Some people become accustomed to shoulder pain and do not pay attention to the gradual onset of weakness and limitations in their shoulder range of motion. They may have a tendency to ignore shoulder pain and continue with their normal everyday routines and recreational activities without pause or consideration. This may cause further aggravation and slowly over time may cause increased pain and more problems. This may be the case with some patients who are referred to physical therapy with a diagnosis of shoulder impingement.
Shoulder impingement is the pinching of soft tissue between the bones that make up the shoulder complex structure during repetitive shoulder movement. The humerus which is the upper portion of the arm, the clavicle also known at the collar bone, and the scapula or shoulder blade are bones with make up the anatomy of the shoulder complex. These bones are surrounded by muscles, tendons and a fluid filled bursa sac which allow for stability and easy unrestricted shoulder movement.
Normal anatomy of the shoulder.
Sometimes the muscles which surround the shoulder blade and attach to the upper arm become weak and no longer work in a unison pattern with each other causing a muscular imbalance. This instability causes a narrowing of the acromion space during shoulder movement. The imbalance and instability change causes the soft tissue impingement. The supraspinatus and bicep tendon are more commonly affected muscles however the infraspinatus and the subscapularis can be impacted as well. Over time, the repeated pinching of these muscular tendons and bursa can cause inflammation and swelling. Once inflamed, every shoulder movement furthers the impingement until the range of motion and muscular strength in the shoulder is affected.
One common symptom of shoulder impingement is a complaint of pain on the superior and anterior portion of the shoulder. Pain may refer into the upper portion of patient’s arm and travel as low as the elbow. Patient may complain of a dull ache while at rest and with positional changes to a sharp pain during overhead, lifting and reaching activities. Dressing, bathing and reaching behind the back or for a seat belt may also cause shoulder aggravation. Neck pain may exist as inappropriate neck muscles help to raise the shoulder and avoid further aggravation of symptoms. As the inflammation becomes more chronic, a patient may begin to have difficulty sleeping, as the pain becomes more intense and comes on suddenly. A patient may complain of severe tenderness with contact. Flexibility is restricted, motion is limited and muscular strength is decreased and weakened. Medical care should be sought for the shoulder because it could eventually lead to a more serious injury.
Physical Therapy treatment goals for shoulder impingement injury are to:
- decrease inflammation
- reduce pain
- improve shoulder range of motion
- increase strength
- restore patient to prior level of function
During the acute stage of impingement, patients are advised to modify shoulder mobility. They are educated to perform everyday activities to tolerance and discontinue any activity that replicates symptoms of pain. This may include any heavy lifting or overhead activities. Rest is stressed until inflammation and pain is decreaed. Physical therapy treatment will utilize modalities such as ice, phonophoresis, and interferential stimulation in order to improve blood flow, reduce swelling and stimulate healing. Manual treatment will focus on reduced muscle guarding and muscular tone. The manual treatments will help to improve flexibility, neuromuscular facilitation and increase scapulae (shoulder blade) mobility. When pain and inflammation is controlled, therapy treatment will focus on shoulder range of motions. In addition, patient is educated on appropriate upright posture and correct body mechanics with shoulder movement. Therapeutic exercise of active assisted and stretching program using pulleys, finger ladder and cane will be implemented. When pain and swelling are sufficiently reduced and symptoms are no longer reproduced with shoulder motion, a strengthening program is then initiated. Elastic tubing, free weights and upper body bike (ergometer) will help to correct muscular imbalance, strengthen rotator cuff muscles, and reinforce normal shoulder scapulae motion.
Shoulder impingement injury can be a debilitating injury where everyday activities can become painful and difficult. Early detection and treatment is a key factor for preventing further injury, resulting in additional treatment. Patients respond well to a conservative treatment in physical therapy and help to avoid further complications. In time, a patient will return to a normal functioning lifestyle with a home exercise program which will help maintain strength and shoulder mobility and avoid reinjures.
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