Acute Phase

Rehabilitation Program--Physical Therapy

Goals of the acute phase are to relieve pain and inflammation, prevent muscle atrophy without exacerbation, reestablish nonpainful ROM, and normalize arthrokinematics of the shoulder complex. A period of active rest should be recommended to the patient, eliminating any activity that may cause an increase in symptoms. ROM exercises may include pendulum exercises and symptom-limited active-assistive range of motion (AAROM) exercises. Joint mobilization may be included with inferior, anterior, or posterior glides in the scapular plane. Strengthening exercises should be isometric in nature, working on the external rotators, internal rotators, biceps, deltoids, and scapular stabilizers (rhomboids, trapezius, serratus anterior, latissimus dorsi, and pectoralis major).

Exercises targeting the rotator cuff muscles are extremely important. Neuromuscular control exercises also may be initiated. Modalities may be used as an adjunct and can include cryotherapy, transcutaneous electrical nerve stimulation (TENS), high-voltage galvanic stimulation, ultrasound, phonophoresis, or iontophoresis. Patient education is particularly important for the acute phase regarding activity, pathology, and avoiding overhead activity, reaching, and lifting. The general guidelines to progress from this phase are decreased pain or symptoms, increased ROM, painful arc in abduction only, and improved muscular function.

Recovery Phase

Initial goals of this phase are to normalize ROM and shoulder arthrokinematics, perform symptom-free daily activities, and improve neuromuscular control and muscle strength. ROM exercises should progress to active exercises in all planes and self-stretches, concentrating on the joint capsule, especially the posterior capsule.

Strengthening exercises should include isotonic dumbbell resistance exercises with the supraspinatus, internal rotators, external rotators, prone extension, horizontal abduction, forward flexion to 90°, upright abduction to 90°, shoulder shrugs, rows, push-ups, press-ups, and pull-downs to strengthen the scapular stabilizers. Joint mobilization and neuromuscular reeducation also should be maintained. Upper extremity ergometry exercises, trunk exercises, and general cardiovascular conditioning should be maintained for endurance. Use of modalities may be continued if necessary. Guidelines to advance from this phase are full pain-free ROM and when manual muscle strength testing is 70% of the contralateral side.

The final goal of this phase is to get the athlete back to throwing and should include improving strength, power and endurance, and sports-specific neuromuscular control. Emphasis is placed on high-speed, high-energy strengthening exercises, and eccentric exercises in diagonal patterns. Continue isotonic strengthening with increased resistance in all planes, allowing resistance in the throwing position, 90° of abduction, and 90° of external rotation. Initiate plyometrics, sports-specific exercises, proprioceptive neuromuscular facilitation, and isokinetic exercises.

Maintenance Phase

The goal of this phase is to maintain a high level of training and prevent reoccurrence. Emphasis is placed on longer, more intense workouts and proper arthrokinematics of the shoulder. Analysis and modification of techniques and mechanics may reexacerbate symptoms. Make refinements in intensity and coordination. Patient education again is reemphasized, maintaining proper mechanics, strength, and flexibility and understanding the pathology. The patient also should have a good understanding of the warnings signs of early impingement and continue with a home exercise program with proper warm-up and strengthening techniques.

Follow-up--Return to Play

Return to play is restricted until full pain-free ROM is restored, both rest and activity-related pain are eliminated, and provocative impingement signs are negative. Isokinetic strength testing must be 90% compared to the contralateral side. When the patient is symptom-free, resuming activities is gradual, first during practice to build up endurance while working on modified techniques/mechanics, and then in simulated game situations. The athlete should continue flexibility and strengthening exercises after returning to his/her sport to prevent recurrence.

Complications

If shoulder impingement syndrome is not diagnosed and treated promptly and correctly, it can progress to rotator cuff degeneration and eventual tear. Other complications may include progression to adhesive capsulitis, cuff tear arthropathy, and reflex sympathetic dystrophy. Complications also may result from surgery, injection, physical therapy, or medication.

Prevention

Primary prevention should be considered an integral part in the treatment of impingement syndrome. Education of patients at risk can do much to circumvent the development of impingement syndrome. Athletes, particularly those involved in throwing and overhead sports, and laborers with repetitive shoulder stress should be instructed in proper warm-up techniques, specific strengthening techniques, and have a good understanding of the warning signs of early impingement.

Prognosis

In general, prognosis for prompt and correct diagnosis and treatment of shoulder impingement syndrome is good and 60-90% of patients improve and are symptom-free with conservative treatment. Surgical outcomes are promising in patients who fail conservative therapy.

Education

Patient education may improve the outcome if the patient is educated regarding avoidance of provocative activities, pathology, and proper shoulder arthrokinematics. Education also should stress proper warm-up techniques, specific strengthening techniques, and warning signs of early impingement. A proper home exercise program should be formulated and encouraged to prevent recurrence of symptoms.

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center and Sports Injury Center. Also, see eMedicine's patient education article Rotator Cuff Injury and Repetitive Motion Injuries

Author: Thomas M DeBerardino, MD, Associate Professor of Orthopaedic Surgery, University of Connecticut Health Center
Coauthor(s): Wing K Chang, MD, Musculoskeletal Spine Fellow, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center