How to Treat and Prevent Shoulder Impingement Syndrome

Shoulder impingement syndrome is a name given to several different conditions that involve inflammation of tendons and/or ligaments in the shoulder region.

If you are not familiar with shoulder impingement syndrome, please take a moment to use your left hand to locate your right collar bone, the bone that borders the top of your right chest wall. Once you locate your collar bone, follow it towards your right shoulder area until you feel a bony protuberance that sits at the top of your upper right arm. You can confirm that you've reached this bony protuberance by going slightly past it, at which point you will find that there is no more bone, only your shoulder (deltoid) muscle and the flesh that lies on top of it.

This bony protuberance that sits on top of both of your shoulders is a joint between your collar bone and the top of your shoulder blade (scapula). Underneath this joint is a space called your coracoacromial arch. This arch houses several structures, the most prominent of which are:

• Your biceps tendon

• Your supraspinatus muscle and tendon - one of your rotator cuffs

• Your subacromial bursa, a jelly-like sac that acts as a lubricant of sorts

A number of different factors can cause inflammation of one or more of these structures, which is usually felt as a sharp twinge of pain whenever you elevate your shoulders in a certain way. This is a classic picture of shoulder impingement syndrome.

The most common causes of shoulder impingement syndrome include:

1. Overuse of your shoulder joint, especially through motions that involve rotation of your shoulder joint. Examples include throwing a baseball, any overhead stroke while swimming, serving while playing tennis, striking a volleyball, chopping wood with an axe, and holding an active baby in one arm.

2. Poor blood circulation. Ligaments and tendons throughout your body are at greater risk of becoming injured when they are not properly supplied with healthy blood circulation to bring nutrients and remove waste products.

3. Lack of restful sleep. All of your tissues are predisposed to becoming injured when they are not well rested.

4. Slouching. Sitting or standing with your shoulders rounded forward will eventually lead to a decrease in volume in your coracoacromial arch. Less space in this region equals more pressure on the structures that run through it, an equation that inevitably translates to inflammation of one or more of those structures.

What follows are several guidelines that I have used over the years to successfully treat and prevent re-occurrences of shoulder impingement syndrome:

1. Before you perform any activity that involves significant use of your shoulder joints, spend at least 5 minutes, preferably 10 minutes, doing light stretches and exercises that will adequately warm up the tissues in your shoulder region. A good warm up session is especially important before explosive activities like throwing a baseball, playing tennis or badminton, and throwing a football.

   Bend over at your waist so that your upper body is perpendicular to your lower body and let your arm sway back and forth like a pendulum. Let it turn in circles, first clockwise, then counter-clockwise. All of these movements will help to increase blood flow to the ligaments and tendons that surround your shoulder.

   Do not underestimate the importance of warming up. Every world class athlete is aware of how important this point is to preventing a debilitating injury to the shoulder region.

2. At least once a day, gently hyper-extend your spine. You can do this by lying back on an exercise ball for a few minutes whenever you can. If you don't have an exercise ball, stack 2-3 puffy pillows on the floor and lie on them so that your neck and bum hang off either end and your arms are allowed to fall off the edges. Lying in this position will counteract the effects of slouching forward at a desk. It may also serve as a good reminder to maintain good posture throughout the day so as to prevent a decrease in space in your coracoacromial arch.

3. Eat lots of green vegetables and other foods rich in omega-3 fatty acids to promote optimal blood circulation to the tissues that surround your shoulder joints. Reduce or eliminate consumption of sugar, refined carbohydrates, and unhealthy fats and oils, all of which contribute to poor blood circulation.

4. Get lots of rest. All tissues heal most efficiently when you sleep soundly. Sound sleep allows your body to release large quantities of growth hormone, erythropoietin, and testosterone, all of which facilitate healing and growth of new tissues.

5. Strengthen your supraspinatus rotator cuff. A strong supraspinatus rotator cuff helps the head of your arm bone to move in a way that does not put pressure on the structures that run through your coracoacromial arch.

   To do this, stand with your feet spread shoulder width apart, facing forward. Keeping your right arm straight, slowly move your right hand up and down, from your right thigh to the point at which your hand is at the height of your shoulder. Your arm shouldn't be moving up and down straight out from the front of your body, nor should it be moving up and down straight out from your right side. It should be moving up and down in a plane that is about halfway between the these two planes. Put another way, if looking straight forward is 12 o'clock, your arm should be moving up and down at about 2 o'clock. As your arm moves up and down, keep your hand turned inward, as though you are trying to completely empty a can of beans. Do about 10 to 12 repetitions. If 10 to 12 repetitions do not cause you to feel mild to moderate fatigue in your shoulder, repeat this exercise while holding a can of beans or another object that allows you to feel some fatigue after your repetitions. Repeat the entire process on your left side.

6. Strengthen your serratus anterior muscle group. This muscle group lines the front and sides of your rib cage and helps to facilitate normal movement of your shoulder blade (scapula) and shoulder joint (glenohumeral joint).

   A simple exercise to strengthen the serratus anterior muscle group is a regular or modified push-up. If regular push-ups are not possible, modified push-ups can be performed by resting on your knees and even putting some pillows under your chest and abdomen area for additional support while moving up and down. Aim for as many repetitions as you can comfortably perform before becoming moderately fatigued.

7. Strengthen your main shoulder muscles (deltoids). Like your supraspinatus rotator cuffs, your deltoids facilitate proper downward gliding of the head of your arm bone (humeral head) in the shoulder joint socket (glenoid fossa of the scapula), which is essential to maintaining proper space in the coracoacromial arch.

   A good exercise to strengthen your deltoids is the standing shoulder press. Stand with your feet shoulder width apart and slowly move your arms up and down, focusing on your shoulder muscles throughout the entire range of motion. If your shoulders don't feel fatigued after 10 to 12 repetitions, hold a weight in each hand, one that is heavy enough to cause fatigue after 10 to 12 reps. Aim for 3 sets of 10-12 repetitions with both arms.

If the suggestions listed above do not lead to complete resolution of shoulder impingement syndrome within a period of 1 to 2 months, I recommend that you look for a competent and trustworthy physiotherapist, chiropractor, or osteopathic physician who may be able to accelerate the recovery process via adjunct therapies like transverse friction massage, therapeutic ultrasound, and perhaps some deep tissue work such as active release technique.

Anti-inflammatory drugs and corticosteroid injections should be avoided whenever possible, as these drugs have a weakening effect on ligaments and tendons and can lead to an unstable shoulder joint complex in the long term.

Finally, it should be noted that the best step you can take as soon as you injure your shoulder is to give it complete rest from the activity that caused the injury, if applicable, for at least a few days, perhaps even up to 2 weeks. Light stretching and some of the exercises described above are fine to do right away, but only if they don't cause any discomfort. Slowly, as you begin to feel more confidence with your movements, you can increase the frequency and intensity of your exercises.