Google+LinkedInTwitterFacebook

Freeing the Neck and Shoulders

Somatics Workshop at Mulberry House, Edinburgh

Jahna Clark is holding a Somatics Workshop for anyone with a stiff neck and shoulders. That’s most of us, right? Especially those of us who sit at a desk all day. Having tried Jahna’s class, and having had experience with a similar approach in the past, I’d thoroughly recommend it. It may even help with headaches related to tension in the neck and shoulders.

What is Somatics?

Somatics exercises are very gentle, so suitable for almost everyone, but also very powerful. They work to change muscular restrictions and tension by retraining movement patterns. With habitual postures, we can all get “stuck” sometimes. With Somatics, you can learn to release unhelpful tension in muscles that may be contributing to stiffness, pain and tension headaches. You already have the most powerful tool for releasing these tensions – movement! But sometimes you need a little help when you’re stuck in an unhelpful pattern. Somatics can provide that help.

10th October 2015
2.00-4.00pm

Mulberry House
21 Manor Place
Edinburgh • EH3 7DX

Cost
£25

To book, contact Jahna.

Eight Week Somatic Movement Course

Jahna has more courses and workshops, including an eight week course at Mulberry House.

“Somatic Exercises is a gentle neuromuscular approach that effectively retrains your brain to release chronic muscle tension – one of the most common causes of muscle stiffness and pain. In this course you will learn a basic routine of safe, simple yet profoundly effective movements that when practised daily will help you move freely without pain.”

These exercises are very gentle, so suitable for older people and those with arthritis, or with chronic pain. At the same time, they’re profoundly effective, and people of all ages could benefit. My first introduction to a similar approach was while training four or five times a week in a martial art. Within a short time, getting thrown around by 4th and 6th Dan black belts felt a lot less challenging, as my body became more responsive, better coordinated and freer in its movement. So, even sports people could benefit.

For more information, follow the link: Sensing Within Workshops

Osteopathy for Sport

Good to see some osteopathic technique being used at Wimbledon! This kind of manipulation could help with your golf swing or bowling in cricket, not just your tennis shots.

The shoulder is fine, says contented Murray (The Scotsman)

Shoulder Injuries in Archery

Osteopathy for Archery InjuriesRecently, I’ve been treating a competitive archer with a shoulder injury. It’s always interesting to come across a patient with a problem related to a specific activity I can find out more about, so I’ve been doing some investigation, which I thought I’d share.

On a quick look at some research, it looks like shoulder injuries pretty much go with the territory, particularly for female archers. In one study, around 60% of competitive female archers suffered some kind of shoulder injury over a ten year career, and around 25% of men.

Most of these are rotator cuff injuries – tendonitis, which can lead to degeneration and tears. These small ‘rotator cuff’ muscles can easily become overstrained by repetitive actions if the position of the shoulder girdle isn’t optimal, particularly if the shoulder blade ‘protracts’, or rolls out and forward around the ribcage. If there’s a noticeable asymmetry in the position of your shoulder blade, you may be prone to this. The biceps brachii can also be overstrained if the elbow of the draw arm comes markedly forward of the line of the shoulders.

The good news is, the research also identifies major factors that contribute to injury, and the chief amongst these are lack of training and non-specific training. So, plenty you can do something about!

If you already have an injury, you should always seek advice rather than diagnose yourself online (even here!), and you should discuss any changes in your training with your coach or instructor if you have one. However, I thought I’d share a few useful resources I found, mainly focused on creating and maintaining a good position of the shoulder girdle. If you have an injury, treatment should help, but unless you address the root of the problem, it may happen again.

Remember, some of these exercises may not be appropriate if you already have a injury.

Korean Archery Team weight training: https://www.youtube.com/watch?v=OZzFARh-HLY

Apparently, the Korean archery team are Quite Good. The things I notice are the slow, controlled performance of the exercises, which not only ensures good form, but allows them to exercise muscles eccentrically (controlling the rate at which they lengthen); some nice rotator cuff exercises, and plenty of exercises that involve pulling and squeezing the shoulder blades together (rows, flies etc.) to provide stability for the shoulder girdle.

Avoid ‘pointy shoulder’: https://www.youtube.com/watch?v=Hxj0-pU7EPs

‘Pointy shoulder’ is another way of describing protraction of the shoulder blade. As the shoulder blade rolls forward and round, the tip of the shoulder points forward. It can put a strain on the anterior capsule of the shoulder joint, as this man vividly demonstrates; but it also puts most of the rotator cuff muscles at a mechanical disadvantage – stretching them and asking them to work at the same time, which muscles don’t appreciate. What I really like about this video is his functional exercise progression with a resistance band – taking a specific exercise and progressing it to something very close to the activity you actually do. This is a Good Thing.

Performance Archery – balance: https://www.youtube.com/watch?v=X49xdu1wGdo

Although you want to avoid ‘pointy shoulder’, you also want to avoid going too far the other way, squeezing the shoulder blade of your draw arm too far in towards the spine and creating muscular imbalances that way, as well as potentially bringing a curve and twist into the spine with a raise of the front shoulder. Although it’s useful to employ a “pinch” of the shoulder blades down and towards each other, it’s perhaps best to think in terms of avoiding protraction (rolling forward and round the ribcage), rather than squeezing too far the other way with the draw arm.

Biomechanics of archery: https://www.youtube.com/watch?v=JJtZT2KcIM0

I won’t say too much about these, as I’m not an archery coach, except to say they were useful to me as a way of understanding the specific issues of archery technique. What they describe as “the wedge”, minimising angles of force acting across joints as far as possible, makes sense to me. Clearly it’s not achievable for everyone, due to differences in anatomy, but an appropriate solution for you is something you should work on with your coach or instructor.

 

Archery hunting exercises: https://www.youtube.com/watch?v=piFvGEL-md0

Another redneck hunter for you. If this man doesn’t get you hyped about stabilising your shoulder girdle, nobody will! To be honest, I’m not too keen on his last two exercises with the ball and the resistance band against the wall – particularly for anyone who might already have a problem. But I do like his bent forward exercises to “pinch” the shoulder blades together. You could do them with a small dumbbell if they feel too easy, but probably they won’t. I also like his straight arm push-up. This is to exercise a muscle called serratus anterior, which attaches to the front surface of your shoulder blades and your ribs at the side. If the side of your shoulder blade nearest your spine tends to “wing” away from your ribcage when you push against the wall or even when you reach forward, this muscle could do with strengthening to provide stability for the other muscles of your shoulder to function at their best. This is a good exercise for that.

Remember, if you have a problem already, it’s always best to get it checked out. Also, I’m not an expert on archery, these are just some thoughts based on knowing about shoulders and how they get injured, and some preliminary investigation into what happens with archers. Please feel free to comment, or get in touch!

Shoulder injuries in archery. Mann DL1, Littke N. Can J Sport Sci. 1989 Jun;14(2):85-92.

How to set up your desk at work

[caption id="attachment_477" align="alignright" width="640"]Osteopathic treatment, osteopathic advice Using a computer at work[/caption]

Having your desk set up wrongly can lead to postural strains and repetitive strain injuries, as well as contributing to shoulder, low back and neck problems, and to headaches.

Osteopathic treatment can usually help with all of these, though the results will be longer lasting if you don’t go back to the same bad habits!

Of course, prevention’s better than cure, so here’s some good advice on ergonomic desk set-up from NHS Choices.

Sitting for long periods can lead to shortening of certain muscles, and weakening of others, which in itself can lead to back pain; and poor posture can strain ligaments and increase wear and tear to joints and discs. So, pay attention to your posture, get up regularly and move around, take regular exercise and include some stretching. Yoga and Pilates are good, but most exercise that you enjoy is good for preventing back pain.

If you already have a back problem, getting up and moving around is even more of a good idea. Movement will help to avoid inflammation building up, and standing also reduces the compressive forces in your low back, which are much higher when you sit. Research has shown that spending part or all of your working day standing reduces the incidence and severity of low back pain; and if you have a disc problem in your low back, working at a standing desk may be the only way you can get through the day. Keeping active is generally best.

The same principles apply to using a laptop at home. Think about where you use it – on the sofa, at the kitchen table? It’s not always ideal. Having a separate keyboard can help, and raising the height of your screen by putting your laptop on a pile of books.

These days we have so many more devices  – tablets, phones, games, MP3 players. Being hunched over them increases the strain on neck muscles, and ultimately the joints in your neck, enormously, leading to neck pain, shoulder pain, and often headaches.

Anyway, I’m going to get off the computer now and move around!

More information is available on the Backcare website.

If you need treatment or advice, speak to an osteopath or other professional.

 

Osteopath: Weekend Appointments Available in Edinburgh

If it’s hard to find time for an appointment during the week, it can also be hard to find an osteopath at the weekend. Osteopath Tom Jordan has appointments for new patients available in Edinburgh at the weekend on a Saturday. For osteopathic assessment and treatment, book your appointment by calling:

0131 557 2211

Eyre Place Osteopathic Practice
23 Eyre Place
Edinburgh
Lothian
EH3 5EX

I’ll be happy to see you!

[caption id="attachment_251" align="alignleft" width="233"]Osteopath Edinburgh available for weekend appointments Edinburgh Osteopath Tom Jordan[/caption]

Mindfulness for Osteoarthritis Pain

Physical approaches such as keeping active, exercise, and hands-on treatment can be very helpful for those with osteoarthritis, but we’ve known for some time that the brain has an important role in pain, apart from any physical damage.

Here’s an interesting piece from Arthritis Research UK on how mindfulness-based approaches may play an important part in helping reduce the pain caused by osteoarthritis.

http://www.arthritisresearchuk.org/news/press-releases/2014/march/new-research-points-to-talking-therapy-treatments-for-oa.aspx

You can learn mindfulness techniques in a number of places in Edinburgh. Here are links to a couple you could try:

Mindfully Being

The Mindfulness Association

Edinburgh Osteopathy supports the idea of managing your pain in conjunction with other approaches, and can offer advice on what might be most suitable.

Look After Your Back in the Garden

gnomeAround this time of year, osteopaths see an influx of patients with bad backs from gardening. After a few months of doing little in the garden, suddenly there’s a lot to do, so it’s common for people to overdo it. A lot of the problem is that your body hasn’t been used to doing so much, so needs time and a little help getting back to it.

Having said that, activity is good for your body. People often worry about what they might do to their back, so the reassuring thing is that most acute episodes of back pain are not caused by anything very serious, and generally get better within 6-8 weeks, often sooner with some treatment and advice. They may limit your activity, and may recur, but this is not necessarily a sign that something more serious is developing. Degenerative changes do happen (they happen to everyone!), but these often cause few or no symptoms. More serious problems such as disc prolapses also happen, and it’s as well to avoid putting too much strain on your discs with forward bending, but they are relatively rare, and though it may take time for things to calm down after a disc prolapse, it’s even more rare that surgery is required.

Here are some general tips, followed by advice on specific tasks.

General Tips

Warm up, take regular breaks, stretch.

Start with shorter work periods and build up slowly.

Vary your tasks – don’t do too much of one thing at a time.

Get others to help out.

Vary your posture – you can do the same task in different ways with different tools.

Avoid sustained postures and too much repetition.

Avoid bending forwards – bend from the knees and hips, not from the back.

When lifting, avoid heavy, unbalanced or awkward loads.

Don’t lift from awkward places.

Position what you’re lifting directly in front of you and keep it close to your body.

Don’t bend from your back when you lift – go down by bending your knees, feet at shoulder width.

Then use your strong leg muscles to lift, not your back.

Position things (and yourself) to avoid overreaching (weeding, sowing, picking, pruning, lifting).

Avoid twisting (e.g. when shovelling to a pile behind you).

Avoid too much overhead activity – use a ladder and/or long-handled tools, and move the ladder often to avoid overreaching.

Warm up

Your warm up should involve gentle, natural movements of all your major joints, without any straining or stretching, and without any painful movements.

You could try:

  • Circling ankles, hips, shoulders, wrists. (Use support to help your balance if you need it.)
  • Gentle movements of your head: forward, back, side to side, look over your shoulder.
  • Gently swinging your arms side to side to rotate your trunk.
  • Circles with your low back and hips (like a slow motion hula hoop!)
  • Gentle knee bends.

Stretches and Core Strength

There are many different stretches and strengthening exercises that can be good for your back.

The British Osteopathic Association has produced videos of a few simple ones which are appropriate for most people with healthy backs:

Exercises for a healthy back

If you have back pain already, consult an osteopath or physiotherapist for advice about treatment, management and exercises appropriate for you.

If any exercise causes you pain, you should stop and seek advice.

Specific tasks

Bending/lifting

When lifting, avoid heavy, unbalanced or awkward loads.

Don’t lift from awkward places – move things out into the open before attempting to lift.

Position what you’re lifting directly in front of you and keep it close to your body.

Don’t bend from your back – go down by bending your knees, feet at shoulder width.

Try to keep your knees over your ankles, no further forward, to avoid stressing your knees.

Make sure you have a good grip with both hands, then use your strong leg muscles to lift, not your back.

When putting your load down, go down the same way.

Digging

Use a split stance, one foot in front of the other.

Keep your back straight, and your arms close to your body.

Position your fork or spade so you won’t have too much earth to lift, especially if the ground is wet.

Using a smaller implement can help avoid lifting too much.

With your weight on your back foot, you can “stamp” your fork into the ground. Use your heel rather than the arch of your foot.

To drive it further in, rock your weight onto your front foot, bending that knee and using it to push, but keeping a straight back.

Shift your weight into your back leg by bending that knee and rocking back to loosen the earth.

Make sure the heel of your rear hand is against the front of the handle to get a good push; your other hand is lower down the shaft.

If the ground is very hard, you can start by loosening the earth forwards first, by bending your front knee to rock your weight forwards.

Bend from the knees and hips, not your back, when lifting the earth, and use your leg muscles to come back up.

Keep your arms close to your sides and simply turn the blade to dump the earth in front of you.

If you’re putting it somewhere behind you, turn your whole body rather than twisting.

Take regular breaks and stretch; mix with other tasks; don’t do too much in a day.

Shovelling

Use a split stance, one foot in front of the other.

Keep your back straight, and your arms close to your body.

Bend your knees and hips rather than your back.

Keep your arms close to your body and avoid overreaching.

Don’t overload your shovel, and use one the right size for you too avoid overly heavy loads.

Use your strong leg muscles to come back up.

Move to where you want to shovel to – don’t reach.

Turn your whole body rather than twisting.

Take regular breaks and stretch; mix with other tasks; don’t do too much in a day.

Weeding (or sowing)

Don’t overreach – move your position to keep what you’re working on directly in front.

Keep anything you need close to hand to avoid overreaching.

Use a variety of positions, and don’t do too long at one time.

All fours

Start with your hands and knees supporting you directly below your shoulders and hips.

Keep your back long and relax any tension.

Reach by pushing your body forward from your pelvis, rather than reaching out with your arms.

Relax your shoulders and pull by shifting your body weight back (move your bottom towards your heels).

Move your trunk and keep a comfortable angle for your shoulders and elbows.

Keep your spine long and monitor tension in your shoulders.

Steer movements (turning, leaning, twisting) from your pelvis, and don’t overreach.

Single knee kneel (split stance)

Your front foot is on the ground, with a right angle at your knee (don’t let your knee go further forward, to avoid straining it).

Your back knee is on the ground, again at a right angle (you can use kneeling pads or a mat).

In this position you can support your upper body with your front arm on your front knee while you work with your other hand.

Sitting on a bucket

You can sit on an upturned bucket with your feet flat on the ground and your knees wide apart.

This allows you to support your weight with an arm on one knee as you work with the other hand.

Move along frequently to avoid overreaching.

Standing

Standing is often used for sowing, but it’s important to avoid hinging forward from the low back.

Use a split stance by stepping back deeply with on leg, feet wide apart.

From here, you can support the weight of your upper body with your front arm on your front knee.

Keep your front knee at a right angle, no further forward.

In this position, the movement is mostly coming from your hips and knees – your back is straight.

Move your position frequently to avoid overreaching.

Mowing

Use an appropriate mower for your lawn, ideally with an electric starter and motor-powered wheels.

Keep your back upright and use your body to drive the movement, not just your arms.

Use forwards and backwards movements, and avoid swinging from side to side.

Wheelbarrow

Use an underhand grip, so you lift from underneath.

Bend from your hips and knees, keep your back straight.

Maintain a long, straight spine while pushing.

Don’t overload, and avoid unbalanced loads to protect from sudden, unexpected movements.

To empty, put the wheelbarrow down and change your grip.

Bend from your knees and hips and use the ‘V’ between your thumb and forefinger underneath the handle.

Straighten from the hips and knees, step forward and shift your weight onto your front leg to tip the wheelbarrow forwards.

Raking

Keep your back straight and rake from in front of you towards your body.

Don’t rake out to the side, to avoid twisting.

Don’t lean or reach too far forward – move your body.

Move your feet and shift your body backwards to rake towards you, rather than pulling with your arms.

Keep upright, looking forwards.

Bend from your hips and knees to lift, not from your back.

Pruning

If pruning or trimming tall hedges, avoid prolonged work above head height.

Use a ladder and/or long-handled pruners to avoid this.

Move the ladder often to avoid overreaching (to avoid overstraining or toppling over!)

Useful links

Good garden design, such as narrow beds to avoid too much bending and reaching, or raised beds for those who can no longer get down low, may be helpful. There are also a range of different tools available, some to avoid bending, some for those with arthritis and other problems. Some of the sites below give helpful advice.

Arthritis Research UK provides advice on gardening for those with arthritis.

Edinburgh Garden Partners is an Edinburgh charity that matches people who want to garden with people who need help coping with their gardens.

Thrive is a national charity that helps people with disability start or continue gardening.

Edinburgh Council provides help with lawns and hedges for the elderly and disabled.

NHS Choices top ten back care tips.

Low Back Pain

A nice brief summary of current knowledge about low back pain and approaches that help. These generally include not worrying too much, understanding that most back pain will go away and even quite severe pain is not necessarily a sign of something seriously wrong, keeping active, changing habits that predispose to back pain, hands on treatment (including manipulation by an osteopath), and exercise.

It’s always best to be examined by a professional such as an osteopath who is trained to assess your problem and advise you on how to manage it, provide hands on treatment, and screen for the rare occasions when you may require referral to your GP or a specialist to determine if something more serious is going on and get you the appropriate tests, imaging or treatment.

Video

(Follow the above link.)

Shoulder Pain from Subacromial Impingement (Rotator cuff tear, rotator cuff degeneration, supraspinatus tendinitis, subacromial bursitis, painful arc.)

Causes of shoulder pain

There are many causes shoulder pain, some due to problems in the shoulder itself, others originating elsewhere. The latter include neck problems, as well as some systemic illness and problems with some of the internal organs.

Shoulder problems

Local causes of shoulder pain include:

  • Biceps tendinopathy
  • Osteoarthritis of the glenohumeral (GH) joint
  • Osteoarthritis of the acromioclavicular (AC) joint
  • Bursitis
  • Frozen shoulder
  • Dislocation
  • Shoulder impingement (rotator cuff tear, rotator cuff degneration, ‘painful arc’)

Osteopaths are trained to screen for more serious causes of shoulder pain that would require referral to your GP or a specialist, and to identify specific musculoskeletal issues for appropriate treatment and management. We can also give advice on other options.

The most common local cause of shoulder pain is shoulder impingement (sometimes referred to as ‘painful arc’). ‘Painful arc’ describes a distinguishing feature of this kind of shoulder problem: pain comes on in an arc either side of 90 degrees as the arm is raised. The pain may be sharp and severe, but if the arm is raised further, it tends to diminish. Particular positions of the arm may be worse than others. Pain is usually felt around the point of the shoulder and a little way down the outside of the arm.

What causes shoulder impingement?

Your glenohumeral joint is the ball and socket joint at the top of your arm. It sits below a bony arch formed where your collarbone meets part of your shoulder blade called the acromion. This is the acromial arch.

[caption id="attachment_263" align="alignleft" width="356"]Subacromial arch, subacromial space, osteopathy for shoulder pain, osteopathy, osteopathy for shoulder impingement The subacromial space[/caption]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rotator cuff muscles

Various structures pass through the space between this and your shoulder joint (the subacromial space). These include the tendons of the rotator cuff muscles: supraspinatus, infraspinatus, subscapularis and teres minor. These are small muscles that originate on various parts of your shoulder blade and attach high on the humerus (your upper arm bone).

[caption id="attachment_278" align="alignleft" width="266"]Osteopathy for rotator cuff problems The Rotator Cuff[/caption]

 

 

 

 

 

They control the position of the head of the humerus (the ‘ball’) as it moves in its socket.

 

Rotator cuff tears, rotator cuff degeneration

Because they are small stabilising and ‘fine-tuning’ muscles, the rotator cuff muscles tend to suffer first if there are traumatic, repetitive or postural strains affecting the mechanics of the shoulder joint. They may be injured by trauma, but commonly suffer degenerative changes, particularly when there are predisposing factors such as repetitive overhead activities, or the kind of round-shouldered posture we often develop sitting at a desk.

Rotator cuff tears or rotator cuff degeneration may result in inflammation and other changes which may lead to increased compression of sensitive structures within the subacromial space as the arm is raised through 90 degrees, resulting in sharp pain. However, as the arm is raised further, the head of the humerus drops, freeing up the subacromial space, and the pain diminishes (though there may be a residual ache).

Supraspinatus is the most commonly affected muscle, due to its position over the shoulder joint putting it under more mechanical strain. It is almost always active, even with the arm hanging by the side. Inflammation of this muscle’s tendon is called supraspinatus tendinitis.

 Supraspinatus bursa, supraspinatus bursitis

There is also a fluid filled sac or ‘bursa’ in this space. It reduces friction between the supraspinatus tendon and the acromial arch. This may also become inflamed (‘bursitis’), and in the longer term may become hardened, so may also contribute to shoulder pain.

Who gets shoulder pain due to subacromial impingement?

Traumatic tears to the rotator cuff may happen at any age, but degenerative changes generally become apparent from the 40s onwards. Repetitive overhead activities may contribute to its onset. These might include:

  • Painting and decorating
  • Pruning
  • Swimming
  • Throwing

Other aggravating factors might be:

  • Driving
  • Hairdressing
  • Poor computer/ desk set-up

A round-shouldered posture will tend to increase the mechanic strain on these muscles, so may also contribute.

What are the symptoms of shoulder impingement?

These may include:

  • Painful arc – shoulder pain either side of 90 degrees
  • Sharp, severe shoulder pain on raising the arm
  • May have the urge to let the arm drop
  • Shoulder pain diminishes on going further – full range possible
  • May have residual ache in the shoulder
  • Pain focused around point of shoulder and into outside of the upper arm
  • May be annoying at night, especially lying on that shoulder

What can an osteopath do to help your shoulder pain?

  • Examine you and determine the cause of your shoulder pain with appropriate tests.
  • In a few cases, advise and refer for appropriate imaging, eg X-ray or MRI.
  • In rare cases, refer to your GP or a specialist to rule out more serious potential causes of shoulder pain.
  • Hands-on treatment.
  • Advice on modifying activities to avoid aggravating the shoulder pain.
  • Advice on what else may help, such as ice packs or cold compresses.
  • Advice on appropriate and effective exercises for shoulder pain.
Treatment for shoulder impingement

This may include work on the muscles of the shoulder joint to improve their health and decompress the subacromial space; it may also include work on the neck, chest, thoracic spine and rib cage to address postural issues and other predisposing factors, and to improve the function of the shoulder as a whole.

Exercises for shoulder pain

Evidence shows that a combination of hands-on treatment and exercise for shoulder impingement from rotator cuff tears or rotator cuff degeneration may be more effective than either on its own. A range of exercises are commonly prescribed, and some have been shown to be more effective than others. An osteopath can advise on those most appropriate for you.

Will your shoulder pain get better?

If the problem is addressed early enough, degenerative changes to the muscles may be reversed through treatment and exercise. If it has progressed further, the symptoms and function can be managed and improved. You may still have degenerative changes to your rotator cuff, but they may not cause you symptoms or loss of function, or these may be minimised. It is always best to try this approach first, as it is often effective, and other more invasive options such as corticosteroid injections and surgery have mixed results. However, in cases where there is significant limitation of activities and pain that is not responding to treatment and exercise, these other approaches may be appropriate.

Some of the evidence on treating and managing this condition is presented in the articles below, including some exercises for shoulder pain. Always remember that a proper diagnosis is the first step in treating and managing any problem, and this should be done by a trained professional, who should also be consulted about appropriate exercises.

The American Journal of Medicine (2005) 118, 452– 455. Shoulder impingement syndrome. Michael C. Koester, MD, Michael S. George, MD, John E. Kuhn, MD

http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS0002934305000847.pdf

Journal of Shoulder and Elbow Surgery. 2009 Jan-Feb;18(1):138-60.

Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Kuhn JE.

http://www.schoudernetwerk.nl/pdffiles/Review.Exercise.Impingement.Kuhn.2008..pdf