Shoulder Impingement Rehabilitation Guide

Understanding Shoulder Impingement

Shoulder impingement is like a door that keeps scraping against its frame every time you open it. The rotator cuff tendons pass through a narrow space (the subacromial space) between the top of your upper arm bone and the roof of your shoulder (acromion). When you lift your arm, especially overhead, this space narrows. If the tendons are irritated or inflamed, they get pinched—impinged—between these bony structures.

Think of your shoulder as a railroad tunnel. The rotator cuff tendons are trains passing through. When the tunnel is wide enough, trains pass freely. But when inflammation narrows the tunnel, trains scrape against the roof. Every overhead movement causes pinching, friction, and pain. This cycle of inflammation and pinching perpetuates itself—the more it pinches, the more inflamed it becomes; the more inflamed it becomes, the more it pinches.

What makes impingement unique is that it's typically a condition, not a specific injury. It develops gradually from repetitive overhead activities, poor posture, muscle imbalances, or anatomical factors. The good news: most cases resolve without surgery. Physical therapy that restores normal shoulder mechanics, strengthens rotator cuff and scapular muscles, and breaks the pain-inflammation cycle is highly effective.

The Impingement Cycle

Understanding why impingement happens is key to fixing it:

Causes and Contributing Factors

Recovery Timeline Overview

Impingement rehabilitation follows a phased approach addressing pain, mobility, strength, and function:

Phase 1: Pain Relief and Protection (Weeks 0-2)

The immediate goals: reduce pain and inflammation, protect irritated tissues, begin gentle motion.

Daily Management Strategies

Phase 1 Exercises

Pendulum Exercises:

• Lean forward, let affected arm hang relaxed
• Use body movement to gently swing arm
• Small circles, forward-back, side-to-side
• NO muscle activation
• 2-3 minutes, 2-3 times daily

Scapular Retraction:

• Stand or sit with good posture
• Squeeze shoulder blades together and down
• Hold 5 seconds, relax
• 10-15 reps, 3 times daily
• Opens subacromial space

Pectoral Stretch (doorway):

• Stand in doorway, elbows at 90° on doorframe
• Lean forward until stretch felt in chest
• Hold 30 seconds, relax
• 3 reps, 2 times daily

Posterior Capsule Stretch (sleeper stretch):

• Lie on affected side
• Affected arm at 90° abduction, elbow bent 90°
• Use other arm to gently push forearm toward floor
• Feel stretch in back of shoulder
• Hold 30 seconds, relax
• 3 reps, 2 times daily

Phase 2: Mobility Restoration (Weeks 2-4)

Once pain is controlled, focus shifts to restoring full range of motion and normalizing shoulder mechanics.

Key Mobility Exercises

Active-Assisted Forward Elevation:

• Lie on back (gravity eliminated)
• Hold stick with both hands, hands shoulder-width apart
• Use non-painful arm to lift painful arm overhead
• Keep affected arm relaxed
• Progress toward full overhead reach
• 2 sets of 10-15 reps, 2 times daily

Active-Assisted External Rotation:

• Stand, hold stick behind back with both hands
• Use non-painful hand to push painful hand away from back
• Stretches internal rotation
• Hold 30 seconds, relax
• 3 reps, 2 times daily

Wall Slides:

• Stand facing wall, forearms on wall at shoulder height
• Slide forearms up wall, reaching overhead
• Keep shoulder blades squeezed together
• Go as high as comfortable
• 2 sets of 10 reps, 2 times daily

Cross-Arm Stretch:

• Stand, pull affected arm across body with other arm
• Feel stretch in back of shoulder
• Hold 30 seconds, relax
• 3 reps, 2 times daily

Phase 3: Strengthening (Weeks 4-8)

Restoring strength is the key to preventing recurrence. Strengthen rotator cuff, scapular stabilizers, and address imbalances.

Phase 3 Strengthening Exercises

External Rotation with Band:

• Stand, anchor band at elbow height
• Hold band with affected arm, elbow at 90° at side
• Rotate forearm away from body
• Keep elbow tucked at side
• 2 sets of 15 reps, 2 times daily

Scaption (empty can):

• Stand with light dumbbells (1-3 lb)
• Raise arms in scapular plane (30° forward of side)
• Raise to 90° with thumbs pointed up (empty can position)
• Lower slowly
• 2 sets of 12-15 reps, 3 times weekly

Prone Horizontal Abduction:

• Lie on stomach, arm hanging off edge
• Lift arm out to side (horizontal abduction)
• Keep thumb pointed up (full can position)
• 2 sets of 12-15 reps, 3 times weekly

Rows:

• Hold resistance band with both hands, elbows straight
• Squeeze shoulder blades together, pulling elbows back
• Keep shoulders down (don't shrug)
• 2 sets of 15 reps, 3 times weekly

Side-Lying External Rotation:

• Lie on non-affected side, affected arm on top
• Roll towel under affected arm for proper positioning
• Hold light dumbbell (1-3 lb)
• Rotate forearm upward, keeping elbow at side
• 2 sets of 15 reps, 3 times weekly

Phase 4: Functional Return (Weeks 8-12)

Progressive loading and return to activities.

Functional Progression

Week 8-10: Intermediate strengthening

• Increase resistance band weight
• Progress dumbbell weight to 5-8 lb max for rotator cuff exercises
• Add diagonal patterns (D1/D2 flexion and extension patterns)
• Continue all previous exercises

Week 10-12: Activity-specific training

• Sport-specific movements for athletes
• Gradual return to previously avoided activities
• Continue strengthening as maintenance program

Return to activity criteria:

• Full pain-free range of motion
• Normal strength compared to other side
• No pain with daily activities
• No night pain
• Successful completion of activity-specific tasks

Warning Signs: When to Seek Help

Long-Term Prevention and Maintenance

Impingement often recurs if underlying causes aren't addressed.

Permanent Activity Modifications

Some activities may always need modification:

Avoid or limit:

• Heavy overhead lifting (＞10-15 lbs)
• Prolonged overhead work (painting ceilings, construction)
• Behind-the-back lifting
• Activities that cause pain (listen to your body)

Alternative approaches:

• Use step stool instead of reaching overhead
• Slide objects instead of lifting
• Take frequent breaks during repetitive activities
• Use proper mechanics for all activities

Maintenance Program (Lifelong)

Daily:

• Posture awareness and correction
• Pectoral stretch if tight
• Shoulder blade squeezes

2-3 times weekly:

• External rotation strengthening
• Scapular retraction rows
• Scaption or prone exercises

As needed:

• Ice after provocative activities
• Stretching after activities
• Rest periods during heavy use

When Surgery Might Be Considered

Most impingement resolves without surgery, but some cases need further intervention.

Surgery may be considered if:

• Significant improvement after 3-6 months of proper treatment
• Structural causes (bone spur, hooked acromion) confirmed on imaging
• Full-thickness rotator cuff tear present
• Significant weakness or loss of function

Surgical options:

• Subacromial decompression: Remove bone spur and create more space for tendons
• Acromioplasty: Reshape acromion to reduce impingement
• Rotator cuff repair: If tear present
• Biceps tenodesis: If biceps tendon involved

Common Questions

References