Rehabilitation of impingement

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Rotator cuff injuries are a common cause of shoulder pain in people of all age groups. Impingement is a type of rotator cuff injury.

Often, a history of repetitive overhead activities involving the shoulders or a history of trauma preceding clinical onset of symptoms is present in younger individuals. However, older individuals may present with gradual onset of shoulder pain without a clear history of predisposing factors.

The rotator cuff muscles assist with some shoulder motion; however, their main function is to provide stability to the joint by compressing the humeral head on the glenoid of the shoulder blade.

In elderly patients, symptoms often are insidious and with no specific injury. Repetitive motion can be associated with the symptoms.

The impingement syndrome associated with rotator cuff injuries tends to cause pain with elevation ranging from 60-120 degrees when the rotator cuff tendons are compressed against the anterior acromion and coracoacromial ligament.

The rotator cuff is surrounded by the coracoacromial arch, which comprises the supraspinatus outlet and consists of the acromion, coracoacromial ligament, and coracoid process.

The rotator cuff, when the shoulder is raised, contacts the coracoacromial arch undersurface.

Rotator cuff abrasions and fiber failure occur when repeated and excessive compression.

This occurs secondary to underlying muscular imbalance and loss of rotator cuff depressor effects.

Dynamic stability may be lost if the shoulder becomes deconditioned. As a result, a vicious self-perpetuating cycle of instability, less use, more muscle weakness, and more instability is present.

These patients frequently have relative rotator cuff muscle weakness, particularly the external rotators and scapular stabilizers.

Mild instability patterns may contribute to the impingement development.

Pain control and inflammation reduction are initially required to allow progression of healing and initiation of an active rehabilitation program. This can be accomplished with a combination of relative rest, icing (20 min, 3-4 times per d), and acetaminophen or an NSAID.

Corticosteroid injection may be considered. A more physiologic approach for rotator cuff tendon healing is the use of ultrasound-guided needle tenotomy with platelet-rich plasma (PRP).

Information from the American Academy of Orthopedic Surgeons and the American Physical Therapy Association

After the pain has been managed, restoration of motion can be initiated. Codman pendulum exercises, wall walking, stick or towel exercises, and/or a physical therapy program are useful in attaining full pain-free ROM. Perform strengthening in a pain-free range only. Begin with the scapulothoracic stabilizers. Shoulder shrugs, rowing, and push-ups isolate these muscles and help return smooth motion, allowing normal rhythm between the scapula and glenohumeral joint. Then, turn attention toward strengthening the rotator cuff muscles.

When strength is restored, continue a maintenance program for fitness and prevention of reinjury.

Return to task-specific activities is the last phase of rehabilitation. This phase is an advanced form of proprioceptive training for the muscles to relearn prior activities. It is an important phase of rehabilitation and should be supervised properly to minimize the possibility of re-injury. At the conclusion of formal therapy sessions, patients should be independent in a ROM and strengthening program and should continue these exercises, initially under supervision and then completely on their own.

When treatment is delayed in rotator cuff injuries and shoulder discomfort persists, the patient can develop adhesive capsulitis. The chance of developing adhesive capsulitis can be minimized through prompt diagnosis of painful problems in the shoulder, such as rotator cuff injuries, and the institution of early shoulder ROM as part of the rehabilitation program.

For more information about tendonitis, visit our sister site:
Tendonitis provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.

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