The shoulder is a complex joint involved with everyday activities such as reaching and sport specific movements. Evidenced based research and my clinic experience as a physical therapist, supports that shoulder impingement is a common movement dysfunction seen in men. This article will review the following about shoulder impingement:

• Pathophysiology
• Common signs and symptoms and contributing factors
• Physical therapy management
• Program design
• Exercises that are contraindicated with rationale

Pathophysiology/mechanism of injury: Shoulder impingement(SI) is the mechanism in which the supraspinatus tendon of the rotator cuff becomes impinged as it passes through a narrow bony space called the subacromial space. With repetitive movement, the supraspinatus the tendon can become irritated and inflamed. SI can also be caused by a decrease in posterior capsule mobility and weakness of capulothoracic musculature. Evidenced based research has shown that shoulder impingement is a common condition believed to contribute to the development or progression of rotator cuff disease(Ludewig, P. 2011)

• Decrease in subacromial space comprises the supraspinatus tendon, predisposing it to micro tears leading to degeneration and ultimately tearing.
• Tightness of the posterior capsule causes the humerus to migrate anterosuperior into the AC joint.
• Weakness of scapulothoracic muscles leads to abnormal positioning of the scapula.

Common signs and symptoms: Clients will complain typically of pain in the front of the shoulder, described as deep, dull ache with stiffness. Reaching overhead and behind one’s back will elicit pain.

painful arc

Figure 1. Painful arc

capsule are some contributing factors. Per the research, the development of SI has been correlated to abnormal muscle activation. Specifically, those with SI, present with the overactive upper trapezius and underactive lower trapezius muscles (Chester, R., et al. 2010).

Physical therapy management:

The goal of physical therapy is to restore scapular mobility, followed with stretching to restore full range of motion (figure 2). Strengthening focuses on targeting the weaker upper posterior musculature that includes rhomboids, low trapezius, external rotators and serratus anterior muscles. Then the patient is taught scapular stabilization and dynamic strengthening exercises.

Manual therapy by physical therapist on shoulder

Figure 2. Manual therapy
by a physical therapist on
shoulder

Program design and exercise prescription for the impingement client

Once discharged from physical therapy, transitioning to the gym should be simple, and based on science, not guessing. The focus on post rehabilitation training is to strengthen the scapular stabilizers (rhomboids, low trapezius, posterior deltoid and external rotators) and posterior shoulder. Core strengthening should progress from static to dynamic exercises.

core strengthening

Figure 3. Posterior capsule stretching         Figure 4. Low trapezius strengthening         Figure 5. Mid row exercise

Upper body exercises that are safe based on biomechanics include:

• Low trapezius pulls downs (figure 4) with cable standing or tubing, depresses and retracts the scapula, unloading the anterior shoulder, improving posture and posterior stability.
• Seated mid row, one arm dumbbell row, seated reverse flies (posterior deltoid) strengthens the weaker phasic muscles of the posterior chain.
• External rotation with cable, seated reverse flyes, seated dumbbell side raises.
• Core strengthening exercises that are safe include but not limited to; standing trunk rotation with cable/tubing, diagonal with cable tandem in place lunge, planks, planks with a ball, trunk rotation with a forward lunge.

Exercises that are contraindicated include with rationale:

• Seated dumbbell shoulder press (creates an excessive load to the medial deltoid).
• Lat pulls downs behind the head (at end or range places greatest stress on all glenohumeral ligaments as well as on the labrum).
• Upright row (at end of range-shoulder is maximally internally rotated which places stress on all glenohumeral ligaments, labrum, and connective tissue)

Summary:

Shoulder impingement is a common shoulder condition that a fitness professional may encounter. Understanding the anatomy, biomechanics and proper program design with evidenced based training strategies, will provide you with a better understanding to work with clients.

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Chris Gellert

Chris Gellert

Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS Chris is the CEO of Pinnacle Training & Consulting Systems(PTCS). A continuing education company, that provides comprehensive continuing educational material in the forms of home study courses, live seminars, DVDs, articles and Elearning courses teaching in-depth, the foundation science, functional assessments and practical application behind Human Movement, that is evidenced based. Chris possesses a strong clinical background, advanced training, clinical and teaching experience and product development that diverse and unique as both a practicing physical therapist and personal trainer. Chris earned a B.S. in Marketing from SUNY Plattsburgh in 1992, an entry level Master's of Physical Therapy from Nova Southeastern University in 1999, and completed a rigorous, advanced masters of Orthopedics and Sportsphysiotherapy in 2011 from the University of South Australia. Chris has been a practicing physical therapist for 16 years, specializing in spinal dysfunctions and orthopedics, a personal trainer for 20 years, having worked from clients from 9 years to 90 years old. Chris has been presenting at international conferences since 2004 and presenting seminars on human movement, manual therapy, exercise and lumbopelvic stabilization training for the last 10 years. Chris has created over 10 courses, 5 live seminars, and is developing a team of experts to be part of PTCS, who will accompany him in writing, teaching and educating the science behind the movement. He is a certified strength and conditioning specialist(CSCS) through NSCA and is presently studying advanced ACSM and Cooper Institute certifications. He is planning on pursuing Fellowship training in Orthopedics and Manual Therapy as well as becoming certified in manual therapy and working with clients with vertigo. PTCS has created a unique educational learning platform. This dynamic continuing education platform will include home study courses, Elearning courses, live seminars, articles, videos, group chat and mentoring to personal trainers. This approach will teach the cognitive, visual and psychomotor training aspect behind the foundation science, functional objective assessments and the application science behind human movement. For more information on a home study course, live seminar, Elearning course or any continuing educational material, please visit www.pinnacle-tcs.com
Chris Gellert

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