What is the treatment for secondary impingement in a high school basketball player?

Treatment of Secondary Impingement in a High School Basketball Player

Complete rest from basketball until asymptomatic, followed by a structured rehabilitation program focused on rotator cuff and scapular stabilizer strengthening, is the definitive treatment for secondary impingement in adolescent athletes. 1, 2

Immediate Management: Complete Activity Restriction

• Mandatory cessation of all basketball activities until the athlete achieves pain-free shoulder motion at rest and during daily activities 1, 3
• This rest period typically lasts a minimum of 6 weeks, though duration depends on symptom severity 3
• No overhead activities, shooting practice, or weight training involving the affected shoulder during this phase 1

Rehabilitation Protocol: Structured 3-Phase Approach

Phase 1: Pain Control and Range of Motion (Weeks 1-3)

• Focus on reducing inflammation and restoring full passive and active range of motion 1
• Gentle stretching exercises for posterior capsule tightness, which contributes to impingement mechanics 4
• Pain-free motion must be achieved before progressing to strengthening 1

Phase 2: Strengthening Program (Weeks 4-12)

The rehabilitation program must target two critical muscle groups:

• Rotator cuff strengthening with emphasis on external rotators and supraspinatus, which are weakened by repetitive eccentric stress in overhead athletes 1, 2
• Scapular stabilizer strengthening to correct dyskinesis—the poor coordination of scapular upward rotation and posterior tilting during arm elevation that directly contributes to impingement 1, 2, 4

The underlying pathophysiology in adolescent athletes is rotator cuff weakness combined with ligamentous laxity, causing the humeral head to fail to maintain proper centering in the glenoid fossa during overhead movements 1, 2. This differs fundamentally from primary impingement in adults, which involves structural anatomic abnormalities 2.

Phase 3: Return to Sport (Weeks 8-16)

• Initiate a progressive throwing/shooting program only after achieving pain-free motion and strength 1
• The athlete must demonstrate external rotation strength equal to at least 90% of the contralateral side before returning to basketball 3
• Re-establish proper shooting mechanics with emphasis on shoulder and spine positioning 1
• Duration of this phase ranges from 1-3 months depending on injury severity 1

Critical Biomechanical Corrections

Address the muscular imbalance pattern characteristic of basketball players:

• Weakened posterior shoulder musculature (external rotators, posterior deltoid) combined with overdeveloped anterior musculature creates pathologic deceleration mechanics 1, 2
• This imbalance leads to repetitive eccentric stress on the supraspinatus, external rotators, and scapular stabilizers during the shooting motion 1

Monitoring for Treatment Failure

Surgical consultation is warranted if:

• Symptoms persist or progress despite 3-6 months of appropriate rehabilitation 3
• The athlete develops progressive weakness, decreased shooting velocity, or night pain suggesting progression to rotator cuff tear 1, 5
• MRI demonstrates undersurface (articular-side) rotator cuff tears, which are more common than full-thickness tears in adolescent athletes and result from atraumatic microinstability 2

Common Pitfalls to Avoid

• Premature return to basketball before achieving pain-free motion and adequate strength leads to recurrent symptoms and potential progression to rotator cuff tears with permanent changes including muscle atrophy and fatty infiltration over 5-10 years 2, 3
• Focusing solely on rotator cuff strengthening while neglecting scapular stabilizers fails to address the scapular dyskinesis that is a primary contributor to secondary impingement 1, 2, 4
• Ignoring the anatomic vulnerabilities of adolescents—the proximal humeral physis remains open until age 17-18 years and is weaker than surrounding structures, making it susceptible to injury from premature loading 2

Prevention of Recurrence

• Limit weekly training time to less than 16 hours per week, as exceeding this threshold correlates with increased injury risk in 14-18 year old athletes 2
• Ensure at least one complete rest day per week for physical recovery 1
• Implement neuromuscular training programs, including modified FIFA 11+ protocols, which have demonstrated effectiveness in reducing lower extremity injuries and show promise for upper extremity injury prevention in basketball players 1