What I do for my shoulder impingement patients

http://jessephysio.com/2011/10/06/what-i-do-for-my-shoulder-impingement-patients/

It’s been a while since I posted an article or “blog” post on my page. I just finished a few courses and needed to spend time doing a few other things over the weekends so writing took a backseat. Now I’m happy to report that I’m back and will start writing weekly posts again!

Today I would like to talk about on of my favourite joints (Yes, I said favourite joint) in the body…the shoulder complex! There is so much stuff going on in the shoulder and rehab and treatment of shoulder pathology can be a tricky process. For starters, most people come to see me with shoulder pain after having the issue for months (or even years!) and they expect me to magically do something to their shoulder for the pain to go away…sigh. Short of an acute injury to the shoulder, most issues stem from muscle imbalances which occurred from over use, postural issues (a big one!), or a combination of many biomechanical factors…which take time and diligence to go away.

The discussion on how to assess the shoulder and surrounding area is beyond the scope of this post. I will simply state a few clinical “pearls” that often help with what is commonly known as subacromial impingement. When you get that “pinch” in your shoulder when raising your arm overhead, you may have the condition that I’m going to be talking about now.

So what do I do about this problem…2 things come to mind first.
1) Address the thoracic spine (or midback)!!! If you have a crappy sitting posture and lean over a desk all day, chances are you will get shoulder issues. Why? Simply put: you are slowly closing off the space that shoulder has to move. Here is a nice little Youtube video describing the condition:

2) Strengthen the shoulder force couples:
Most of us are upper trap dominant and lose the ability to fully contract the lower traps and serratus anterior. If this happens, our arm bone will go up when we lift up our arm, but the shoulder blade will lag behind causing the bones to but up against one another as seen in the youtube clip above.

How do I treat a classic subacromial impingement? I usually start my addressing biomechanical factors such as thoracic spine mobility. Manual therapy including mobilization, manipulation, ART, myofascial release, and PNF stretching work well to that end.

But the REAL work is on the clients end. Some conditions respond well to passive care such as tension headaches or ankle stiffness (with exercises done as well). But shoulder issues are 90% on the patient and 10% on the therapist. That means I’m just the coach with these types of patients. I direct my patients on what to do and how do to the exercises and it’s up to them to adhere religiously to the program. It’s sad to say that this is why many shoulder clients fail to achieve maximal results…cause many want a “quick fix” which isn’t always possible.

Based on research and what I see clinically, here is a list with youtube links to common exercises I give to restore proper scapular stability and kinematics

1) Pushup plus: 
This exercises targets the serratus anterior muscle. The job of this muscle is to aid in scapular upward rotation, protraction and keeping it firm to the ribgage. A weak serratus anterior can result in scapular winging (h)

2) Lower trap “Y” raises:
This exercises can be done on a flat table but doing it on an incline helps reduce the chance of arching through the low back while completing the exercise. NOT a lot of weight (if any) is needed to do this exercise well

3) Scapular “W” retraction/external rotation/posterior tipping exercise: 
This is my new favourite exercise because it works so many things at once. It really gives you bang for your exercise buck! This simple yet highly effective exercise works the scapular retractors (rhomboids/middle traps), external rotators ( Teres Minor/Infraspinatus), and posteriorly tips the scapula which conteractes a tight pec minor which acts to anteriorly tip the scapula…which is a bad thing!

4) The classic row exercise: 
With so many of us sitting in front of computers all day with slouched posture, doing upright rows to promote scapular retraction is critical. It also helps with thoracic spine extension!

5) Dynamic Hugs: 
this exercise also works the serratus anterior but is less intense then the pushup plus. I give it to my older clients with shoulder issues or those who can’t get into a pushup position.

These are starting point exercises for those with classic subacromial impingement. Overhead athletes will require more “functional” exercises since there shoulders usually have specific adaptations to the demands placed upon them from the game. Along with exercise, I often employ a stretching program since I find the posterior capsule to be an issue with many people who have shoulder pain. I also use my manual therapy skills to help restore motion and try to help with immediate pain reduction (not always successful) haha.

For a GREAT refernce on shoulder issues and to get an understajnding of where many of my exercise ideas come from please visit www.mikereinold.com
Mike Reinold it an athletic therapist and physiotherapist for the Boston redsox and his posts on his site are great! I read them weekly.

Please comment with anything you do for your shoulder clients. It’s all good in my books.

Thanks for reading!!
Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist

Main reference used:
Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature
httpp://www.jospt.org/issues/articleID.2290,type.2/article_detail.asp

Dr. Greg Lehamn’s site: I advise you all to take a look..I can’t believe he lets us read ths stuff for free!
http://thebodymechanic.ca/2011/01/18/shoulder-impingement-rehabilitation-part-one/