Shoulder pain – Impingement Syndrome

Shoulder pain – Impingement Syndrome

Have you ever noticed that you get pain with overhead movements like dumbbell shoulder press or even something as simple as putting the clothes on the line? You may have shoulder impingement syndrome.

Shoulder pain is the third most common condition that presents to a chiropractic clinic. Impingement syndrome is one of the most common shoulder issues that we treat (1).

Impingement syndrome can occur secondary to trauma to the shoulder but more commonly it occurs due to chronically held postures, muscular imbalances and repetitive movement.

First some anatomy

The shoulder joint is complex, when referring to shoulder impingement; people are most commonly referring impingement under the acromioclavicular joint or AC joint. The AC joint is made up of the proximal end of the acromion and the distal end of the clavicle (collar bone). Under the acromion there is the sub-acromial space, through this space runs three tendons of the rotator cuff, the long head of the biceps tendon and the subacromial bursa. When we perform overhead movements or have a slouched postured the size of this space decreases and the contents of the space can become compressed and irritated, leading the impingement symptoms (2).

Symptoms of shoulder impingement

The symptoms vary from person to person and with the degree of impingement.

Symptoms include

  • Pain on the anterior (front) or lateral (side) aspect of the shoulder Painfularc
  • Pain with overhead activities
  • Pain with repetitive movements
  • Pain with shoulder abduction painful arch
  • Popping or clicking in the shoulder
  • Weakness
  • Night pain
  • Pain relieved by rest or postural change (2)(3)

Treatment

Fortunately shoulder impingement can be treated successfully by conservative (non surgical) treatment. At Cartwright physical therapy we pride ourselves on our wide variety of treatment options.

  • Soft tissue work – Massage, active release technique
  • Dry needling
  • Joint mobilization
  • Joint manipulation
  • Individualised rehabilitation program for more information on exercises that are prescribed you can read our previous blog post on shoulder exercises

If you have any questions on shoulder pain or are suffering from shoulder pain or any other type of pain come in and see us or book an appointment today on 02 99226116 or visit our clinic on the Ground Floor, Suite 6, 157 Walker Street North Sydney for more information.

By Patrick Lind

*DISCLAIMER: This discussion does not provide medical advice. The information, including but not limited to, text, graphics, images and other material contained in this discussion are for informational purposes only. The purpose of this discussion is to promote broad consumer understanding and knowledge of various health topics. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read in this blog.

 

  1. Pribicevic M, Pollard H, Bonello R. An epidemiologic survey of shoulder pain in chiropractic practice in australia. J Manipulative Physiol Ther. 2009;32(2):107-17.

  2. Seitz AL, McClure PW, Finucane S, Boardman ND, 3rd, Michener LA. Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clinical biomechanics (Bristol, Avon). 2011;26(1):1-12.

  3. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18(1):138-60.
Shoulder pain exercises

Shoulder pain exercises

Exercises for rotator cuff problems, shoulder impingements, shoulder instability and SLAP tears

The shoulder is an incredibly complex joint. It has a large degree of freedom at the expense of reduced stability. For this reason it is subject to a wider range of injuries, most of which involve damage to the rotator cuff.

The following exercises are designed to rehabilitate the rotator cuff muscles. They will be particularly useful for injuries such as shoulder impingement, tears in the rotator cuff, shoulder instability and SLAP lesions. The information has been adapted from the book, The Shoulder Made Simple (Version 6.0), by Dale J Buchberger.

Due to the volume of information surrounding this rehabilitation program, this article is only a summary of the exercises. It is strongly recommended that before attempting these exercises that you consult a physical therapist for a proper diagnosis of your shoulder condition, and any other information pertinent to the rehabilitation of your particular shoulder injury.

Rotator cuff & scapular strengthening – Day 1

1. Side lying abduction

Keep the humerus (upper arm) in the scapular plane.

Lift the humerus in the scapular plane. This is a linear movement. Only raise the arm to the height of the knee. Approximately 30 degree arc.

2. Push-up Plus

Keep elbows fully extended with scapulae retracted. Ensure your torso, spine and back muscles are all firmly activated.

Protract the scapulae (do not flex thoracic spine) whilst keeping the elbows extended. Progress from using a Dyna-Disc to doing the exercise with your feet on a physio ball and vary the lever length (start with the physio ball under your knees first and progress to using it under your feet).

3. Field goal

Place the Dyna-Disc under your chest while your arms hang relaxed off the bench. The first progression is to retract the scapulae (pinch the shoulder blades together).

While maintaining scapular retraction, extend the shoulders to 90 degrees. Keep the elbows flexed at 90 degrees.

Maintain 90 degrees of shoulder extension and scapular retraction. From this position, externally rotate the shoulder with the thumbs pointed up as pictured. Be sure to reverse each motion, but do so SLOWLY!

4. Concentric/Eccentric

Side lying external rotation, pointing the thumb backwards. Elbow tucked into the front of your hip (the part part).

From the externally rotated position, press up to the ceiling, extending the elbow. In the next photo, keep the elbow fully extended while you perform horizontal adduction with internal rotation (turning the thumb to the floor while crossing the chest). If there is anterior shoulder pain, lower the arm to a comfortable level of adduction.

5. Modified empty can

Start in the thumbs down or “empty can” position. Retract the scapulae. In the next photo, elevate the humerus with the thumbs pointed downward in the scapular plane. At approximately 45 degrees of scapular plane elevation, start externally rotating the arm whilst continuing to elevate the humerus. You must maintain the scapular plane throughout the motion.

Ensure you continue to elevate the humerus whilst externally rotating. Notice the position of the elbow (100 degrees of abduction). The scapula should be reset before each repetition.

6. Elbow flexion with pronation and supination

It is difficult to see in this photo, but the subject has anchored a length of resistance tubing (with handle) at a distance from his right side. The right arm would have initially been fully straightened at 90 degrees from the body. We see in this photo, the subject has flexed the elbow (as in a bicep curl) whilst simultaneously supinating the forearm (he has turned the forearm/wrist so that the palm of the hand faces the ground at the end of the exercise)

Again, in this photo the right arm would have initially been fully straightened at 90 degrees from the body. We see in this photo, the subject has flexed the elbow (as in a bicep curl) whilst simultaneously pronating the forearm (he has turned the forearm/wrist so that the palm of the hand faces the ceiling at the end of the exercise). In both DO NOT drop the elbow! Maintain the elbow position during elbow flexion. This will also work the serratus anterior muscle.

Rotator cuff & scapular strengthening – Day 2

7. Subscapularis pull

Start with the elbow fully extended and the thumb up. Pull the tube behind the back (internal rotation) and touch the bottom tip of the opposite scapula with your thumb.

8. External rotation with scapular retraction

Keep the elbow tucked into your side as you externally rotate the humerus. As external rotation is completed retract the scapulae together.

9. Bilateral Blackburn 3 [BB3] – position 1 & 2

Use a Dyna-Disc under your chest, with your arms externally rotated. Retract the scapulae with elbows fully extended.

Lift thumbs to the ceiling with the elbows fully extended. Do not hyperextend the shoulders. Hyperextension of the shoulders will cause excess stress on the anterior shoulder capsule leading to shoulder instability.

10. Standing 3-way

Start with the arms lowered by the side of your body, with elbows extended. Retract the scapulae, and raise the arms forward keeping the thumbs up, elbows still extended. Perform this motion slowly.

As above, start with the arms lowered by the side of your body, with elbows extended. Retract the scapulae, and raise the arms in the scapular plane. Keeping the thumbs up and elbows fully extended.

11. Dynamic Blackburn

Merely place the hands on the buttocks, and retract the scapulae.

Depress the scapulae by reaching for your feet. Keep the hands together.

While keeping the hands together lift them off of your buttocks.

Slowly release hands. Begin to externally rotate the humerus while continuously abducting the humerus.

Continue externally rotating whilst abducting, thumbs should point upwards now, and the arm is at 90 degrees of abduction.

Continue externally rotating whilst abducting, thumbs should point upwards now, and the arm is at 100 degrees of abduction. This is the end range of motion for this exercise. Do not go higher! Reverse the motion slowly. Begin the next repetition from position 1.

12. Scapular retraction – End range

Lie face down with a dyna-disc under the chest. Shoulders and elbows are at 90 degrees. The first movement is to retract the scapulae. The forearms should not come off the floor.

Whilst maintaining scapular retraction, lift the elbows and thumbs to the ceiling. Maintain 90/90 degree position.

How many should I do?

The twelve exercises have been split into two days. There is no need to perform more than one day’s worth of exercises each day. You should perform two to three sets of each exercise. The advice Dale Buchberger suggests is to start each exercise with no weight and perform 10-15 repetitions. If this seems too easy, you can increase the number of repetitions by five until you can perform 30 repetitions pain free (eg. 15, 20, 25, 30). Before you can increase or add weight to an individual exercise, you must be able to perform 30 repetitions of that exercise. Some of the exercises will seem harder than others so expect to be using different weights across the twelve exercises.

Furthermore, you cannot increase repetitions until you have spent at least two weeks on the starting amount. For example, you must perform two to three sets of 15 repetitions of each of the twelve Buchberger exercises for two weeks. Only then, in the following two weeks may you increase to 20 repetitions of each exercise. Aim to do the Day 1 and Day 2 exercises four times each in the two week period.

If you do the maths, you’ll start to realise how long this rehabilitation program can take. Understand however, that it may well have taken longer than you realise to have damaged your rotator cuff in the first place. Whilst it might be a slow process to recover from your injury, know that Dale Buchberger has developed these exercises over a period of longer than 15 years and has assisted numerous professional baseballers (mostly pitchers) return to activity. The rotator cuff is a small muscle group and so you need only work up to a weight of four to five kilograms maximum. Overloading these small muscles is a frequent cause of rotator cuff damage.

The level of discomfort you may or may not feel after each exercise should help determine whether you can manage more, or whether you should reduce the repetitions. You should not feel pain during these exercises. If you do feel pain you may well be performing them incorrectly. It is acceptable to experience a degree of discomfort while performing some of the exercises. Your challenge is to determine the difference between damaging pain and rehabilitative discomfort. The emphasis must be on quality of performance, not quantity of weight.

You can access more information on tips to save your shoulders here. Ensure you have run through these exercises with a practitioner, and that you understand their purpose.

*DISCLAIMER: This discussion does not provide medical advice. The information, including but not limited to, text, graphics, images and other material contained in this discussion are for informational purposes only. The purpose of this discussion is to promote broad consumer understanding and knowledge of various health topics. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read in this blog.

5 Tips to save your shoulders

5 Tips to save your shoulders

Exercises to ensure healthy shoulders

The shoulder joint allows a lot of movement, however, this movement comes at the expense of stability and security, and is often the cause of many dislocation and instability conditions. The shoulder joint is a “ball and socket” joint, and is supported by a network of ligaments and muscles. More specifically, the shoulder joint is supported and controlled by four muscles known as the rotator cuff: supraspinatus, infraspinatus, teres minor and subscapularis. These small, but very important stabilisers are easily overloaded and injured due to poor exercise design and technique.

Many of the following injury reduction techniques focus on reducing the load on these small joint stabilisers.

Tip 1 – Limit overhead exercises: the safest overhead press is the “Arnold Press”. This exercise allows a greater range of motion whilst keeping the hands closer to the centre of the body. It also reduces shearing forces around the shoulder joint.

Tip 2 – Avoid the dislocation position: imagine yourself lying face up on a bench with your arms at 90 to your body, elbows bent 90, and palms facing the ceiling. ALT TEXT Keeping your arms in this position, if you were then to rotate your arms such that your hands would approach the floor and allowed to continue, you would eventually dislocate your shoulder joints. Avoid, shoulder pressing behind the neck, 90/90 pec-deck machines, and wide grip lat pulldowns behind the neck.

Tip 3 – Avoid small muscle overload: your rotator cuff muscles are small muscles. Exercising your chest on day 1, shoulders day 2, then back on day 3, will be exercising your rotator cuff on all three days. In this instance, you’re more likely to fatigued your rotator cuff and predispose yourself to injury. Either group pressing movements into a single workout session or rest your body by training other non-related muscle groups on consecutive days.

Tip 4 – Increase thoracic spine mobility: the thoracic spine (or upper back) plays an integral role in loading and unloading the shoulder joint. Spending long hours at a desk inevitably results in a more “hunched-over” posture. This is accompanied by stiffness and tension felt along the length of your back. You may well be in need of physical therapy to relieve yourself of this increasing tightness, and at the very least, a series of back extension exercises to offset poor posture at work. A physio roller can be used at home to relieve thoracic tension.

Tip 5 – Avoid the impingement position: impingement occurs when you raise your arm above shoulder height whilst keeping your arm internally rotated. ALT TEXT Mimicking this position repetitively, causes a continual “pinching” or “jamming” of structures between your arm bone and shoulder blade occurs, felt as pain at the tip of your shoulder. Avoid exercises such as lateral raises with thumbs down, close grip high upright rows and some versions of bench pressing where the bar is in a high position, almost under the chin.

The shoulder joint is a joint that can be easily overloaded and damaged in poorly constructed health programs. It is essential that a health professional understands intimately, the anatomy, physiology and common risk areas and exercises for treating shoulder injuries.

An effective modality for treating shoulder injuries is active release technique. Combined with chiropractic care, these two applications of physical therapy can improve both range of motion and muscular health at the shoulder joint.

*DISCLAIMER: This discussion does not provide medical advice. The information, including but not limited to, text, graphics, images and other material contained in this discussion are for informational purposes only. The purpose of this discussion is to promote broad consumer understanding and knowledge of various health topics. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read in this blog.