Nonoperative Rehabilitation Protocol for Subacromial Impingement
Phase I (< 1 week)
- Patient education: To avoid activities involving symptomatic shoulder elevation into impingement zone (≅70°-140° flexion/abduction)
- Oral NSAIDs and/or topical NSAIDs/analgesics
- Range of motion
- PROM, A/AROM in painfree range
- Pulleys (only above shoulder height if minimal to no pain), Codman’s pendulum and cane exercises
- Strengthening
- Prone scapular stabilization exercises
- Resisted elbow and wrist strengthening exercises
- Manual therapy:
- Soft tissue therapy to subscapularis, pectoralis minor and rotator cuff insertion
- Modalities: as needed for pain (i.e. kinesio tape, electrotherapeutic, acupuncture etc.)
Phase II (weeks 1 to 4)
- Patient education: To avoid activities involving symptomatic shoulder elevation into impingement zone (≅70°-140° flexion/abduction)
- Oral NSAIDs and/or topical NSAIDs/analgesics
- Range of motion
- Pain-free/minimal pain progression with active-assisted and active ROM to functional limits (i.e. dowel, PNF D1/D2 exercises)
- Soft tissue manual therapy to pectoralis muscles and posterior capsule tightness
- Active stretching for the pectoralis muscles and posterior capsule
- Strengthening
- Rotator cuff isometrics
- Can progress to light free weight / theraband exercises below impingement zone or pain free range
- Prone scapular stabilization exercises
- Manual therapy:
- Soft tissue therapy (subscapularis, pectoralis)
- Joint mobilizations
- Modalities: as needed for pain (i.e. kinesio tape, electrotherapeutic, acupuncture etc.)
Phase III (weeks 4 to 10-12)
- Strengthening
- Progressive rotator cuff and periscapular strengthening exercises
- Closed-chain rotator cuff and periscapular strengthening exercises
- Proprioception-based exercises, as tolerated
- Modalities: as needed for pain (i.e. kinesio tape, electrotherapeutic, acupuncture etc.)
- Home self-stretching program
- >6-8 weeks with moderate to severe pain with minimal improvement may warrant referral to shoulder specialist (orthopaedic surgeon, sports medicine physician, advanced practice provider)
Phase IV (weeks 12+)
- Patient that is improving in function with minimal to no pain:
- Home exercise and self-stretching program
- Advanced/sports/work-specific strengthening exercises
- Patient that is not improving with significant dysfunction and moderate to severe pain may warrant referral to shoulder specialist (orthopaedic surgeon, sports medicine physician, advanced practice provider)