SHOULDER IMPINGEMENT REHABILITATION OF IMPINGEMENT SYNDROME SHOULDER By Ian Matthews, RI and Jo Burgess, MCSP

REHABILITATION - THE EVIDENCE Initial management of SIS should be rest from pain-provoking activities combined with non-steroidal anti-inflammatories (NSAIDs) to reduce pain and inflammation (1). Physiotherapeutic techniques may also include the application of ice for 20-30 minutes to reduce pain and inflammation and to settle irritation post-exercise (2).

Studies have shown that shoulder impinge- ment syndrome (SIS) can be effectively managed with exercise rehabilitation. A study comprehensively described an exer- cise regime that initially used sling sus- pension to neutralise gravity to re-educate supraspinatus. Once active range of move- ment was painless and normal scapulo- humeral rhythm had been restored, low resistance exercises were added. Successful rehabilitation took up to six months with patients being encouraged to continue with the programme as home exercises (3).

Rehabilitation based on stretching exercis- es for muscles found to be short, strength- ening exercises for muscles found to be weak and motor retraining aimed at restor- ing scapulohumeral rhythm during the per- formance of upper limb tasks, has also been shown to significantly improve recovery (4).

A recent study (5) demonstrated benefits in terms of range of motion, strength and function in subjects with SIS using exercis- es to passively stretch the anterior and posterior capsule and six strengthening exercises. The strengthening exercises were based on the results of EMG studies from previous research which showed optimal activation of: ■ upper, middle and lower trapezius ■ levator scapulae ■ the rhomboids ■ pectoralis minor ■ middle and lower serratus anterior (6) ■ the rotator cuff and pectoralis major

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There are many contributing factors relating to shoulder impinge- ment syndrome (SIS) and generic shoulder strengthening exercises are likely to aggravate the symptoms rather than reduce them. This article demonstrates the need for postural correction, biomechani- cal re-alignment, muscle re-balancing, attention to the muscle tension/lengthening relationship and scapula stabilisation. The article reflects the evidence base with respect to current rehabili- tation techniques combined with personal experience.

■ the three parts of deltoid (7).

In a study of patients suffering from SIS (8) 67% of 636 shoulders reported excel- lent/satisfactory results with simple stretches and resisted internal and exter- nal rotation exercises.

The outcome was

better in younger patients, in those with acute problems and in those with Type 1 acromions, which corresponds with Neer’s findings. A prospective RCT has shown, however, that all patients with a diagnosis of SIS improved with physiotherapy, with 26% no longer requiring surgical interven- tion. They conclude that physiotherapy should be thought of as the first line man- agement for the generic diagnosis of SIS (9).

In a recent study all patients were given exercises for the recruitment and strength of scapulothoracic muscles, focusing main- ly on serratus anterior and lower fibres of trapezius to enable them to stabilise the scapulothoracic joint in a neutral position. The aim of this was to optimise the length-tension relationship of the rotator cuff muscles, enabling efficient activity of the rotator cuff whilst using the arm and during exercise. The exercises were then progressed to involve strengthening of infraspinatus, subscapularis and teres minor, aiming to restore the necessary depressor effect of the rotator cuff on the humeral head during arm elevation, result- ing in less impingement (10). There is lit- tle evidence to support postural correction as a treatment aim, however forward-head posture has been implicated in SIS (11) and efforts should be made to correct it.

Based on the available evidence and clini- cal experience the following areas should be focused on when designing an exercise programme for a patient suffering with SIS.

KEY POINT

The evidence states that a pro- gramme of exercises to restore range, strength and stability of the glenohumeral joint along with improved scapulohumeral rhythm is likely to be beneficial.

POSTURE Poor posture can be a pre-disposing factor of impingement as the thoracic spine has an effect on the position of the scapula, which in turn affects the extensibility of the shoulder complex (12). Excessive ante- riorly translated glenohumeral (GH) joints have been linked to poor posture, leading to SIS (13,14).

A person with SIS usually presents with the following posture: ■ protracted head and neck ■ tight muscles in anterior compartment (medial rotators, latissimus dorsi, pec- toralis major/minor, subscapularis and teres major)

■ anteriorly presented humeral head ■ winging/abducted/laterally-rotated scapula

■ thoracic kyphosis.

To overcome this posture, stretching of anterior muscle groups of the pectoral girdle, strengthening of deep neck flexors,

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