This document provides guidelines for rehabilitation of internal impingement in overhead athletes. It describes internal impingement and hyperangulation mechanisms that can cause posterior shoulder pain. The case study examines a volleyball player with internal impingement symptoms including posterior shoulder pain and loss of internal rotation. Treatment focused on stretching to improve range of motion, strengthening the rotator cuff and scapular muscles, and improving scapular control during arm movements. The results showed decreased pain but incomplete return to sport, indicating the need to address other links in the kinetic chain.

1. Internal impingement in the
overhead athlete: GUIDELINES FOR
REHABILITATION
Prof dr Ann Cools, PT, PhD
Dept Rehab. Sciences & Physiotherapy
Ghent University, Belgium

2. Impingement symptoms
External Internal
Subacromial (posterior)
impingement impingement
Primary Secundary
Impingement Impingement
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
Ann Cools Wrightington nov 2012
(Cools et al. BJSM 2008)

3. “HYPER-ANGULATION”
1. Anterior instability
Excessive humeral head
translations
2. Posterior shoulder stiffness
Alterations of glenohumeral
kinematics
3. Scapular dyskinesis:
Insufficient scapular retraction
during cocking
Ann Cools Wrightington nov 2012
(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)

4. Patient presentation
Female volleyball player (attacker)
27 years old
Chronic shoulder pain (6 months)
During serve and smash, pain at
the back of the shoulder
G.I.R.D.
Pain in ABER – positive Relocation
test – positive Release test
Ann Cools Wrightington nov 2012

5. Patient presentation
Anterior tilt scapula during rest
and arm movements
Positive tests scapular
involvement in shoulder pain
(scapular assistance & scapular
retraction test)
Pectoralis minor short & tight
Ann Cools Wrightington nov 2012

6. “HYPER-ANGULATION”
1. Anterior instability
Excessive humeral head
translations
2. Posterior shoulder stiffness
Alterations of glenohumeral
kinematics
3. Scapular dyskinesis:
Insufficient scapular retraction
during cocking
Ann Cools Wrightington nov 2012
(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)

7. Stretching posterior
shoulder: clinical experience
Ann Cools Wrightington nov 2012

8. POSTERIOR SHOULDER
STRETCHING
Sleeper’s stretch & cross body
stretch improve ROM (Mc Clure
2005)
Additional manual mobilisations
improve ROM (Manske 2010,
Cools 2011)
Improvement ROM is related to
reduction of symptoms (Tyler
2010)
Ann Cools Wrightington nov 2012

9. STRETCHING G.I.R.D.:
influence on the subacromial space?
Measurements:
- Acromiohumeral distance (Echoblaster 128; Telemed, Vilnius,
Lithuania)
- Glehonumeral ROM (Acumar inclinometer)
Quantifying acromiohumeral distance in overhead athletes with glenohumeral
internal rotation loss and the Ann Cools Wrightington nov 2012
influence of a stretching program. Maenhout A,
Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)

10. STRETCHING G.I.R.D.:
influence on the subacromial space?
Intervention:
- 6 weeks stretching
- Sleeper’s stretch
Quantifying acromiohumeral distance in overhead athletes with glenohumeral
internal rotation loss and the Ann Cools Wrightington nov 2012
influence of a stretching program. Maenhout A,
Van Eessel V, Vanraes A, Van Dyck L, Cools A. (Accepted AJSM May 2012)

11. STRETCHING G.I.R.D.:
120
influence on the subacromial space?
*
100
Range of motion (°)
80 *
*
D
60
ND
40
*
10
20
9
0 *
8
Internal rotation External rotation *
Horizontal
7 adduction
6
AHD (mm)
5 D
4 ND
3
2
1
0 Quantifying acromiohumeral distance in overhead athletes with glenohumeral
0°
internal rotation loss and60° Ann Cools Wrightington nov 2012
45°
Degree of abduction
the influence of a stretching program. Maenhout A,
Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)

12. STRETCHING G.I.R.D.:
influence on the subacromial space?
Stretching improves ROM , and increases the
subacromial space in overhead athletes with GIRD
Quantifying acromiohumeral distance in overhead athletes with glenohumeral
internal rotation loss and the Ann Cools Wrightington nov 2012
influence of a stretching program. Maenhout A,
Van Eessel V, Vanraes A, Van Dyck L, Cools A. (AJSM May 2012)

13. “HYPER-ANGULATION”
1. Anterior instability
Excessive humeral head
translations
2. Posterior shoulder stiffness
Alterations of glenohumeral
kinematics
3. Scapular dyskinesis:
Insufficient scapular retraction
during cocking
Ann Cools Wrightington nov 2012
(Wilk et al. AJSM 2002, Cools et al. BJSM 2008, Castagna et al. BJSM 2010, Ludewig et al. Man Ther 2011)

14. (Ellenbecker & Cools, BJSM 2010)
Scapular Rehab Algorithm
Lack of Lack of
Soft-tissue flexibility Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae - infraspinatus - co-contraction - lower/middle trap
- pectoralis minor - posterior capsule - force couples - serratus anterior

15. Stretching pectoralis minor: literature
Borstad et al. JOSPT 2005: short PM
influences scapular kinematics and induces
changes similar to impingement related
dyskinesis
Cools & Johansson BJSM 2010: significant
decrease PM length in elite junior (11-17yr)
tennis players
Reeser PM&R 2010: tight PM is associated
with history of shoulder pain in volleyball
players
Borstad et al. JSES 2006: unilateral self
stretch (in 90° ABER) best results,
Ann Cools Wrightington nov 2012
however…

16. Stretching pectoralis
minor: clinical experience
Ann Cools Wrightington nov 2012

17. (Ellenbecker & Cools, BJSM 2010)
Scapular Rehab Algorithm
Lack of Lack of
Soft-tissue flexibility Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae - infraspinatus - co-contraction - lower/middle trap
- pectoralis minor - posterior capsule - force couples - serratus anterior
(SAT+) (SRT+)

18. Ann Cools Wrightington nov 2012

19. Scapular muscle balance during RC
exercises - progression
Ann Cools Wrightington nov 2012

20. Scapular muscle control during basic daily
activities: external rotation component!
Ann Cools Wrightington nov 2012
(Kibler 1998, Vanderhoeven 2006, Kibler 2006, Cools & Walravens 2005, Cools 2008)

21. Results 5 weeks
treatment
Basic clinical exam is (-)
Scapular control increased, however not
sufficient
No pain during (beach) volleyball, however
no full return to sport (season)
Working on other links of the kinetic chain
(very poor pelvic stability, contol during
squat...)
Continue self-stretching
Ann Cools Wrightington nov 2012

22. Thank you
www.eusser.org
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