Rehabilitacion De Sindrome Del Hombro Doloroso

S houlder injuries in athletes

Rehabilitation of shoulder impingement syndrome and
rotator cuff injuries: an evidence-based review
Todd S Ellenbecker1, Ann Cools2
1Physiotherapy

Associates
Scottsdale Sports Clinic,
Scottsdale, Arizona, USA
2Department of Rehabilitation
Sciences and Physiotherapy,
Ghent University, Ghent,
Belgium
Correspondence to
Todd S Ellenbecker,Physiotherapy Associates
Scottsdale Sports Clinic, 9917
N 95th Street, Scottsdale, AZ
85258, USA ; ellenbeckerpt@
cox.net
Accepted 6 January 2010

ABSTRACT
Rehabilitation of the patient with glenohumeral
impingement requires a complete understanding of
the structures involved and the underlying mechanism
creating the impingement response. A detailed clinical
examination and comprehensive treatmentprogramme
including specific interventions to address pain,
scapular dysfunction and rotator cuff weakness are
recommended. The inclusion of objective testing to
quantify range of motion and both muscular strength
and balance in addition to the manual orthopaedic
clinical tests allows clinicians to design evidencebased rehabilitation programmes as well as measure
progression and patientimprovement.
Rehabilitation of the athlete with shoulder
impingement is a complex process that requires
a comprehensive evaluation and multifactorial
treatment programme. The purpose of this article
is to present an evidence-based review of the key
treatment strategies to rehabilitate and restore
shoulder function of the athlete with rotator cuff
impingement.

TYPES OF SHOULDER IMPINGEMENTSignificant advancement in the basic science
research in the areas of anatomy and biomechanics of the human shoulder has led to the identification of multiple types of impingement, as well
as other causes of rotator cuff pathology, including instability and intrinsic tendon overload.
This greater understanding of the cause or causes
of impingement can lead to a more specific and
non-generalisedtreatment approach to treat this
disorder.

Primary impingement
Primary compressive disease or impingement is a
direct result of compression of the rotator cuff tendons between the humeral head and the overlying anterior third of the acromion, coracoacromial
ligament, coracoid or acromial clavicular joint.1 2
T he physiological space between the inferior
acromion and the superior surfaceof the rotator
cuff tendons has been measured using anteroposterior radiographs and found to be 7–13 mm
in patients with shoulder pain 3 a nd 6–14 mm in
normal shoulders.4
Neer1 2 has outlined three stages of primary
impingement as it relates to rotator cuff pathology. These have been extensively reported and
referred to in both the surgical and rehabilitative
literature, and give theclinician a progressive
understanding of the role compressive disease
plays in mechanical loading of the rotator cuff.
Br J Sports Med 2010;44:319–327. doi:10.1136/bjsm.2009.058875

For the sake of space limitations, additional discussion of these three stages will not be undertaken, however, the reader is referred elsewhere
for a complete discussion of these stages.1 2

Secondary impingementIn addition to impingement playing a primary
role, impingement or compressive symptoms
may be secondary to underlying instability of the
glenohumeral joint. 5–7 Attenuation of the static
stabilisers of the glenohumeral joint, such as the
capsular ligaments and labrum, from the excessive demands incurred in throwing or overhead
activities can lead to anterior instability of the
glenohumeraljoint. Due to the increased humeral
head translation, the biceps tendon and rotator cuff can become impinged secondary to the
ensuing instability. 5 A lso, a progressive loss of
glenohumeral joint stability may be created when
the dynamic stabilising functions of the rotator
cuff are diminished from fatigue, intrinsic overload and subsequent tendon injury. 5 I n addition,
rotator cuff...