OV E R COM I N G

SHOULDER IMPINGEMENTSYNDROME

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What Is Shoulder Impingement?

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What Is Shoulder Impingement?

This booklet is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem.©2003 The StayWell Company, 1100 Grundy Lane, San Bruno, CA 94066-3030.www.krames.com 800-333-3032. All rights reserved. Lithographed in Canada.

What Are the Symptoms?You may feel pain, pinching, orstiffness in your shoulder. Painoften comes with movement.But you may also feel it whenyou’re not using your shoulder.For example, you may feel painwhile trying to sleep.

What Causes It?Shoulder impingement can becaused by making repeated over-head movements. A forceful actionrepeated day after day withoutrest can cause a repetitive motioninjury (RMI). Some activities thatcan lead to RMIs include:

• Warehousing or shipping

• Painting or carpentry

• Swimming, tennis, softball, baseball, and other sports

• Weekend home repair

Impingement can be worsened by certain bone problems. In somecases, you may get impingementafter many years of normalshoulder use.

Do you have shoulder pain when raising your arm? If so, you mayhave shoulder impingement. This condition, also called bursitisor tendinitis, causes pain and problems with arm function. It isoften caused by doing overhead activity. Your healthcare providercan help you relieve pain and treat your problem. You can alsolearn how to prevent shoulder problems from returning.

Frequent overhead motions can lead to impingement.

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How Is It Diagnosed?To learn more about your problem,your doctor will examine your shoulder.He or she also may do some of the following tests:

• Impingement sign. Your doctor willslowly raise your arms and guidethem. Tell your doctor when youbegin to feel pain.

• Strength test. With your armsraised, your doctor gently pressesdown on them while you try to resist.

• X-ray. This creates images of yourshoulder bones. X-rays can showwhether bone shape is causingimpingement. They can also helprule out other problems.

• Other tests. Certain other tests maybe done on your shoulder to checkfor impingement. Your doctor canexplain these to you.

An impingement sign helps your doctor assess your problem.

Table of ContentsLearning About the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Understanding Shoulder Impingement . . . . . . . . . . . . . . . . . . . . . 5

Resting the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Relieving Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Increasing Flexibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Increasing Strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Having Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

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Learning About the Shoulder

The shoulder is made up of bones, muscles, ligaments, andtendons. They work together so you can reach, swing, and liftin comfort. Learning about the parts of the shoulder and jointwill help you to understand your shoulder problem.

Supraspinatus (muscleand tendon that helpform the rotator cuff)

Acromion

Bursa

Long head ofbiceps tendon

Humerus(upper armbone) Scapula

(shoulder blade)

Coracoacromial ligament

Coracoidprocess

Clavicle(collarbone)

Understanding Shoulder Impingement

The Parts of the Joint The shoulder joint is where thehumerus (upper arm bone) meets thescapula (shoulder blade). Muscles andligaments help make up the joint. Theyattach to the shoulder blade and upperarm bone. At the top of the shoulderblade are two bony knobs called theacromion and coracoid process.

The Subacromial Space The subacromial space is between thetop of the humerus and the acromion.This space is filled with tendons andmuscles. This space also contains thebursa, a sac of fluid that cushionsshoulder parts as they move. When youraise your arm, the subacromial spacecompresses. When you lower your arm,the space opens again.

Subacromialspace

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Impingement occurs when the subacromial space is too small to let the parts move easily. This may be caused by jointinflammation (swelling). Swollen parts of the shoulder take upmore room, making the joint space smaller. The shape and condition of shoulder bones may also add to impingement.

Hookedacromion

Flatacromion

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Swollenbursa

Inflamedtendon

A hooked acromion makes the subacromialspace smaller.

Understanding Shoulder Impingement

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How Problems BeginShoulder problems develop slowly over time. Youmay not notice a problem until it causes pain. Thereare many factors that can affect your shoulder.

OveruseConstant shoulder use can irritate thetendons and bursa. Then the body sendsmore blood to the irritated areas, causingswelling. As the swelling gets worse,two problems can develop:

• Bursitis is inflammation of the bursa.The bursa fills up with too much fluid,filling and squeezing the joint space.

• Tendinitis is inflammation of the tendons. Swollen tendons make thejoint space smaller.

Acromion Shape and ConditionThe acromion is part of the shoulderbone. It may be flat or hooked. Ifyour acromion is hooked, the acromial space may be smallerthan normal. This makes you moreprone to shoulder problems. Bonespurs (growths on the bone) canalso narrow the subacromial space.

Other CausesYour shoulder health may also beaffected by poor posture, weak muscles, and other conditions.

Finding ReliefIf shoulder problems remain untreated, they can leadto more serious problems. Read on to learn how to starttreating your shoulder so it can heal.

Subacromialspace

Side viewof scapula

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Resting the ShoulderResting the Shoulder

Rest is a key step in healing your shoulder. Remind yourself: Ifan activity hurts, don’t do it. Otherwise, you may prevent healingand increase pain. To give your shoulder the best possible rest,read the tips here. They can help you adjust your posture anduse your shoulder wisely.

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Using Active RestWhen you have impingement, your shoulder needs activerest. This means avoiding overhead movements andactivities that cause pain. Don’t stop using your shouldercompletely. This can cause it to stiffen or “freeze.” As youheal, use these tips to reduce strain and increase comfort.

Adjusting Your Posture

Use good posture at work and athome to help your shoulder heal.

• Make sure your neck, shoulders,and hips are in line. This helpsreduce strain on your shoulder soyou can heal more quickly.

• Check and adjust your posturewhen you’re sitting, standing, andeven lying down. Try not to sleepon the affected shoulder.

• Fit your workstation to your body(ergonomics). Place your monitoror work at eye level. Adjust worksurfaces so you don’t have to leanor stretch.

• Support your lower back.Slumping over can add strainto your shoulders.

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der

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Using Your Shoulder WiselyMaking changes in how you use your shouldercan lessen your chances of impingement. The ideas below focus mainly on preventingrepetitive motion injuries (RMIs). Remember,if a movement hurts, don’t do it.

Positioning Your Body • Keep your work within easy reach.

This helps you avoid stretching or twisting your arms and shoulders.

• Avoid raising your arms when workingabove shoulder level.

• Use a stool or stepladder to bring your body closer to overhead tasks. This prevents awkward reaching.

Changing Tasks• Vary your on-the-job activity to reduce

the risk of RMIs. Limit tasks that must bedone over your head.

• Give your shoulder enough time to restand recover from stressful tasks.

• If one task causes you to feel pain, stop. Rest your shoulder. Go on to anothertask, if possible.

Limiting Force• Limit activities that could strain shoulder

muscles and tendons. This includes heavylifting, pushing, and pulling. Get help whenneeded, or use dollies and wheelbarrows.

• Find the best tools for each activity. The best tool lets you use the least force.

• Rest before repeating a task that requires a lot of force. The more frequent the force, the greater the risk of RMIs.

Keep work below shoulder level.

Vary activities to help prevent RMIs.

Ask for help when you need it.

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Relieving Pain

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Relieving Pain

Impingement can be treated a number of ways. Your healthcareprovider will discuss your treatment options with you. Manysteps can be taken to relieve pain on your own at home. But inother cases, you may need treatment that requires yourhealthcare provider’s help.

q IceIce reduces inflammation and relievespain. Apply an ice pack for about15 minutes, 2 or 3 times a day. You canalso use a bag of frozen peas instead ofan ice pack. The bag will mold nicely tothe shape of your shoulder. A pillowplaced under your arm may make youmore comfortable.

Note: Don’t put the cold item directly on your skin.Place it on top of your shirt or wrap it in a thintowel or washcloth.

q HeatHeat may soothe aching muscles, but itwon’t reduce inflammation. You can usea heating pad or take a warm shower orbath. Do this for 10 to 15 minutes.

Note: Avoid heat when pain is constant. Heat is bestwhen used for warming up before an activity.You can also alternate ice and heat.

q MedicationTry over-the-counter pain relievers. Yourdoctor may also prescribe medication torelieve pain and inflammation. If so, askhow and when to take your medication.Be sure to follow all instructions.

Finding the Best Treatment for YouIce, heat, and medication can help relieve shoulder painquickly. But if your pain continues, call your healthcareprovider. Keep in mind that no two people are alike. Youmay need to try a few pain relief methods before youfind the best one for you.

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q Injection TherapyInjection therapy may be usedto help diagnose your problem.It may also be used to reducepain. The doctor may begin by numbing a small spot on the shoulder. He or she theninjects an anti-inflammatorymedication into the shoulder. It can take a few hours or even a couple of days before the injection helps.

Note: Talk to your healthcare providerabout the possible risks andbenefits of injection therapy.

q Electrical StimulationElectrical stimulation can help reducepain and swelling. Your healthcareprovider attaches small pads to yourshoulder. A mild electric current thenflows into your shoulder. You may feeltingling, but not pain.

q UltrasoundUltrasound can help reduce pain.First a slick gel or medicated cream isapplied to your shoulder. Then yourhealthcare provider places a smalldevice over the area. The device usessound waves to loosen shoulder tight-ness. This treatment is also pain-free.

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Increasing Flexibility

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Increasing Flexibility

Stretching exercises can help increase your pain-free range ofmotion. Your healthcare provider will pick the best stretchingexercises for you. Breathe normally when you exercise. And tryto use smooth, fluid movements.

q Broom Stretch1. Stand up or lie on the floor. Place

the palm of your hand over theend of a broomstick or cane.Grasp the stick farther down withthe other hand, palm facing down.

2. Push the end of the stick up onthe side of your injured shoulderas high as you comfortably can.

3. Hold for a few seconds.

4. Return to the starting position.

5. Repeat 3 to 5 times.

Note: Don’t force the stretch. Build up to holdingeach stretch for 10 to 30 seconds.

q Back Scratcher1. Stand straight, placing the back

of the hand on the injured sideflat against your lower back.

2. Throw one end of a towel overyour shoulder. With your otherhand, grab the towel behind your back.

3. Pull down gently on the towelwith your front arm. Let yourback arm slide up as high as itcomfortably can. You’ll feel astretch in your shoulder.

4. Repeat 3 to 5 times.

Note: Build up to holding each stretch for 10 to 30 seconds.

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q Pendulum Exercise1. Lean over with your good arm

supported on a table or chair.

2. Relax the arm on the painful side,letting it hang straight down.

3. Slowly begin to swing the relaxedarm. Move it in a circle, thenreverse the direction. Then moveit backward and forward. Finally,move it side to side.

Note: Spend about 5 minutes doing the exercise,3 times a day. Change direction after 1 minuteof motion. Or follow your healthcare provider’sinstructions if they differ from these.

q Wall Walk1. Stand with your shoulder

about 2 feet from the wall.

2. Raise your arm to shoulder leveland gently “walk” your fingersup the wall as high as you can.

3. Hold for a few seconds. Thenwalk your fingers back down.

4. Repeat 3 to 5 times.

Note: Do this stretch only if your healthcareprovider recommends it. Move closer tothe wall as you repeat. Build up to holdingeach stretch for 10 to 30 seconds.

Note: Your healthcare provider may give you special instructions for doing the exercises on these pages. Make sure you follow them closely. If you feel pain, stop the exercise. If the pain continues even after stopping,call your healthcare provider.

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Increasing Strength

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Increasing Strength

q Internal Rotation1. With knees bent, lie on a firm

surface. Using the hand on thesame side as your injured shoulder,grasp a weight. Bend that arm to aright angle (90 degrees). Rest yourelbow on the floor.

2. Keeping your elbow next to yourside, lower your forearm towardthe floor, away from your body.Do not lower your hand all theway to the floor.

3. Slowly return your forearm toyour side. Repeat.

Note: Support your head with a pillow.Work up to 5 to 15 lifts.

Strengthening exercises help make your injured shouldermore stable. To warm up, do flexibility (stretching) exercisesfirst. Your healthcare provider will tell you what size handweights to use for the strengthening exercises below. If youdon’t have hand weights, try using cans of soup instead.

q External Rotation1. Lie on your uninjured side with

your head supported by a pillowor your arm.

2. Place a small rolled-up towelunder your top elbow. Grasp aweight with your top hand andbend that arm to a right angle,resting your forearm againstyour stomach.

3. Keeping your elbow against thetowel, slowly lift the weight untilyour forearm is slightly higherthan your elbow. Return to thestarting position. Repeat.

Note: Be sure to keep your elbow againstthe towel. Work up to 5 to 15 lifts.

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q Wall Pushup1. With feet and hands shoulder-

width apart, place your palmson the wall, standing about anarm’s length away.

2. Keeping your knees straightand heels on the floor, bendyour elbows and lean forwardas far as you comfortably can.Your elbows should be pointingdown. Then push away fromthe wall to the starting position.Repeat.

Note: Wear shoes that keep you from slipping.Work up to 5 to 15 wall pushups.

q Side Raise1. Stand with your arms out and

held slightly in front of you.Hold one weight in each hand.

2. Keep your elbows straightwith your thumbs pointingdown. Lift your arms upward.Don’t lift your wrists higherthan shoulder level.

3. Slowly lower your arms to thestarting position. Repeat.

Note: Build up to 5 to 15 lifts.

Note: Your healthcare provider may give you special instructions for doing the exercises on these pages. Make sure you follow them closely. If you feel pain, stop the exercise. If the pain continues even after stopping,call your healthcare provider.

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Having Surgery

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Having Surgery

For many people, self-care measures are enough to relieveshoulder impingement symptoms. But if self-care and othertreatments haven’t worked, surgery may be an option. Surgerycan help free up the joint space, allowing pain-free motion. Talk to your doctor to see if surgery is right for you.

A swollen bursa may be removed.

A tight coracoacromial ligament may be released.

A portion of the acromionmay be removed.

Surgery for Shoulder ImpingementThe type of surgery you have depends on your shoulderproblem. Surgery can remove the bursa if it is swollen. Ifthe coracoacromial ligament is tight, it may be released.If the acromion is hooked or has bone spurs, a portion of itmay be removed. Before surgery, you’ll be given medication tokeep you free from pain. There are different types of surgery:

• During arthroscopy, small incisions are made in the shoulder. Next, a small lighted instrument (arthroscope) isinserted. A tiny camera is attached on one end of thearthroscope. The camera sends images to a video monitor,allowing the surgeon to see inside the shoulder.

• During open surgery, incisions are made in the shoulderso the surgeon can work inside.

Risks and Complications of Surgery

Your doctor will discuss the possible risks and complications of the procedure with you. These may include:

• Infection

• Damage to nerves or blood vessels

• Loss of flexibility

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After SurgeryYou’ll be taken to a recovery area after theprocedure. A doctor or nurse will give youmedication to relieve discomfort. Know that:

• If you had arthroscopy, you may go homethe same day. If you had open surgery, youmay need to stay overnight.

• You should ask about self-care before yougo home. This may include wearing anarm sling, taking medication, or using ice.

• It may take a few months to feel the fullbenefit of the surgery.

Before SurgeryYou need to prepare ahead of time for shouldersurgery. Follow all your doctor’s instructions.

• Stop taking anti-inflammatory medication,including aspirin, before surgery if directed.

• Tell your doctor about any prescription orover-the-counter medications, herbs, or supplements that you take. Ask whetheryou should stop taking any before surgery.

• Don’t eat or drink anything after midnightthe night before surgery. This includes water.

• Arrange for a friend or family memberto give you a ride home.

The night before surgery, don’t eat ordrink anything after midnight.

Keeping your arm in a sling as instructedwill help you recover faster.

When to Call the DoctorAfter surgery, it’s normal to feel some shoulder numbness for the first few days. But call your doctor if you notice any of the following:

• Excessive pain or swelling

• Excessive drainage from the wound

• Numbness in your fingers or hand

• Increased redness near an incision

• Fever or temperature of 101°F (38.3°C) or higher

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Taking Care of Your Shoulder

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Work with your healthcare provider to fill in the chart below.Then, be sure to do your exercises as directed. Continuing your self-care program will help keep your shoulder strong and flexible. This ensures easy, pain-free shoulder movement.

Consultant:A. Shabi Khan, MD, Orthopaedic Surgery Contributions by:Douglas A. Flory, MD, Orthopaedic Surgery Terri Jo Rucinski, PT, Physical TherapyTaylor K. Smith, MD, Orthopaedic Surgery Arnold J. Weil, MD, Orthopaedics

OV E R COM I N G

SHOULDER IMPINGEMENTSYNDROME(Repetitions/sessions per day)

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

q Broom stretch

q Back scratcher

q Pendulum exercise

q Wall walk

q Internal rotation

q External rotation

q Wall pushup

q Side raise

q

q

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