Running head: FIXING SUBACROMIAL IMPINGEMENT

Fixing Subacromial Impingement at the Glenohumeral Joint

Parker Kennedy (V00863929)
Orrin Watkinson
Amiralli Hassini
Universtiy of Victoria
FIXING SUBACROMIAL IMPINGEMENT

Fixing Subacromial Impingement at the Glenohumeral Joint

1. Maria is suffering from shoulder complex imbalances associated with prolonged

forward posture in the workplace, compounded by possible muscular fatigue from rock climbing.
This leads to both compromised glenohumeral (GH) stability and scapulothoracic rhythm. The
resulting subacromial impingement (SAI) at her GH joints explains the shoulder pain she feels
during elevation.

In Maria’s case, SAI is primarily due to her poor posture at a desk all day; however, there
are other contributing factors. As a female, she is more likely to develop SAI, and having just
started rock climbing, she may have muscular fatigue and poor technique affecting the activation
of her scapular upward and downward rotators (Alizadehkhaiyat, Roebuck, Makki, & Frostick,
2018). As well, rock climbing involves repetitive motions of the GH and scapulothoracic joints
undergoing overhead movement while weight bearing, affecting the rotator cuff and pectoral
girdle muscles (Alizadehkhaiyat et al., 2018).

To elaborate, both rock climbing and painting require optimal abduction of the humerus
at the GH joint and upward rotation of the scapula at the scapulothoracic joint. Specifically, her
scapulohumeral rhythm is “off” because of muscular imbalances between upward and downward
scapular rotator muscles; this explains her suboptimal upward rotation. Maria’s upward scapular
rotation is restricted by tight downward rotator muscles such as levator scapulae and pectoralis
minor. Similarly, her weak upward rotators (i.e. upper trapezius and serratus anterior) contribute
to suboptimal upward rotation. Finally, the imbalance between tight upper trapezius and weak
lower trapezius muscles also reduces upward scapular rotation (Weon et al., 2010).

During painting and rock climbing, the arms are elevated by abduction and flexion at the
glenohumeral joint, which relies heavily on the active stabilizers of the rotator cuff muscles. The
cuff is composed of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles.
Together, these muscles restrict superior and anterior translation of the humeral head and provide
joint stability through balanced compressive forces on the humeral head into the glenoid fossa of
the scapula in the scapular plane (Sharkey & Marder, 1995). Maria works a desk job as a
financial advisor and is known to have poor posture. This places the head of the humerus
internally rotated at the GH joint for a prolonged amount of time, leading to muscle imbalances
of the rotator cuff (Alizadehkhaiyat et al., 2018). This involves the lengthening and weakening of
infraspinatus and teres minor (lateral rotators of humerus), leading them to be less active
compared to subscapularis and pectoralis major (medial rotators of humerus), which then
become shorter and overactive. This imbalance between overactive medial rotators and
underactive lateral rotators leads to a decrease in the compressive forces on the head of the
humerus into the glenoid fossa of the GH joint along the scapular plane. The result is anterior
joint instability during overhead motions, which can lead to excess anterior motion of the
humeral head during rock climbing as Maria is experiencing (Alizadehkhaiyat et al., 2018).

Maria's shoulder pain during GH abduction and scapular elevation/upward rotation is due
to SAI, which aggravates structures such as the GH superior capsule, subacromial bursa,
subdeltoid bursa, infraspinatus tendon,supraspinatus tendon and tendon of long head of biceps
brachii. SAI is due to superior instability of the GH joint, whereby both the greater tubercle and
proximal shaft of the humerus impinge the tissues inferior to the acromion and superior to the
FIXING SUBACROMIAL IMPINGEMENT

humeral head. Maria's SAI is attributable to an array of muscular imbalances such as weak
upward rotators and tight downward rotators which, together, account for her restricted upward
scapular rotation. Her weak serratus anterior (inferior protractor), tight pectoralis minor (superior
protractor) and weak rhomboid major and minor (retractors) forces her scapula to tip forward
anteriorly. Anterior tipping reduces the subacromial space such that the humeral head impinges
on the aforementioned GH capsular structures.

2. The objective of Maria’s rehabilitation is to promote proper posture by regaining optimal

arthrokinematic movement of the humeral head. This will prevent further anterior humeral
gliding and SAI of the GH superior capsule, subacromial bursa, subdeltoid bursa, supraspinatus
tendon, infraspinatus tendon and tendon of long head of biceps brachii muscle during shoulder
elevation. As such, rehabilitation must exclude (1) any overhead movements that cause Maria
pain and (2) actions that worsen her scapulohumeral rhythm by increasing muscular imbalances
of the shoulder girdle.

It is important that Maria strengthens her lateral rotators such as infraspinatus and teres
minor. These muscles are weakened due to her prolonged ‘hunched-over’ posture. Strengthening
Maria’s lateral rotators will increase their compressive forces and centre the humeral head on the
glenoid fossa. Increased glenohumeral stability will prevent further superior translation of the
humeral head. Maria can indirectly strengthen her lateral rotators by stretching her pectoralis
major, a medial rotator whose excessive tightness lengthens the already weakened infraspinatus
and teres minor. Stretching a tight pectoralis major will therefore prevent further superior
translation of the humeral head.

Treating Maria’s restricted upward scapular rotation requires that muscular balance be restored
between her upward and downward rotators. Specifically, her tight levator scapulae and
pectoralis minor (downward rotators) must be stretched while her weakened lower trapezius and
serratus anterior (upward rotators) must be strengthened. Similarly, the muscular balance
between her upper and lower trapezius must be restored by stretching her overactive upper
trapezius. These actions will prevent further impingement by restoring scapulohumeral rhythm
during upward rotation. SAI via anterior tipping of the scapula must be treated by stretching
pectoralis minor to reduce scapular protraction while strengthening rhomboids major and minor
to increase scapular retraction. The increased subacromial space will lessen her impingement and
adjust her forward posture. By alleviating her SAI, Maria will regain optimal upward scapular
rotation such that she can return to rock climbing and paint her apartment without pain

Stretching
For Maria’s prescribed stretching exercises, she should aim to complete them all for a
minimum of 1 minute each, broken up into four sets of 15 seconds. The stretches will be static,
so the stretch will be applied and released slowly, and not pushed to a point of pain. In
between sets she should allow the muscle to relax for 5-10 seconds. The stretching routine
should also be done anywhere from two to seven days of the week, up to her discretion and
based on the following precautions:
• she does not push past her typical range of motion at the GH joint,
• if sharp pain or acute inflammation occurs during or after stretching,
• if soreness occurs more than 24 hours post stretching, then she needs to rest and be less
aggressive for the next session, and
FIXING SUBACROMIAL IMPINGEMENT

• she has adequate cooldown after each session.

All stretches will be demonstrated to Maria initially, and she will practice them to
make sure she has correct form before completing them on her own. As well, she can apply
cold to the muscle afterwards to treat any irritation that arises, and incorporate her gained
ranges of motion into the strengthening exercises as she progresses through the grades.

Upper Fibers of Trapezius

• Flex the neck forward and towards the
opposite shoulder
• Look towards the ipsilateral side
• Actively depress the ipsilateral shoulder
girdle
• To increase the intensity of the stretch, apply
pressure with the contralateral hand.
Prescription: 4 sets x 15 seconds

Levator Scapulae
• Flex the neck forward and towards the
contralateral side.
• Rotate the neck to the contralateral side
• Depress the ipsilateral shoulder
• The trunk must stay in a neutral position
throughout the stretch
• To increase intensity, use the contralateral
hand to apply pressure to the head.
Prescription: 4 sets x 15 seconds

Note: To maximize the effectiveness of the

stretch, turn the head first, then tuck the chin

Pectoralis Major
• With the elbow bent, externally rotate,
abduct and horizontally extend the shoulder
• Stand and rest the forearm on a wall
• To increase the intensity of the stretch, rotate
the body away from the arm
• To target the different fibers of the pectoralis
major, change the degree of arm abduction.
Prescription: 4 sets x 15 seconds
.
Note: Ensure to stretch the pectoralis major
before the pectoralis minor as tight pectoralis
major can limit the effectiveness when
stretching the pectoralis minor.
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Pectoralis Minor
• Stand upright with arm abducted to 110
degrees and elbow flexed to 150 degrees
• Place arm against the wall, move into
horizontal extension and retract the scapula
• In order to maximize stretch for the
pectoralis minor, increase upward rotation of
scapula and arm abduction.
Prescription: 4 sets x 15 seconds

Strengthening
For her strengthening exercises, Maria will use them in tandem with the stretching exercises
she was provided, in order to gain new strength in her gained ranges of motion that are pain
free. The goal will be to increase the endurance strength of these muscles, starting with
completing the desired GH and ST motions against gravity without pain before adding weight.
In between each set she should rest for two minutes, completing the routine five to seven days
per week due to its low intensity. Precautions to this program include:
• watching for signs of fatigue and if need be, regress to lighter weight or previous stage,
• if pain in certain ranges of motion, limit to pain free range of motion or stop exercise
for that day,
• avoid trunk rotation and maintain a strong core in all movements, and
• avoid overworking the muscles, if too sore after 24 hours then take a rest day.
All exercises will be demonstrated to Maria, and then she will have an opportunity to
practice them to make sure she has adequate form before performing them on her own. As
well, open and closed chain exercises will be incorporated into the functional aspect of her
rehabilitation as well, to imitate the open chain of painting and open/closed combination in
rock wall climbing

Lower Trapezius
Grade 2 or 3
• Hold arms to side while lying prone
• Retract and depress both shoulder blades
into each contralateral back pocket

Grade 3+
• Touch hands above head in a diamond
shape while lying prone
• Lift the arms one inch off the ground
• Upwardly rotate the scapula as done in
previous grade ⅔ exercise
*Minimize upper trap contribution
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Grade 4/5
 Raise arms into a “W” shape while lying
prone
 Focus on pulling each scapula towards
the contralateral back pocket
 As arms extend into a “Y” shape,
upwardly rotate the scapula
 Add small amount of weight to progress
to grade 5
*Try to minimize the use of upper traps by
limiting scapular elevation
Serratus Anterior
Grade 3
*Tubing required
 Attach piece of tubing to fixed object at
elbow level
 Start the exercise from a flexed elbow
position
 “Punch” forward allowing the scapula to
protract and upwardly rotate

Grade 4/5
 Lie supine, arms flexed to 90 degrees at
shoulder
Protract scapula up against gravity

Infraspinatus/Teres minor
Grade 3/3+
 Flex elbow beside the body while
lying on the side
 Externally rotate the shoulder
 Continue to rotate through full ROM
 Progress to 3+ by adding weight

Grade 4
 Performed standing
 Flex elbow beside the body
 Externally rotate at the shoulder
 Increase difficulty by using stronger
tubing
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Grade 4 & 5
 Hold resistance band in hand
 Externally rotate arm while arm is in
90 degree abduction
 The arm will rotate about the
horizontal axis

Rhomboid Major/Minor
Grade 3
 Hinge at the hips while keeping the
back in neutral alignment
 Extend the shoulder and retract
scapula’s together at end ROM
Use resistance of gravity (No weights)
Grade 4/5
Add weight to exercise listed above

Functional Rehabilitation
Complete the functional rehabilitation exercises once subacromial impingement is
eliminated and muscular imbalances are fixed. Ensure there is no pain present when
performing overhead movements.

High-to-Low Rows Wax on Wax off

-Attach resistance band to stable object above -Stand with feet shoulder width apart
head -Place ball on wall at shoulder height
-Drop back knee to the ground while keeping
front knee flexed to 90 degrees -Place hand on ball and move the ball in
-Pull resistance band until the humerus is in line clockwise and counterclockwise positions
with the middle of the sagittal plane
-Ensure to retract the scapula when end ROM is Perform for 3 sets of 15 seconds. Continually
reached increase time until 45 seconds is reached per rep
Perform for 3 sets of 10 reps. Start off at a weight
that is appropriate and increase once you can
perform 20 reps each set unbroken

3. Maria has pain due to SAI whenever she moves her hands above her head. Therefore during
rehabilitation, she should initially avoid actions that require this motion. Failing to do so could
increase subacromial tissue irritation, potentially prolonging her stretching and strengthening
program. Rock climbing especially, due to its overhead actions requiring extension of the humerus at
the GH joint and upward rotation of the ST joint under the load of body weight, should be avoided
during initial rehabilitation. With concern to painting, Maria must judge her ability to paint her
apartment based on her rehabilitation progress. Her plan to begin painting within the next two weeks
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might not offer enough rehabilitation time to regain proper overhead motion against gravity while
handling a brush or paint roller. To avoid this issue, she can use a stepping ladder to reach high
places and only use painting strokes that are below the level of elevation that causes her shoulder
pain (below approximately 90 degrees of GH flexion). As well, she could ask friends or hire help to
paint the apartment. For other home conveniences, she could lower daily appliances originally in
high cupboards to avoid reaching overhead during her rehabilitation and also use a stepping stool to
reach fixed spaces such as the upper freezer compartment of a fridge.
   
     For exercise, Maria can engage in activities that do not require overhead GH motion, such as
cycling, jogging, or walking to stay physically active. If the requirement to complete overhead
motions during daily living becomes apparent, additional taping for partial alleviation of her SAI
may be required. This treatment option comprises of underwrap and in-elastic tape such as leukotape
P, wherein the tape runs from the mid third of the clavicle, over the main belly of the upper trapezius
fibers and down the belly of the lower trapezius fibers. During application, tension is applied
posteriorly and inferiorly while still allowing for shoulder motion (Smith, Sparkes, Busse, & Enright,
2009). This will partially alleviate her pain with SAI pain by increasing the innervation of the
weakened lower trapezius while decreasing innervation of the tight upper trapezius muscle fibers
(Smith et al., 2009). Another viable taping method is to apply rotator cuff support while the tape is
applied laterally on the humerus and pulled medially over the supraspinatus and the deltoids. Strips
are then pulled posteriorly over teres minor and down to the middle trapezius muscle fibers (Goksu,
Tuncay, & Borman, 2016). This taping pattern increases GH stability and specifically correct anterior
translation associated with her weakened lateral rotator cuff muscles; however, neither of these
taping methods are long term solutions  and are necessary only if her daily functioning is
compromised.
   
Since Maria’s poor forward posture at the desk aggravates her SAI, functional adjustments in
the workplace are also recommended. This includes focusing on keeping her back straight and
adjusting her work desk to avoid her slouching forward. These changes require less activation of
medial rotators of the humerus such as her pectoralis major and subscapularis while also maintaining
the length of her humeral lateral rotator muscles, infraspinatus and  teres minor. These rotator cuff
muscles, in addition to the supraspinatus muscle, are thus free to maintain GH stability and properly
center the head of the humerus in the glenoid fossa so as to alleviate her previous issue of anterior
displacement of the humeral head. Another option would be to obtain a standing desk, allowing her
to avoid the urge to slouch and round her shoulders at all. A standing desk also decreases neck
flexion that can tighten the upper trapezius muscle, making it overactive relative to the lower
trapezius muscle and causing an imbalance. Most likely working 40 hours a week, 8 hours a day,
Maria should also allow herself breaks at least every hour to walk around and avoid becoming tense
while sitting or standing at her desk all day.

After completing her rehabilitation, before rock climbing, painting, or completing overhead
activities, Maria should properly stretch her rotator cuff and upward and downward scapular rotator
muscles. For this she should follow the recommendations made in the stretching program, and this
will activate the muscle optimally to reinforce GH stability and allow proper range at the GH and ST
joints. This creates optimal scapulohumeral rhythm and avoids anterior displacement of the humeral
head and SAI in the future. The functional exercises outlined in her strengthening program should
also be continued after her rehabilitation. They should be completed at least 2-5 days per week to
allow maintenance of her functional movements.
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References

Alizadehkhaiyat, O., Roebuck, M.M., Makki, A.T., & Frostick, S.P.  (2018). Subacromial impingement
syndrome: An electromyographic study of shoulder girdle muscle fatigue. Journal of Electromyography
and Kinesiology, 38, 136-142.

Goksu, H., Tuncay, F., & Borman, P. (2016). The comparative efficacy of kinesio taping and local
injection therapy in patients with subacromial impingement syndrome. Acta Orthopaedica et
Traumatologica Turcica, 50(5), 483-488.

Hundza, S. (2019, Fall). EPHE 355 Clinical skills manual. Victoria, British Columbia: University of Victoria.

Sharkey, N.A. & Marder, R.A. (1995). The rotator cuff opposes superior translation of the humeral head.
The American Journal of Sports Medicine, 23(3), 270-275.

Smith, M., Sparkes, V., Busse, M., & Enright, S. (2009). Upper and lower trapezius muscle activity in
subjects with subacromial impingement symptoms: Is there imbalance and can taping change it?.
Physical Therapy in Sport, 10(2), 45-50.

Weon, J. H., Oh, J. S., Cynn, H. S., Kim, Y. W., Kwon, O. Y., & Yi, C. H. (2010). Influence of forward head
posture on scapular upward rotators during isometric shoulder flexion. Journal of Bodywork and movement
therapies, 14(4), 367-374.