tolerate the exercises. The injection is an anti-inflammatory and reduces the general anger and inflammation within the shoulder itself and can allow patients to more effectively engage in the exercises needed to recover from shoulder impingement.
• Surgery: clearly this should be the last resort for patients with shoulder impingement and in fact the evidence is very clear that mostly patients will get better without surgery. However, there are some patients that despite following the exercises and doing all the right things can not get rid of their shoulder impingement and pain. For these a procedure called a sub-acromial decompression can provide pain relief and an opportunity to be able to do effective strengthening and rehab work.

Exercises and Shoulder Impingement

There are a whole range of exercises that can be useful for helping with shoulder impingement and without an assessment from a physio it would be difficult to be certain about the best ones and how often to do them. Most though are based around the idea of strengthening the rotator cuff and generally stabilising the shoulder whilst not irritating it too much in the first place. Over the next few months we will be adding some videos about shoulder rehab to our YouTube channel for you to have a look at.

How Long will it Take for My Shoulder Impingement to Heal?

This is in general “the million dollar question” and is always specific to the person, how painful their shoulder is, what they do for living, how long they have had shoulder pain and how diligent they are with their exercises. I think it would be fair to say that if you have shoulder impingement you should in general be thinking of at least a 6 – 8 week period of rehabilitation and physiotherapy.

What things Should I Avoid for My Shoulder Impingement

Obviously you need an assessment first and a clear diagnosis but I think it is far to say that there are a few things that you should try to avoid doing too much of in order to avoid irritating your shoulder impingement:

• Overhead Lifting: try as much as you can to avoid lifting things above your head height – at least until your physio says that it is okay.
• Lifting Heavy Objects: fairly common sense I know! However, it is important to realise that most shoulder impingement is caused by overload and doing lots of lifting is only going to irritate it.
• Repetitive Overhead Work: avoiding having your arms above your head should be fairly easy if you work in an office however if you are a plumber, electrician or painter/decorator this will present a real challenge.

How Can ThreeSpires Physiotherapy Help with My Shoulder Impingement?

As a home visit physiotherapy service with a large amount of experience of seeing patients with shoulder impingement we can help in a number of ways by firstly having one of our physiotherapists assess your condition and make an accurate diagnosis. If indeed you do have shoulder impingement then our physiotherapist will be able to develop an effective management plan combining exercises and manual therapy to help maximise your recovery and return your shoulder to pain free movement. Possibly an example of how we have helped a patient with shoulder impingement in the past might help illustrate things:

In this case of shoulder impingement our patient was a male in his mid-30s who was physically active, played badminton and had a relatively sedentary job. He had recently developed shoulder impingement about 4 weeks ago after deciding to play badminton 3 times a week rather than his usual once a week. So, after booking an initial assessment our physiotherapist visited him at home and he had a full assessment to diagnose the cause of his shoulder pain and also decided on an effective management plan. On assessment the patient had relatively full range of motion at his shoulder but got pain whenever he took his arm above shoulder height and on resisted external rotation. Based upon his physical assessment and the information from the discussion our physiotherapist made a diagnosis of shoulder impingement due to overload and a weak rotator cuff. So, he was given a programme of exercises to follow and advised to take a week off badminton and any overhead lifting. Slowly over the coming weeks and several sessions of physiotherapy including some manual therapy his shoulder pain improved and he was able to return to badminton (a few gentle sessions initially). His rehabilitation exercises were targeted at strengthening up his rotator cuff muscles, making his shoulder more generally stable and reducing the risk of further injury in the future. After approximately 8 weeks the majority of the symptoms of his shoulder pain had resolved and he was happy to self-manage and continue without further physiotherapy.

 

So, now that we have had a good look at what shoulder impingement is, who it affects, the symptoms, some treatment options and how physiotherapy can help we can have a look at what a recent review of studies said about shoulder impingement and exercise.

This review looked at the results of over 200 trials to examine the effectiveness of various treatments for shoulder impingement and pooled the results to try and give an idea of which treatment or combination of treatments might be the most effective for shoulder impingement. The interventions that were looked at for shoulder impingement included exercise, manual therapy, shockwave, anti-inflammatory medication, laser, taping, corticosteroid injections and nerve blocks. So this was a fairly comprehensive attempt to pool the evidence relating to the majority of interventions that are used to relieve shoulder impingement. The results of the study were interesting despite the fact that they had to use a large amount of low quality evidence. Exercise was found to be better than doing nothing and specific exercises were found to be more effective. This from my perspective as a physiotherapist makes complete sense and confirms what I have found to be the case with many patients with shoulder impingement. Often they have looked on the internet and have been doing some generic exercises that they have found there. Mostly they have been slowly getting better with some ups and downs but after an assessment by a physiotherapist and a prescription of carefully designed exercises they generally improve much more quickly and with a great deal more confidence. Looking at the other treatments steroid injections were found to be better than placebo and manual therapy was found to be helpful especially in conjunction with exercises. Laser, shockwave and taping were found to be marginally better than placebo. If you wish to have a look at the whole review please click here https://bjsm.bmj.com/content/early/2017/07/19/bjsports-2016-096515  

So, great news for us physiotherapists (and also our patients!), another large systematic review shows that carefully prescribed exercises can be helpful in treating shoulder impingement.

I hope that you have found this article helpful. If you or anyone you know has shoulder impingement then please feel free to get in touch. We are a home visit physiotherapy service serving Lichfield, Sutton Coldfield, Tamworth, Cannock, Rugeley and Walsall.