The information contained is generalized for people with a confirmed diagnosis of shoulder impingement. Before engaging in any activity, always consult a medical professional regarding your problem. Get your issue checked out and self-diagnosis is never recommended. This blog is not intended to be a substitute for a physician, physical therapist, or medical treatment. Any activity you engage in is solely your responsibility.
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Shoulder impingement syndrome, like many other orthopedic pain syndromes, is fundamentally an imbalance of the “shoulder joint”. The shoulder joint is in quotations because really it is made up of a number of joints including the shoulder blade, trunk, and collar bone. It has contributions from the neck. Often the series of joints involved for sake of ease is referred to as shoulder joint complex.
Shoulder pain caused by impingement of either the biceps tendon or one of the rotator cuff tendons can start as a result of a defined event such as lifting something, pushing or any physical activity and the individual can report the exact moment this event occurred. Or it can come on gradually, be ignored for a time until it can no longer be brushed aside. Pain and limitation of lifting the arm or moving it away from the body in certain ways is the primary symptom. Holding the arm at the side and limiting movement generally is comfortable and tolerable.
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The first line of intervention is of course the “commonsense approach” Simply employ what in the health care world is termed “R.I.C.E.” The acronym stands for:
Rest – Pretty obvious here. Rest the shoulder and avoid provoking pain. As a rule, if a strain it gradually starts to improve and you limit your activity to non-painful actions and over 2 – 6 weeks, it resolves.
Ice – This is understood in general terms placing ice or cold packs(i.e., gel packs) over the area that hurts. In my experience though beyond that, the range of inadequate use of ice/cold packs is astounding. This is unfortunate as it is a simple procedure which can help manage the problem more effectively, if it is used effectively. The rule of thumb is 10 – 15 minutes of cold directly to the skin (not on top of a shirt, jacket, or coat which I have seen). That would be pointless. Never more than 15 minutes unless it is a gel pack which warms up with use.
You can place a warm wet cloth over the area first then the cold pack or ice pack. If this is used keep the ice pack there for 5 extra minutes. The frequency or how many times you ice in a day is most important. Most people think 2 - 3 times is sufficient. It is not. The minimum number of times is 5 times. More would be better. Wait for the shoulder to warm back to normal before applying again. If you want to be more precise, you could occasionally check the area you ice with light touch by your finger. If numb. You can stop, wait, and reapply when warm. Gel packs are fool proof. They get warmer so it is difficult to over cool. As a rule, “when numb, you are done.”
Compression - Not very applicable for the shoulder as a rule unless it is a severe injury in which there is a great deal of swelling. Under this scenario though you likely already would be under the care of a physician/specialist anyway. Compression is rarely utilized for shoulder impingement scenarios.
Elevation - As a rule elevation does not apply. “R.I.C.E” is a general term for acute injury. Elevation of the shoulder is not going to be applicable.
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Shoulder pain which persists and increases likely will need a medical screen to rule out other causes such as cervical pain referral or even heart related problems. Once this screening has occurred and you have a preliminary diagnosis, you may start some measures to address the likely imbalances which are contributing to the shoulder impingement.
The imbalance(s) of the shoulder complex can develop due to a number of factors. The most common is posture in which the head is forward, and the shoulder is rounded as in a “slouch”. This abnormal posture causes some key muscles to get tight and other opposing muscles to get weak. This prevents clearance of the biceps and rotator cuff tendons as the shoulder lifts upwards resulting in "pinching" or impingement against the boney aspect of the shoulder blade called the acromion process. The pain can range from mild to severe usually at the front of the shoulder. The biceps tendon and the supraspinatus tendons are most commonly involved. The imbalance of the mechanisms creates the “pinching” and resultant trauma of these tissues.
Once the imbalance advances to a certain level, the pain and swelling persist unless the imbalance can be reversed.
The general approach in terms of resolution of impingement syndrome is to restore the following metrics:
1. Posture: upright, head, neck and shoulder aligned with the trunk. Posture is a habit so this can be more challenging than you may think.
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2. Restoring the muscle length(stretching) of muscles involved in normal movement and control of the shoulder complex which includes the arm, collar bone, neck, trunk, and the shoulder blade.
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3. Restoring the muscle strength of weak and painful musculature involved in normal movement and control of the shoulder complex which includes the arm, collar bone, neck, trunk, and the shoulder blade.
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For a generalized approach which means not tailored to any specific person, the length of the discussion from the exercise-activity alone would be a 15 page document. It would have to cover every common set of circumstances and would be so involved, that few, if anyone would be able to engage in a program that was self-directed and reasonably able to resolve the problem. This is a diagnosis that requires the direction of a good PT.
Expectations: You should notice substantial improvement within two weeks if you are appropriately protecting the injury and following an appropriate and custom protocol. Within 4 - 6 weeks you should be close to resolution of the problem. By 8 -12 weeks, if the problem can be mitigated conservatively and most of the time this is the case, then the problem should be resolved. This will vary of course depending on a number of factors, including but not limited to age, severity of the injury and overall compliance. If there is no improvement or the problem gets substantially worse, then re-seek medical advice. This is part of the commonsense approach.
Warm Regards
Dr. Michael J. Malawey, PT
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