Shoulder pain is a common presenting complaint for patients of all ages and activity levels. Unfortunately, for those who are more active, particularly in overhead sports and regular weight-lifting, the dreaded presentation of shoulder impingement is even more common. As you will come to learn, the shoulder is a complex joint - involving multiple articulations - and as such rehabilitating shoulder injuries (shoulder impingement included) can be a very tricky undertaking! Therefore, this article will discuss what shoulder impingement actually is, how it develops, and of course what rehabilitation and foam roller exercises you can do to help!
So, What Is Shoulder Impingement?
Shoulder impingement, sometimes referred to as sub-acromial impingement syndrome, is a blanket term that includes a wide range of subacromial space pathologies including:
- Partial Thickness Rotator Cuff Tears
- Rotator Cuff Tendinosis
- Biceps Tendinopathy
- Calcific Tendinitis
- Subacromial Bursitis (Koester et al., 2005)
Whilst the diagnosis of "shoulder impingement" may encompass a number of specific pathologies, the overall problem is the same... a combination of factors (discussed below) leads to excessive superior (upwards) movement of the head of the humerus and this pinches (impinges) components of the rotator cuff (and overlying bursa) against the undersurface of the acromion or coraco-acromial arch.
Repeated episodes of impingement of the soft tissues causes pain, inflammation and eventually damage to the bursa and rotator cuff tendons. If left untreated, there is potential for early impingement signs to progress to partial and even full thickness rotator cuff tears. Below we discuss the most common anatomical and biomechanical contributors to shoulder impingement. Quick Video Explanation - What Is Impingement?
Anatomical and Biomechanical Contributions to Shoulder Impingement
Scientific research has identified a number of biomechanical and anatomical faults which is associated with subacromial impingement syndrome. These include:
Reduced ROM and Muscle Tightness
There are 2 main tightnesses seen in the pathophysiology of shoulder impingement. These are:
- Posterior Shoulder Tightness and Loss of Internal Rotation: It has been suggested that lack of posterior flexibility relates to anterior scapular tilt (think rounded shoulders) and a process called the "Diablo Effect", check out how it relates to shoulder impingement here (Borstad, 2006).
- Pectoral Minor Tightness: Tightness of the pectoralis minor result in anterior pelvic tilting of the scapula, also known as Type 1 Scapular Dyskinesis which is discussed below (Borstad & Ludewig, 2005).
Both of these flexibility deficits have been associated with shoulder impingement presentations.
Rotator Cuff Weakness (Or Imbalance)
Many research articles have displayed the associated between rotator cuff weakness or imbalances and shoulder impingement. Reddy et al (2000) displayed significant decreases in supraspinatus and infraspinatus activity in those with shoulder impingement. This means a weakness in the external rotators of the shoulder
, when compared to the internal rotators.
Scapular Dyskinesis (or Poor Motion of the Scapula)
There are 3 main types of scapular dyskinesis and the issue can become quite complex, so for more information see this great post on assessing scapular dyskinesis
. However, scapular dyskinesis is generally characterised by a lack of upward rotation, a lack of posterior tilting and increased internal or medial rotation of the scapula. This has been shown to result from altered/reduced activation and weakness in the serratus anterior and lower to middle fibres of trapezius and increased activity in the upper trapezius (Ludewig & Cook, 2000). Often, this will result in a rounded or tilted shoulder posture, which is likely to increase shoulder impingement.
Poor posture is also associated with shoulder impingement. This includes:
- Rounded Shoulders
- Increased Thoracic Kyphosis
- Forward Head Posture
For a previous post on improving thoracic spine pain and posture, check this out
. So, you may ask - what can I do for my shoulder impingement?
Foam Roller Exercises for Shoulder Impingement
There are many options available to assist with your rehabilitation from this complex pathology. The best foam roller exercises are those aimed at the following areas:
- Anterior chest: specifically pectoralis minor and major
- Posterior shoulder capsule
- Posterior rotator cuff muscles - specifically infrapinatus and teres minor
- Improving thoracic spinal extension
The techniques are shown in the videos below: Chest - Pec Minor and Major Posterior Shoulder Capsule and Rotator Cuff Improving Thoracic Spine Extension
What Size Foam Roller Will Be Most Useful?
Given that you are going to cover a medium sized area i.e. the chest and shoulder muscle, the best foam rollers for this condition would be:
Should I Do Anything Else For Shoulder Impingement?
Absolutely!! Unfortunately, using the foam roller is only one component of the successful rehabilitation of the very complex shoulder impingement syndromes. This condition is multifactorial and requires a comprehensive rehabilitation program to resolve (Ellenbecker & Cools, 2010). To fully resolve this complex problem you should also undertake:
- Regular stretching – anterior chest and posterior shoulder (including the 'Sleeper Stretch')
- Rotator cuff and scapular muscle strengthening
- Postural awareness and correction exercises
- Load management - if your shoulder is painful - you must ensure that you get adequate rest and recovery time by avoiding aggravating activities and positions!
- Be guided by your physiotherapist – who can take you through all of this including a full rehabilitation program
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Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther 2005;35:227–38. Borstad JD. Resting position variables at the shoulder: evidence to support a posture-impairment association. Phys Ther 2006;86:549–57. Shoulder Elbow Surg 2008;17:893–7. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med 2010;44:319–327. Koester MC, George MS, Kuhn JE .Shoulder impingement syndrome. The American Journal of Medicine (2005) 118, 452–455 Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther2000;80:276–91 Reddy AS, Mohr KJ, Pink MM, et al. Electromyographic analysis of the deltoid and rotator cuff muscles in persons with subacromial impingement. J Shoulder Elbow Surg 2000;9:519–23. Photo Credit: WikiCommons