How to Better Treat “Shoulder Impingement” with Jo Gibson

Subacromial shoulder pain drives many people to seek physiotherapy treatment. However, conflicting narratives about the causes of shoulder pain and poor exercise adherence can make its management challenging. So we sat down with shoulder rehab expert Jo Gibson.

Jo Gibson is a physiotherapist at the Royal Liverpool Hospital, UK and a renowned international lecturer on shoulder rehab. These insights are from her appearance on our podcast Physio Explained (Episode 16), where you can learn from the best in 20 minutes or less. This conversation touches three parts of shoulder rehab: how we talk about shoulder pain, assessment and treatment.

An update to how we talk about shoulder pain

Like other pain syndromes, the early model of subacromial “impingement” was based on a biomechanical model. The theory was that soft tissue compression in the subacromial space (e.g. rotator cuff, bursa, etc.) led to shoulder pain. However, recent research questions this theory and imaging findings don’t correlate precisely with symptoms (1, 2). Also, there are psychosocial factors related to the onset and persistence of shoulder pain, so we may be led astray by only focusing on biomechanical factors (3).

So should we abandon the term “impingement” completely? Unfortunately, it’s not that simple. The reality is that many patients and clinicians still use this verbiage. Jo Gibson acknowledges that we may have to use this term when talking to other clinicians and sometimes, even with patients. For patients, we must uncover how their understanding of this diagnostic label affects their openness to physiotherapy treatment.

Some patients may simply hear this term and be ready to go with rehabilitation. However, others may believe that physiotherapy can’t do anything to prevent compression of tissue in the subacromial space. For such patients, rather than debate the narrative head on, Jo Gibson recommends using your assessment to show a patient how to change their pain. This “show-then tell” approach builds trust, strengthens your therapeutic alliance and improves exercise adherence.

How to assess shoulder pain

Traditionally, physiotherapy assessment of the shoulder included a variety of special tests to identify the culprit soft tissue. But with shoulder pain, we already know that the patient hurts and these tests are likely to be provocative. Also, these tests don’t reliably tell us what structures are involved in subacromial pain (1).

Instead, Jo Gibson suggests assessing:

• Shoulder range of motion
• Instability
• Contributions from the cervical spine to shoulder pain
• Thoracic spine mobility
• Isolated rotator cuff muscle performance

Finally, Jo Gibson recommends symptom modification procedures (such as changing scapular position, muscle activation patterns, etc.). We simply try a procedure, retest a movement, and ask “How does that feel?”. Then the relieving procedures help guide our treatment.

How to improve adherence to shoulder exercise programs

Using exercises rooted in symptom modification procedures improves adherence because the patient feels how we improved an activity they care about. For example, I worked with a woman with persistent subacromial pain when reaching overhead in an exercise class. During the assessment, I manually rotated her scapula upward which allowed her to reach higher with less pain. We then tried a wall slide into flexion while pulling a resistance band apart. She reported that this exercise replicated the experience of my manual assistance for scapular upward rotation.

There are biomechanical theories as to why this worked. Regardless of the mechanisms, what matters is that this patient felt we improved a movement that mattered to her. Of course, we may need a couple exercises to target the rotator cuff that don’t exactly match a meaningful movement. However, we must ensure that the patient understands how the whole program helps them return to what matters to them. A secondary benefit of such exercises is that patients better stick to non-painful exercise programs.

Another key to exercise program adherence is limiting the number of exercises. For the general population, 1-3 well-chosen exercises is likely sufficient, otherwise adherence falls off (4). Jo Gibson adds the caveat that athletic populations usually need a more comprehensive program.

Wrapping up

Subacromial pain is a common condition we see in the clinic and we can empower these patients through exercise. The key points from this podcast are:

• We may have to use the term “subacromial impingement” to communicate with clinicians and patients
• We need to dig into a patient’s understanding of what this diagnostic label means. If their understanding might impact our physiotherapy treatment, we can do a “show-then tell” approach
• Keep assessments concise and avoid unnecessary special testing
• Use symptom modification procedures for assessment and treatment to make exercises meaningful
• Choose 1-3 exercises for general population patients

For more on shoulder pain assessment and treatment, check out this podcast episode with Jo Gibson here.