This information has been prepared to help you fully understand your condition so you will be in the best position possible to work with your physio and follow the steps to your full recovery. Understanding the goals of your treatment and having complete confidence in your physio are vital elements of your recovery plan, so if you have any questions then please feel free to ask your physio.
Impingement syndrome is common in various groups of people such as swimmers, throwers, racquet sports players and gym-goers. Some occupations also are more at risk such as jobs that involve lifting, carrying and repetitive tasks, especially if they are performed with the arm away from the side of the body.
The shoulder is made up of 3 bones: the scapula (shoulder blade), the humerus (arm bone) and the clavicle (collar bone). It is a ball-and-socket joint and the rotator cuff holds the ball at the top of the humerus in the centre of the socket on the side of the scapula.
The rotator cuff is formed by the tendons of 4 muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. As the arm is raised, the rotator cuff keeps the ball of the humerus tightly in the socket of the scapula. If this position is not maintained well then the tendons of the rotator cuff may be pinched between the top of the arm bone and the bony “roof” of the scapula.
A fluid-filled sac called a bursa is located between the scapula and the rotator cuff tendons. It has an important role in protecting the rotator cuff tendons from being impinged upon and squashed between the top of the humerus and the over-hanging bone of the scapula.
Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily through the gap. In certain positions, such as having the arms at shoulder height or above, this gap is prone to becoming narrowed and the cuff tendons are pinched. This causes pain and inflammation, and because the tendons have a relatively poor blood supply they do not repair very well so the problem tends to persist and get worse until treatment is started.
Shoulder impingement syndrome causes generalised shoulder aches in the condition’s early stages. It also causes pain when raising the arm out to the side or in front of the body. Most patients complain that the pain makes it difficult for them to sleep, especially when they roll onto the affected shoulder. If left untreated the pain usually becomes very sharp and movement in your shoulder becomes reduced.
As the condition worsens the shoulder pain increases. The joint may become stiffer. If the cause of the impingement is not addressed the rotator cuff tendons can tear, resulting in weakness and an inability to raise the arm. Some rotator cuff tears or longer-term pain may require a cortisone injection, and larger tears that don’t respond to physio may require surgery.
Depending on the impingement severity, recovery can take anywhere from 6 weeks to several months. Starting treatment early greatly increases the expected speed of your recovery.
Your physio has been extensively trained to thoroughly assess and diagnose your injury. They will give you a step-by-step recovery plan to make your treatment easier for you to understand. The most common phases, or steps, that you will go through during your recovery plan are outlined below. The order and timing of the phases are tailored individually for you and so may vary form this list. Please feel free to ask your physio if you have any questions about your recovery plan.
Inflammation is the redness and swelling that occurs whenever you injure yourself. Our bodies need inflammation to start the normal healing process but we also need to control it. Reducing the inflammation associated with shoulder impingement can help to take away that initial ‘throbbing’ pain that clients describe. By reducing inflammation your physiotherapist is able to work a lot more intensively on your shoulder to restore the movement you have lost.
The techniques your physio may use to manage your inflammation include specific local massage and muscle releases, joint mobilisations, ice and stretches. Importantly, they will also guide you on modifying your current activity and exercise to ensure that you are not continually reaggravating your inflammation as this will significantly slow your recovery.
A major contributing factor in the development of impingement in the shoulder region is tightness of certain muscles, especially the back part of the rotator cuff. Restoring full length to these structures is vital to help your current pain settle down and restoring your movement. It is also an important factor in minimising the chance of problems in the future.
Techniques your physio may use to restore your muscle length include specific releases, massage, stretches and heat. A trigger point ball may be recommended to help you work hard on releasing tight muscles at home.
Your shoulder relies heavily on there being correct balance within your rotator cuff group of muscles to hold your shoulder in the correct position. Your muscles that hold your shoulder blade in the right position on your rib cage are also very important for correct movement mechanics in the shoulder. Pain and injury alter the function, length and timing of these muscles so the next big goal of your recovery plan is to restore their correct balance.
Your physio will guide you through specific exercises to strengthen your rotator cuff and scapula (shoulder blade) muscles. Your home program will be as fast and convenient as possible whilst still being highly effective.
Shoulder impingement can lead to improper use of the muscles in and around the shoulder when attempting tasks such as reaching and lifting. This commonly includes shoulder “hitching”, where the shoulder blade is raised to allow for above shoulder level movement of the arm. This can lead to tight muscles at the top of the shoulder and further muscle imbalance. It can also start to cause neck pain.
Your physio may use muscle activation techniques, biofeedback, taping and specific strengthening to re-educate your movement patterns. We will often use video feedback to help you become more aware and confident in performing your exercises correctly.
Your shoulder can become stiff at the very end of range of motion due to muscle, ligament and tendon tightening. In this phase, stiffness in the shoulder at end of range is corrected by soft tissue releases, contract/relax stretches, joint mobilizations and stretches for you to do at home. Further strengthening towards the end of your available range is also used extensively.
This is the last phase of your journey to full recovery. When you are returning to your activity you must be able to do it at full speed and resistance before being back in the game. You need to be able to apply your speed and force with the correct technique in training first to prevent another injury. In this phase we tailor exercises specifically to your activity by doing advanced sports-specific strengthening and high speed movements combined with rapidly changing directions. This phase is essential both for getting your back to your full level of performance, and also for preventing re-injury due to persisting background weakness or reduced co-ordination of muscle contractions.
Many clients find that seeing one of our Exercise Physiologists, Strength and Conditioning coaches or Personal Trainers is a great way to build strength, ability and confidence for a smooth return to full sporting activity. If Pilates is more your style then our great Sports Pilates program is an ideal way for you to continue to build your stability and strength. As well as being an important part of your rehab program these services can help you lift your sports performance whilst staying safer and reducing your risk of future injury.