CONDITION CHART: Shoulder Impingement

By: Taylor Stamper

Case Study (address PEOP)

Jared is a 22 year old, right hand dominant, male that plays college baseball and works for a
landscaping company. His preferred leisure activities include working out, playing for
recreational baseball leagues, and riding motorcycles. Two weeks ago, he made a diving catch
during a game, landing with force on his elevated, abducted, right shoulder. Jared did not go to
the doctor until his symptoms of pain worsened over the course of a month. Symptoms include
pain when bringing his right arm to shoulder level, reaching up to cupboards, doing pushups,
making sharp turns on the bike, and emptying wheelbarrows and shoveling mulch during work.
Ultrasounds performed at the doctor revealed tendonitis (stage II SIS). Otherwise, the patient is
healthy and on no medications, but is currently taking 400mg of ibuprofen every 6 hours to
manage pain. Jared has arrived at the outpatient clinic under his physician’s and coach’s
recommendations, and after evaluation, ROM is limited in external rotation, shoulder flexion,
shoulder abduction, and scapular adduction, rating pain at a 7/10 while doing so. Because the Pt
presents with limited ROM and pain throughout the range, the injury is considered subacute.

About The Condition

Epidemiology
Standard Anatomy:The glenohumeral joint (GHL), aka the shoulder joint, is a ball and socket
joint made up of the glenoid fossa of the scapula and the humeral head of the humerus.4 Being
one of the most mobile joints in the body with three degrees of freedom (flexion, extension,
abduction, adduction, and internal and external rotation capabilities), this joint inherently lacks
stability.4 The rotator cuff thus serves the purpose of providing stability to, and moving the
humerus within the GHL.4 The rotator cuff is comprised of the supraspinatus, infraspinatus,
teres minor, and subscapularis muscles.4
Above the GHL is the subacromial space, made up of the coracoacromial arch and the humeral
head.1 The coracoacromial arch consists of the acromion and coracoid process of the scapula
and the coracoacromial ligament - used to prevent upward translation/dislocation of the
humerus.1 Within this subacromial space is the long head of biceps m. tendon, supraspinatus m.,
and the subacromial bursa.4
Mechanism of Injury: Shoulder Impingement Syndrome (SIS) is ultimately a collection of
shoulder symptoms and signs that result from a narrowed subacromial space that impinges
muscles tendons within the space.1 SIS can occur due to internal factors, such as degenerative
changes from age, overuse, trauma, or overload, or extrinsic factors including compression of
muscle tendons within the space due to anatomical variations of the acromion (curved or
hooked), or thoracic kyphosis.1 Thoracic kyphosis reduces the ROM of the GHL by forcing the
scapula to take on a protracted, downward, and anteriorly tilted position, which then allows the
tendons and bursa to rub against the bony processes more frequently.1 Given the different
mechanisms of injury, SIS can be classified as one of three different stages, see figure 1.2

Figure 1: Stages of SIS 3

Signs and Symptoms

Patients with SIS may present with pain when reaching overhead, bringing the arm up to
shoulder level or higher, or while reaching into a back pocket.5 Pain and tenderness at the front
of the shoulder, along with a pain that moves to the side of the arm may also be present
depending on the muscle tendon involved.5 Patients may also experience pain when laying or
applying pressure/force to the affected side and general stiffness of the arm.5 From a diagnostic
standpoint, signs of SIS would include limited ROM or expression of pain with
AAROM/PROM, and imaging that reveals swelling, fibrosis or tendonitis, and bone spurs.5

Incidence
Shoulder Impingement Syndrome is one of the most common pain disorders seen in the general
population (second to low back pain).6 More specifically, in 2021, SIS has accounted for 30-
35% of all shoulder disorders.6

Standard Body Posture and Resulting Imbalances

Standard Posture Standard Anatomical

Posture Stability requirements:

Global: The shoulder is comprised of

Zero position, or standard
anatomical posture, may be
determined by examining an
imaginary “plum line”
through the coronal plane of
static stabilizers; like the
glenohumeral joint capsule,
and the coracoacromial
ligament, and dynamic
stabilizers.10 Dynamic

Figure 2: Plum line 7
Figure 3: Positioning of the GHL
joint in standard posture 9
the body, see figure 2. The
line should include the ear
lobe, center of the shoulder
joint, midway through the
trunk, the elbow, greater
trochanter of the femur (hip),
midline of the knee, and the
lateral malleolus.8 Natural
lordotic curves should also be
present in the cervical and
lumbar spinal segments, with
kyphotic curvature of the
thoracic and sacral segments.
Looking at the UE in specific
from a lateral view, they are
midrange of the GHL with
forearm rotation, 10 degrees
of wrist extension, and 45
degrees of finger flexion.8
In an anterior view of this
position, the eyes, clavicles,
ASISs, and knees should be
level with feet facing
forward.7 From a posterior
perspective, the scapula,
PSIS, back of the knee, and
back of the ankles should be
aligned and underneath the
shoulders with forward facing
feet.7
Local:
The hand and scapular
positions should be parallel in
standard posture.8 For
example, with a pronated
hand, the scapula is
abducted.8
stability can be broken down
into a global (scapulothoracic
stability), and a local
perspective (glenohumeral
stability). While both
perspectives look for the
agonist, antagonist, and
synergies to work in
balance/coordination with
each-other for stability, the
scapulothoracic component
will specifically include
serratus anterior m., the
trapezius mm., the pectoralis
mm., the rhomboid mm., teres
major m., and levator
scapulae m..10 The
glenohumeral stability will
focus primarily on the rotator
cuff muscle balance/synergies
(supraspinatus, infraspinatus,
subscapularis, teres minor),
and the deltoid m..10
Mobility requirements:
From the same global-and-
local-perspective, the
scapulothoracic muscles, hold
the power, or allow the gross
motor movement of the UE to
occur.11 Looking at the
rotator cuff and deltoid then,
we see more fine movements
that allow the tendons and
bony prominences to avoid
hitting or impinging one
another during movement;
see table 1 for a more
detailed look at the fine-
movers and their functions.11
With proper co-contraction,
muscle recruitment, and
overall strength, these
synergies work to create a 2:1

Skeletal Imbalance
Skeletal imbalance or
deformities can be either a
cause or result of shoulder
impingement.
Causes:
Referring back to the
mechanism of injury,
differences in the shape of the
acromion process can cause
limited subacromial space -
this would then cause the
greater tuberosity of the
humerus to impinge tendons
as it moves into
abduction/flexion/etc., and
would also rub the processes’
together, degrading the
surrounding cartilage.1 In
general, osteoporosis may
occur at the joint and cause
relative muscle deformities,
but this can also cause
osteophyte, or bone spur,
growth.12 Improper posture,
i.e. rounded shoulders, can
cause scapular upward
rotation and anterior tilt
which would limit the ROM
of the GHL joint, thereby
decreasing the subacromial
space.8 Irritation thanks to
posture, a genetic
predisposition, trauma, or
overuse can also result in
bone spurs that could cause
an impingement.12
scapulohumeral rhythm, best
identified in shoulder
abduction.
Results:
Weakened RC muscles can
allow the deltoid to
pull/migrate the humeral head
upward, thereby decreasing
the subacromial space while
simultaneously weakening the
ligaments that work to
prevent a superior translation
(coracoacromial and superior
glenohumeral ligaments).8
This can be illustrated in
figure 4. In the act of
impingement itself, the
greater tuberosity of the
humerus can also become
“stuck” or impinged
underneath the acromion
process.8
Figure 4: Superior migration of
the humerus
Muscle and soft tissue
Imbalance
Figure 5: Anterior view of
musculature involved in shoulder
impingement.13
TABLE 1: Involved muscles and their relative faults. 14-17
Biceps mm. ● Purpose: flex the elbow and
**The tendon internally rotate the arm
being impinged ● Fault: tightens and becomes weak
Supraspinatus m. ● Purpose:external rotation & keeps
the humeral head in place in the
glenoid fossa during shoulder
Abduction
● Fault: weak/weaker than deltoid m.
Infraspinatus m. ● Purpose: external rotation of the
shoulder
● Fault: can be weak and/or tight
Subscapularis m. ● Purpose: Internally rotates and
Adducts the humerus
● Fault: weak enough to be
overpowered by deltoid m.
Teres Minor m. ● Purpose: external rotation
● Fault: can be weaker than deltoid m.
and/or tight
Deltoid m. ● Purpose: internal rotation and
shoulder Abduction
● Fault: tight & can generally
overpower the external rotators
Teres Major m. ● Purpose: Adduction, extension, or
internal rotation of humerus and
scapular downward rotation and
retraction
● Fault: tight
Pectoralis minor ● Purpose: Scapular downward
m. rotation, internal rotation, and
anterior tipping & adduction and
internal rotation of the shoulder
● Fault: tight - pulls on the coracoid
process, respectively pulling the
shoulders forward and inward to
create FHRS, thoracic kyphosis, and
a winged scapula.
Pectoralis major ● Purpose: Adduct shoulder & internal
m. rotation
● Fault: tight - pulls on the humerus
and clavicle, respectively pulling the
shoulders forward and inward to
create FHRS and thoracic kyphosis,
and a winged scapula.
 Trapezius m.
Latissimus dorsi
m.
Serratus anterior
m.
Rhomboid mm.
Compensation and Adaptation
The Compensation
Rounded shoulders/excessive thoracic and
cervical kyphosis & forward head 18
Upper cross syndrome - protracted shoulder
girdle with excessive thoracic flexion which
later on influence the lumbar spine and LEs
18
Standard position has now become one of
guardian (internal shoulder rotation with
adduction/slight horizontal abduction,
commonly paired with elbow flexion and a
shrugged, affected shoulder)
Increased thoracic extension and lateral bend
during reach
● Purpose:
Upper - scapular upward rotation &
external rotation & elevates & retracts
clavicle
Middle - protractor and upward rotator
of the scapula
Lowe - scapular upward rotation
● Fault: weak
● Purpose: Adduct and depress scapula
● Fault: tight
● Purpose: Scapular upward rotation,
external rotation, and posterior tilt
● Fault: weak
● Purpose:Retract scapula
● Fault: weak
The Reasoning
Tight pectoral/internal rotation muscles and
pressure/pulling forward of the scapula
(protraction and anterior tilt) 18
Tight pectoral muscles 18
This position favors the “stable” and tighter
muscles and works almost like a joint-
protection principle to stop pain sensations
from activating the weakened muscles, i.e. the
external rotators, shoulder flexors, and
adductors 8
Decreased ROM in shoulder
flexion/abduction
Occupations Patient Presentation

ADLs

Showering: Pt. expresses pain when trying to reach up

Reaching up and behind the hair/back to wash
hair and front and back of the upper body.
and behind the back to wash the upper body
from the shoulders (front) and scapula (back)
up. Pt. also stated that he shaved his hair so
as to not have to spend as much time
reaching up to wash it as well as a result of
pain.

Grooming/self-care: Pt. expresses pain when reaching up to fix his

Reaching up to fix, form the front of the hair hair and shave his face. Because of the sharp
and shave the face. pains, the client also tends to lose his grip on
the hairbrush and/or razor.

IADLs

Home Management: Pt. expresses pain when reaching and lifting

Reaching to cupboards to put away dishes
and/or retrieve them
up to put dishes away or retrieve them.
Because of the sharpness of the pain, this has
caused the client to lose his grip of the dish
on multiple occasions, resulting in dropping
and breaking the items.

Money/Home Management: Pt. expresses pain when reaching into his

Reaching into the back pocket to retrieve right back pocket to retrieve his wallet.
wallet while shopping for groceries, food
when out to eat, etc..

Work

Work: Pt. expresses pain when lifting the

Work/landscaping (emptying wheelbarrows,
and shoveling mulch)
wheelbarrow up to empty it, and when
shoveling mulch. The shoveling task requires
moving the affected arm across midline and
lifting up to transfer the mulch to the new
pile.

Leisure

Leisure: Pt. expresses pain when moving/pushing the

Making turns on the motorcycle
arm across midline for a left turn on the bike,
and when moving/pulling it back towards the
body (scapular adduction) for a right turn.
The spike of pain that results from either
movement demonstrates poor flow and is

Leisure:
Working out (shoulder press, push ups, tricep
extensions, curling)
Leisure (social participation):
Playing baseball (throwing and catching)
dangerous to the client and others on the road.
Pt. expresses pain when reaching overhead
and pulling down during a shoulder press,
stabilizing a tricep extension and push-up,
moving the body during the push up
(breaking the plane then returning to start
position), and lifting during curls. See Figure
6 for a demonstration of breaking the plane in
a pushup.
Figure 6: Notice how in the broken plane, the
scapula are adducted, and the elbows are in a flexed
position higher than the rest of the body. 19
*It should be noted that the Pt uses his right
hand for both catching and pitching/throwing,
unlike typical throwers that use a different
arm for each.
Pt. expresses pain when reaching up to catch
to catch a hit or thrown ball, resulting in many
missed catches during the game.
Pt. expresses pain when reaching back during
the cocking phase of a throw, and forward at
the start of the acceleration phase. See Fig. 7
for throwing phases.
Figure 7: The Throwing Cycle in Baseball. 20
 Assessments

Type Details

Impairment based

ER resistance ● Explanation: Used to assess rotator cuff

muscles for weakness and pain where MMT
3+ = +LR 10.56 rules SIS in and >-LR 0.17
rules SIS out. 21
● How to:
○ Seated or standing, have the Pt flex
elbows to 90 degrees with palms
facing medial and wrists in neutral
○ OTprovides force in the direction of
ER while the patient resists
movement

Measure the length of the pec muscles
● Explanation: The pec muscles attach to the
sternum and clavicle, pulling the shoulders
inward and forward as they tighten. This is a
sign of SIS and also puts the shoulder in a
“guarded position”. Normal results would be
a measurement of 1” or less and rule SIS out.
Anything greater than 1” indicates tight
pectoral muscles and rules SIS in. 22
● How to:
○ Pt lies supine with forearms rested on
the abdomen and towels placed under
the elbows for comfortable elevation.
○ OT measures the distance between
the acromion process to the table.

AROM ● Explanation: Identify specific movement

limitations in relation to the functional limits
values.
● How to:
○ Traditional AROM measurements of
the shoulder.

Performance based

Patient specific: ● Explanation: Using a traditional assessment

Visual Pain Analogue Scale while throwing with strong convergent validity during
meaningful occupations in order to see how
and catching a baseball over the course of 10 performance is being affected by the
throws/catches condition. 23

Patient specific:
Patient is able to complete a number of
pushups within the average range according to
his age group, over the course of 2 minutes.
(average for Pt. age 17-29) 24
SROM 25
DASH: Disabilities of the Arm, Shoulder, and
Hand
UEFS: Upper Extremity Functional Scale
● How to:
○ Allow the Pt to wear his usual
baseball glove and stand
approximately 9 feet apart
○ OT should use a mixture of overhand
and underhand throws to send the
ball to the Pt at various points in their
ROM
○ Pt should throw the ball back to the
OT, aiming for a catch at chest level
from varying distances and directions
○ Upon completion of the activity, the
Pt should record his pain level using
a visual analog scale
● Explanation: Multiple exercises that the
patient enjoys performing are push-lifts, i.e. a
push-up or bench press. This assessment
determines where the client is within the
average strength range for his age/gender.
● How to:
○ Have the Pt assume push-up position
(flat body with hands shoulder-width
apart and elbows under the body, toes
on the ground)
○ Start a timer for 2 minutes and count
the number of push-ups (with broken
plane) that the client can complete
● Explanation:
○ 30-item questionnaire that looks at
the ability of a patient to perform
certain upper extremity activities.
This questionnaire is a self-report
questionnaire that patients can rate
difficulty and interference with daily
life on a 5 point Likert scale.
● Explanation:
○ Patient reported outcome measure
used to assess the functional
impairment in individuals with
musculoskeletal upper limb
dysfunction. A 20-item questionnaire
answered on a 5- point rating scale
that assesses the level of difficulty in
performing activities of daily living
using the upper extremities including
household and work activities,
hobbies, lifting a bag of groceries,
washing your scalp, pushing up on
your hands, driving etc.
Special Tests

Wall Test (postural observation)
● Explanation: Used to evaluate the Pt’s overall
posture as compared to the standard normal. 8
● How to:
○ Have Pt stand against a wall with feet
slightly out away from it
○ Instruct to bring hips to wall, then
shoulders (scapula), then the head
and hold the position
○ Instruct the Pt to take a step away
from the wall and hold the position

Hawkins Kennedy ● Explanation: This is the most sensitive of the

special tests for SIS, meaning if the result is
negative (no pain symptom reproduction), SIS
can be ruled out. A positive result (pain
symptoms present) would rule SIS in. 26
● How to:
○ Pt is seated w/OT standing to
back/side
○ OT passively takes Pt arm into
flexion, horizontal adduction (90
elbow flex), stabilize the top of the
shoulder and internally rotate
humerus (by pressing down on the
wrist)
○ Compare to opposite

Neer ● Explanation: Used to assess for SIS, where a

positive result produces pain symptoms,
thereby ruling SIS in. A negative result would
not produce the symptoms, thereby ruling out
SIS. 27
● How to:
○ Pt can be standing or seated w/ OT
standing beside/behind
○ OT passively takes Pt shoulder into
full shoulder flexion maintaining
internal rotation (hand fwd)
○ If no pain do again while providing
overpressure - flat hand on scapula
and a hand in the axilla near the GHL
jt (grab the arm just above the armpit)
pushing into flexion & ADduction

Empty Can ● Explanation: Used to assess for a

supraspinatus impingement or tear, where a
positive result rules the condition in --
determined by a decrease in strength or
increase in pain in “empty” position. A
negative result would rule out SIS, and be
achieved with an average strength
measurement and no pain in either position.
28
 ● How to:
○ Pt standing or seated
○ Pt lifts arms to a T with palms open
and thumbs up then brings them fwd
about 15 degrees (large v)
○ Start with the can up, then slowly tip
the can over
○ Observe from front and back

Interventions

What How

Biomechanical/Remediation

Stretching 29
Stretches are performed to loosen tight muscles so that skeletal imbalances may be
corrected. This should be performed prior to strengthening exercises as the decreased
ROM as a result of tight muscles will further exacerbate a muscle imbalance.

Door Stretch

Target muscle(s): pectoralis major and minor

mm.
Posterior Capsule Stretch

Target muscle(s): supraspinatus m.,

infraspinatus m., teres minor m., and
subscapularis m.

Levator Scapulae Stretch

Target muscle(s): Levator Scapulae m. &

upper and lower portions of trapezius m.

Latissimus Dorsi Stretch

Target muscle(s): Latissimus Dorsi m.

Strengthening

Side Lying or Standing Isometric holds of ER 1. Place a small ball or folded towel

Target muscle(s): external rotators
(infraspinatus m., teres minor m.,
supraspinatus m., and posterior deltoid m.) 30
Standing or seated rows with theraband
Target muscle(s): erector spinae m., middle
and lower portions of trapezius m., rhomboid
mm., latissimus dorsi m., teres major and
minor mm., posterior deltoid m., infraspinatus
m., and pectoralis major m. 31
Pendulums
Target muscle(s): supraspinatus m.,
infraspinatus m., subscapularis m., and teres
minor m. 32
Prone Flyers
Target muscle(s): middle and lower fibers of
the trapezius m., supraspinatus m., and
infraspinatus m. 33
between the Pt’s elbow and the side of
their ribcage.
2. Instruct Pt to keep the elbow bent and
arm against the towel throughout the
movement.
3. Instruct Pt to lift their wrist and
forearm away from the stomach and
slowly lower it back down.
1. In a standing position, instruct the Pt
to bend forward 15-45 degrees,
holding onto a theraband that is
secured under the feet with both
hands. In seated position, have the Pt
hold onto the theraband with both
hands while it is wrapped around the
feet for stability.
2. Instruct the Pt to keep their wrists in
neutral, shoulders down, and to pull
the wrists to the body by bending the
elbow and adducting the scapula (“try
to touch your shoulder blades
together”).
3. Instruct the Pt to slowly release to the
starting position.
1. Instruct Pt to lean on their uninvolved
arm onto a table or desk, allowing
their head to rest on their forearm.
2. The Pt’s involved arm should hang
towards the floor as the Pt rocks their
body forward, backwards, and side to
side allowing momentum to move
their arm.
3. Pt can also perform small circles going
clockwise and counterclockwise.
4. To upgrade the task, have the Pt place
a weight in the hand of the affected
arm.
1. Have the Pt lie prone on a table with
the affected arm hanging off the edge,
perpendicular to the floor
(approximately 90 degrees flexion)
2. Beginning without a weight, have the
Pt horizontally abduct the arm, aiming
 for 90 degrees
3. Hold the position for a count of one
and slowly lower back down to
starting position

Occupation-Based Interventions

Educate the Pt on how to adapt work ADLs under joint protection principles. For example,
when dumping the wheelbarrow during work, instead of lifting straight up through shoulder
flexion, adjust the grip from underhand to overhand, flex the elbows, and use the triceps to
extend the elbows, tipping over the wheelbarrow. This includes aspects of reducing the effort
and force in addition to the use of larger/stronger joints and muscles.8

Use backward chaining of a pitch/throw first without a ball, then with a weighted ball, having
the Pt stop to hold the ball at the particular “phase positions” for a count of 2 when they occur.
For “phase positions,” please refer to figure 7. This would look like the Pt holding the ball in a
follow through position; then a follow through and an acceleration; then a follow through,
acceleration, and cocking; followed by a fully phased throw. Performing this backwards with
isometric holds at every “stop” allows for the progression of a challenge and also works to
stretch or warm up the muscles.

To decrease pain and improve performance during work activities, have the Pt use the shovel
attachment with the BTE. Walk through just the motion of shoveling and ensure there is no
pain for a consistent period (5 shovels) before adding any weight. Slowly progress until the Pt
can lift the approximate weight of a shovel full of mulch.

Treatment Session for Case Scenario

Preparatory (15 min.) Begin the session by having the Pt perform

the aforementioned stretches (see
interventions - biomechanical - stretching).
As the Pt performs each stretch, the OT
should provide concurrent ultrasound to
increase the extensibility of tight tissues like
the pec mm.. The tissue temperature must
increase by 4 degrees Celsius, so the
ultrasound should be provided on a
continuous setting at 3Hz for about 5 minutes
per stretch/targeted muscle.34

Skill (15 min.) In a seated position, have the Pt hold onto a

taut theraband with his right hand. The other
end of the theraband should be secured to
 either a door handle, table, or other heavy
object. The theraband should cross in front of
the body. Instruct the Pt to slowly go into
external rotation, but not to a position of pain,
hold at this end range for a count of 2, then
slowly return to starting position. Repeat this
10 times on each side. Watch the Pt’s
shoulder and provide tactile and verbal cues if
necessary to ensure there are no compensatory
motions.

Occupation based (15 min.)
Have the Pt put on a baseball glove he has
brought to therapy and stand about 10 feet
apart. Start with low pitches that alternate
from left to right, toss the ball underhand to
the Pt and have him catch it. Work your way
upwards with the tosses while still alternating
sides until the Pt expresses pain. From here,
work your way back down from this position.
Complete this activity for the remainder of the
session.

HEP suggestion Provide the Pt with instructions on how to use

cryotherapy - specifically how to perform an
ice massage - throughout his day at work
when he experiences pain. 34 Instruct the Pt
on how to properly stretch and strengthen
those involved with his impingement
(specifically stretch the pecs and strengthen
the ERs), and to try to do so every night in
order to see the best results. Pt should run
through all of the stretches each night at a
minimum, and only perform the strengthening
exercises (see intervention table for
information on both) if pain has not been a
persistent issue throughout the day.

References

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