Dr Juhl’s Treatment series


    The primary characteristic of shoulder impingement syndrome (SIS) is that the space between the head of the humerus and the web formed by the coracoid process, the coracoacromial ligament and the underside of the acromion is diminished. It is a common denominator of progressive shoulder impairment, and can occur by one or both of the following mechanisms

  1. The tissues normally occupying that space, the subacromial bursa, the Bicep and supraspinatus tendons swell up secondary to inflammation or poor lymphatic drainage.
  2. The humerus is pulled up into the coracoacromial web by decreased tone of the subscapularis, infraspinatus, teres minor and latissimus muscles and/or by the increased tone of the deltoid and supraspinatus muscles.

     The second situation is more amenable to exercise rehabilitation and therapy modalities, but both will engender scapulothoracic guarding and disruption of scapulohumeral rhythms of motion. Shoulder Internal Rotation and Adduction (IRAD) is typically the first Range of Motion lost and the last to fully recover. We can evaluate this with the Apley Scratch test. Persons with loss of shoulder flexion and/or abduction will almost always have loss of the smaller accessory motions and more extensive impairment. Effective treatment series will begin with passive range of motion followed by active range of motion with strength training occurring as a third stage. Cold at the end of sessions may bypass the inevitable inflammatory flair that typically follows a session where range of motion is increased or adhesions are lysed. The following treatment sequence is designed to introduce  distraction of the humerus from the coracoacromial web early in the treatment process.


  1. Nutcracker Exercise
  2. Humeral auto-traction Exercise
  3. Crane Wing elbow Exercise
  4. Wringing Towel Exercise
  5. Shoulder Rolls→ The Kite and the String
  6. Walking the Wall Isometrics

1)     The Nutcracker Exercise has been described previously. Seated or standing with both hands behind the back, grasp one wrist with the other hand. Turn the palms up. Straighten the elbows until the cubital fossa is facing forward and out at a 45° angle. This rotates the shoulders back, stretches the anterior chest wall muscles and fascia, and extends the shoulder with external rotation. Once the first position can be done, relax the elbows but maintain the wrist grasp; lift the hands up a few inches and then re-extend the elbows. Do this until the arms can extend back horizontally, allowing them to drop forward if the upper body is allowed to hang down below the waist. Upright, the neck can be flexed down and away from the posteriorly extended arms, 45° to the right and left. This exercise engages the rhomboids, the infraspinatus and teres minor, and stretches the anterior pectoralis and subscapularis muscles.

2)     The Humeral Auto-traction Exercise is designed to distract the humeral head from the coracoacromial web by use of the subscapularis, infraspinatus and latissimus muscles. Seated or standing, press the shoulders down and slightly back. Flex the elbows to 90º supporting one hand with the other in front. Maintaining this configuration, pull the elbows straight down a centimeter, then relax. You want to feel a gap open between the acromion laterally and the humeral head as you pull down. Repeat 5x then rest. Increase one set each day to 5x5. This exercise engages distraction and stretches the supraspinatus. A more dynamic version of this exercise is to hold a half gallon jug of water in each hand, while allowing the shoulder and upper arm muscles to relax. Alternate supination and pronation of the entire arm from the shoulder. The elbow should remain straight. The weight of the jugs should help to distract the humerous from the acromion.

3)     The Crane’s Wing Exercise can be done sitting or standing. Abduct the arms to 90º, or the height that both arms can reach. Turn palms down. Flex the elbows bringing the medial epicondyles forward until they are in front of the wrists and shoulders. Then bring the elbows together until they touch in the midline. Keep the palms down with the wrists ulnar deviated in opposition to the antero-medially moving medial epicondyles. This exercise engages external rotation and strengthens the serratus anterior.

4)     The Wringing Towel Exercise is done standing. Arms hang down. Externally Rotate one arm out from the shoulder while rotating the other arm internally. After three seconds reverse the arm rotations. After each repetition abduct the arms out 15 degrees. After the sixth repetition, the arms should be abducted horizontally. This exercise engages abduction, internal and external rotation.

5)     Start shoulder rolls rotating backwards emphasizing the back and down positions 5x. Then rotate the shoulders forward 5 times emphasizing the forward and down positions. Repeat this backward /forward series 5x. Are your shoulder circles round and symmetric?

6)     Walking the Wall Isometrics are one of the oldest and most useful shoulder rehab exercises if done well. Standing less than arm’s length from a wall, place the palm of arm to be treated on the wall. Move the body around the arm, stretching the shoulder into flexion, internal and external rotation, adduction and abduction, and extension. See if you can put the arm into all of those positions relative to the body without moving the hand off the wall. Especially explore flexing the whole body forward towards the wall until the arm is flexed above the head. Then walk the fingers up a few inches and start the exercise again. This exercise can engage the entire rotational range of motion of the shoulder.

     This shoulder treatment plan is a work in progress. What  physical signs  would suggest success or failure of a particular approach? Does a particular sequence of exercises work better than another, and for who? Is the distraction exercise a core exercise ? How do we document improvement? Degrees of supine shoulder flexion? Full IRAD?  Let me know what you come up with, and what works for you.

Dr. John Juhl
Shoulder impingement
11-5-03, 02-27-08, 5-9-11, 10/12/11