Boulders for Shoulders – Bulletproofing your shoulders


Often a term used to describe shoulder pain, shoulder impingement syndrome was initially described to explain pain within the shoulder as it was thought to be a result of tendons and bursae (fluid filled sacks) being pinched or impinged within the joint.

This is not always the case and has lead to the diagnosis of Sub Acromial Pain Syndrome (rather than impingement) as it is simply pain beneath the acromion that may be a result of a range of pathologies.


Subacromial Pain Syndrome (SAPS) is defined as all non-traumatic, usually unilateral, shoulder problems that cause pain, localized around the acromion, often worsening during or subsequent to lifting of the arm.

There is not a single cause, nor is there usually a mechanism for the injury onset. However, SAPS has been associated with….

  1. Repetitive movements of the shoulder, hand or wrist
  2. Work that requires significant or prolonged upper arm strength
  3. Hand-arm vibration (e.g use of a drill)
  4. Working in/prolonged durations in poor ergonomic shoulder posture
  6. Excessive load through the shoulder, especially in overhead positions

These factors can be combined and are associated! For example, poor thoracic spine mobility and shoulder pain and range of motion have been associated (Strunce et al., 2009).

Potential causes of subacromial pain syndrome are……

  • Bone spurs
  • Bursal Hypertrophy
  • ACJ arthrosis/bone spur
  • RC disease
  • Labral injury
  • GIRD – Glenohumeral Internal Rotation Deficit
  • LHOB tendinopathy
  • Scap dyskinesis
  • Cx radiculopathy
  • GH instability

BUT DOES IT MATTER WHAT’S CAUSING THE PAIN? RARELY! – The rehabilitation protocol will often have the same focus

Guidelines for assessment and treatment were highlighted in a study from 2014 (Diercks et al., 2014).

  1. Diagnosis is determined from a combination of special tests/pain provocation tests and muscle testing that highlight whether there is pain but not the exact causes or implicated tissue.
  2. Subacromial pain syndrome should be treated non-operatively!!!
  3. Pain can initially be treated with Non-steroidal anti-inflammatory drugs (NSAIDs) along with advice that pain is not due to damage and is unlikely to have a long term effect.
  4. If symptoms last for longer than 6 weeks, workplace alterations may be necessary to reduce the likelihood of the conditions progression to a chronic syndrome
  5. home exercises of low intensity and high frequency, combining eccentric training with stabilization of the scapula and focusing on proper posture.
  6. Treatment of trigger points with manual therapy and stretching can SUPPORT exercise rehabilitation. However, symptoms are likely to persist if ONLY manual therapy treatment is completed and not rehabilitation!
  7. Rehabilitation in a specialized centre can be considered for chronic, treatment-resistant SAPS, in which pain-perpetuating behaviour plays a role.
  8. With persistent symptoms, it may be necessary to rule out rotator cuff tendon tears. It then must be determined whether or not surgical treatment is required.


    1. Strict immobilization. MOVE IT!!
    2. No active intervention to prevent overload in work or sports and to address psychosocial factors.
    3. Limiting imaging to conventional radiographic examination.
    4. Ultrasound examination with suboptimal technique and experience.
    5. ESWT in the acute phase, and in absence of tendinosis or bursitis calcarea.


  • Surgical treatment without exhaustive non-operative treatment. SURGERY IS RARELY NECESSARY IN SAPS, exercise therapy is the best option for treatment!




Rehabilitation of SAPS must be focused on restoring adequate shoulder position to increase the subacromial space. If the shoulder is rotated forwards and inwards (protracted), if the upper back is stiff and rounded (kyphotic) and if the posterior cuff of the shoulder is weak, it will reduce the space between the acromion and humeral head.


Rehabilitation is focused around regaining an upright mid-back posture and shoulder position. Reboot’s keys for rehab are the following

  • Thoracic Extension/mobility
  • Pec length
  • Lat length
  • Rhomboid endurance
  • Posterior cuff strength

If you have any questions about your shoulder please get in touch via our contact forms or email us at


Diercks, R., Bron, C., Dorrestijn, O., Meskers, C., Naber, R., de Ruiter, T., Willems, J., Winters, J. and van der Woude, H. (2014). Guideline for diagnosis and treatment of subacromial pain syndrome. Acta Orthopaedica, 85(3), pp.314-322.

Strunce, J., Walker, M., Boyles, R. and Young, B. (2009). The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain. Journal of Manual & Manipulative Therapy, 17(4), pp.230-236.


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