Primary objectives that I attempt to achieve with rehab of the shoulder include: dynamic stability of scapula, adequate tissue mobility both at anterior chest wall and posterior capsule if needed, adequate compressive forces, and proprioception. Regional interdependence is a concept I consider in evaluation and treatment of SIS. Therefore, I utilize manipulation of the thoracic spine (TSM) if indicated. Mintken et. al., confirmed that TSM can drive successful outcomes. If three out of the following 5 variables are found in treatment, patient has a 90% post manipulation success rate in patients with shoulder pain: Pain free shoulder flexion <127 degrees, shoulder IR <53 degrees at 90 degrees of abduction, negative Neer Test, not taking medications for shoulder pain and symptoms less than 90 days.8 More information to come on if this is validated as this study is currently in trial. Regardless of validation – it makes sense to incorporate thoracic mobility in treatment of SIS as thoracic spine translates into extension with reaching tasks – and this is a common complaint with SIS patients.
Other manual techniques I utilize in clinic are based at glenohumeral mobility and/or scapular mobility along with any soft tissue required to achieve motor plan recommended. Until recently, I speculated use of manual techniques to improve comfort with motion, to put tactile input positively into the central nervous system, and lastly to loosen up possible restrictions. Test-re-test protocol is utilized after each technique (if irritability is low) so I can match a take home exercise to maintain mobility. Interestingly enough, Bang et. al, released an RCT in 2000, where patients had manual therapy (MT) and exercise or just exercise alone.9 In this study, over three weeks – only patients with manual therapy had strength gains while patients with exercise alone saw improvement in other areas, but not strength. 9 Possibly, manual techniques make strengthening more comfortable or there is a nueromuscular effect – I am unsure. Regardless, I use it.
Strengthening and exercise routines are ever-evolving in the world of research. It seems to pendulum from specific localized treatment at the GH joint, to global targeting at core and dynamic movements. Once static strength/stability/proprioception has improved, a therapist should then think dynamically and think globally. Clinical pearls are to reference Ludewig et. al and their examination at scapular kinematics in asymptomatic vs. symptomatic individuals. Interesting point from this article was: scapular upward rotation is greater in SIS but less in adhesive capsulitis. Seems intuitive to how we think of scapular stability – but always nice to have supportive literature. Dr. Reineld also has some excellent literature on EMG studies with exercises to reference what muscle you are trying to improve in clinic and how to match this with best available exercise.3,4,5 Also for good reference, he has an excellent blog where he commonly talks shoulder pathology and exercises (http://www.mikereinold.com/). This has been quite useful for me in clinic, as I commonly focus efforts on manual techniques and literature surrounding this area. I need to force myself to stay up to date on exercise intervention – thankfully the blogging world helps make this quick and easy. Last take home point for me was the debate of resistance bands vs. dumbbell strength – an article by Anderson et al, found no meaningful change in EMG output between two modes of strength.7 Thus, inferring not to focus strength training on mode between bands and dumbbells but more focused on patient impairments and outcomes you are trying to achieve.
Overall, we know literature supports conservative management of SIS both manually and with exercises. I won’t touch on modalities as I find them a waste of clinic time and can’t find an article within the shoulder that shows clinically meaningful change compared to alternative treatments. Therefore, use them or don’t, turn them on or not – kidding – kind of- we all have varied opinions on their worth in clinic. Although the shoulder has its idiosyncrasies, follow what you see in each patient both manually and with exercise and you should see the outcomes you want to obtain and if you don’t – re-evaluate.
Original post: September 16, 2013
1) Kuhn, J. E., Dunn, W. R., Sanders, R., An, Q., Baumgarten, K. M., Bishop, J. Y., … Wright, R. W. (2013). Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons … [et al.], (07), 1–9. doi:10.1016/
2) Ludewig PM, Reynolds J. The Association of Scapular Kinematics and Glenohumeral Joint Pathologies. Journal of Sports and Orthopedic Physical Therapy. 2009; 39: 90-104.
3) Reinold, M. M., Wilk, K. E., Fleisig, G. S., Zheng, N., Barrentine, S. W., Cody, R. C., … Email, P. F. (2003). Electromyographic Analysis of the Rotator Cuff and Deltoid Musculature During, 385–394.
4) Reinold M.M, Macrina LC, Andrews JR. Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. Journal of Athletic Training. 2007; 42: 464-469.
5) Dark A, Ginn K, Halaki M. Shoulder Muscle Recruitment Patterns During Commonly Used Rotator Cuff Exercises: An Electromyographic Study. Journal of Physical Therapy. 2007; 97: 1039-1046.
6) Anderson L, Anderson CH, Mortensen OS, Poulsen OM. Muscle Activation and Perceived Loading During Rehabilitation Exercises: Comparison of Dumbbells and Elastic Resistance. Physical Therapy. 2010. 90: 538-549.
7) Paul Mintken. (2013, September). Exercise For Selected Shoulder Disorders. Lecture conducted through EIM.
8) Mintken, P. E., Cleland, J. A., Carpenter, K. J., Bieniek, M. L., Keirns, M., & Whitman, J. M. (2010). Cervicothoracic Manipulation :, 90(1).
9) Bang, Deyle, G. D. (2000). Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement Syndrome, 30(3), 126–137.