What is the recommended exercise prescription for shoulder impingement syndrome?

Exercise Prescription for Shoulder Impingement Syndrome

Supervised progressive strengthening and stretching exercises are the evidence-based first-line treatment for shoulder impingement syndrome, with manual physical therapy providing additional benefit when combined with exercise. 1, 2

Core Exercise Program Components

Strengthening Exercises

• Focus on rotator cuff and posterior shoulder girdle strengthening while addressing anterior shoulder girdle flexibility 3
• Begin with low resistance (40-60% of 1-repetition maximum) and higher repetitions (10-15 reps) to avoid excessive strain 3
• Perform 1 set of 8-12 repetitions for each exercise, 2-3 days per week on non-consecutive days 3
• Target major muscle groups: rotator cuff (internal/external rotation), scapular stabilizers, and deltoid 4, 2
• Progress resistance gradually based on pain tolerance, starting with as few as 2-3 repetitions if needed 3

Range of Motion and Flexibility

• Exercise the affected shoulder through pain-free range of motion only 3
• Emphasize external rotation and abduction movements to prevent secondary complications 5
• Perform stretching exercises 2-3 days per week, holding each stretch for 15-30 seconds, with 2-4 repetitions per stretch 3
• Apply local heat before exercise to improve tissue elasticity and reduce pain 6, 5

Scapular Exercises

• Assess and address scapular dyskinesia or winging, which is critical in impingement syndrome 3
• Include exercises targeting neck and scapular stabilizers to improve scapulohumeral rhythm 3, 7

Exercise Execution Guidelines

Technique and Safety

• Perform exercises in a rhythmical manner at moderate to slow controlled speed through full range of motion 3
• Exhale during the contraction/exertion phase and inhale during relaxation to prevent Valsalva maneuver 3
• Alternate between upper and lower body exercises to allow adequate rest 3
• Use pain threshold as intensity guide—discontinue if pain lasts more than one hour after exercise 3

Critical Contraindications

• Avoid vigorous, repetitive exercises and explosive movements that stress the impinged structures 3
• Never perform overhead pulley exercises, as these encourage uncontrolled abduction and have the highest incidence of developing shoulder pain 5
• Avoid exercising during acute flare-ups with significant inflammation 3

Supervision and Progression

Initial Phase (Weeks 1-6)

• Attend one supervised physical therapy session per week for monitoring and program advancement 4
• Perform daily home exercises including resistive strengthening, stretching, and postural exercises 4
• Supervised strengthening leads to greater short-term improvement in pain and disability compared to wait-listing or no treatment 1

Long-term Management

• Supervised and home-based strengthening leads to similar outcomes as surgery for persistent impingement syndrome 1
• Improvements in pain, satisfaction, and function are maintained at 6-month follow-up 4
• Continue exercises indefinitely as maintenance, as approximately 49% of patients never receive proper exercise instruction before considering surgery 8

Adjunctive Manual Therapy

Manual physical therapy combined with exercise is superior to exercise alone for increasing strength, decreasing pain, and improving function 2. When available, manual therapy applied by experienced therapists should be incorporated, particularly during the initial 3-week intensive phase (6 sessions) 2.

Patient Education Components

Provide education on:

• Shoulder anatomy and basic mechanics of impingement 4
• Strategies for reducing load on the shoulder during daily activities 4
• Early recognition of symptom exacerbation (unusual fatigue, increased weakness, decreased range of motion) 3
• Proper positioning and protection from trauma during activities 5

Common Pitfalls to Avoid

• Do not prescribe passive range-of-motion exercises performed aggressively or improperly, as these can cause more harm than benefit 5
• Avoid being overly restrictive with exercise prescription—a cautious but progressive approach is essential 3
• Heavy load eccentric training does not add benefits to standard rotator cuff strengthening and should not be prioritized 1
• Do not rely solely on modalities (ultrasound, electrical stimulation) without the core strengthening and stretching program 6, 5