Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

A review published in the North American Journal of Sports Physical Therapy (1) gives a good outline of the challenges facing physical therapists in helping the patient with a swimmer’s shoulder.

“Physical therapists involved in the treatment of competitive swimmers should focus on prevention and early treatment, addressing the impairments associated with this condition, and analyzing training methods and stroke mechanics.”

“Swimmer’s shoulder is a condition that may be prevented with adequate preseason screening that can identify impairments and training errors that may lead to symptoms. If a swimmer does become symptomatic during the season, the physical therapist should identify the most likely impairments or training errors and rule out any significant tissue pathology that would warrant a referral to an orthopedic surgeon. A comprehensive rehabilitation program usually includes strengthening of the rotator cuff and scapular stabilizers, stretching anterior chest musculature that may be shortened, and implementing activity modification so the athlete can still participate in the sport.”

Exercise is ineffective in some subacromial pain syndrome patients who suffer from a greater sensitivity to pain, and they have a lower tolerance for pain

A July 2022 study published in the European Journal of Pain (2) examined the effects of exercise on clinical pain and pain mechanisms in patients with subacromial pain syndrome.

This study examined:

• If 8-weeks of exercise could modulate clinical pain or temporal summation of pain (this is a condition where the same arm movement causes an increase in pain intensity, if you lifted your arm above your head, it hurts worse the more you do it), conditioned pain modulation (the patient was given a treatment to lessen the pain), and exercise-induced hypoalgesia (exercise decrease pain intensity) and
• If any of these parameters could predict the effect of 8-weeks of exercise in patients with unilateral subacromial pain syndrome in this study of 37 patients.

In this study of 37 patients, the researchers’ findings suggested a reduction in pain and improved sleep quality after 8-weeks of exercise. Furthermore, the results suggest that low pain intensity and high temporal summation of pain scores (indicative of pain sensitization) may predict a lack of pain improvement after exercise.

• The reason physical therapy and exercise are not being successful in some subacromial pain syndrome cases is that the patient suffers from a greater sensitivity to pain and lower tolerance for pain.

The best training regimen for subacromial impingement syndrome – is there one?

A January 2022 study from researchers in Denmark published in the journal BMC Musculoskeletal Disorders (3) looked to answer the question regarding the best training regimen for subacromial impingement syndrome. While they found effective training programs, they did not find the best. Here is what they wrote:

“There is no consensus on the best training regimen for subacromial impingement syndrome. Several have been suggested but never tested. The purpose of the study is to compare a comprehensive supervised training regimen based on the latest evidence, including heavy slow resistance training, with a validated home-based regimen (you are on your own training). We hypothesized that the supervised training regimen would be superior to the home-based training regimen.

In this study, 126 consecutive patients with subacromial impingement syndrome were recruited and divided into two groups, with each group getting 12 weeks of either a supervised training regimen or a home-based training regimen. What the researchers found was that both the supervised by therapist group and the at-home do-it-yourself group had very similar results for pain and function after six months. They wrote: “We found no significant difference between a comprehensive supervised training regimen including heavy training principles, and a home-based training program in patients with subacromial impingement syndrome.”

For many people, there are no long sessions of physical therapy. Many, perhaps like yourself, were given one or two or three sessions of supervised physical therapy that focused on demonstrations of exercises that you would be able to perform on your own. Most of the exercises involved stretching and then strengthening exercises. You were probably also given instructions not to do those activities that would aggravate your shoulder pain.

Improving exercise outcomes in middle-aged men with subacromial impingement

An August 2022 study (4) looked at purposeful blood flow restriction in strengthening exercises in two patients with subacromial impingement and high irritability.

In brief, the case history doctors noted that evidence shows that exercise can help patients presenting with subacromial impingement syndrome. This includes strengthening exercises directed at the shoulder musculature. The doctors write: “Patients with subacromial impingement syndrome can present with pain during and after completion of heavy resistance training, limiting the applicability of this recommended treatment approach. Blood flow restriction (in simplest terms, the use of a compression cuff to restrict blood flow temporarily to the injured shoulder ) training is indicated for patients who have pain while completing heavy resistance training and may represent an important treatment modification for patients with subacromial impingement syndrome unable to fully participate in a strengthening exercise program.”

In this study, “Two middle-aged, non-operative patients with signs and symptoms consistent with subacromial impingement syndrome and high levels of irritability were included. Treatment over one month consisted of three commonly used exercises in the treatment of subacromial impingement syndrome in conjunction with a standard BFR protocol: 75 reps broken up into sets of 30,15,15,15 with the BFR cuff placed over the proximal humerus (to of the shoulder). At the end of the course of treatment, clinically meaningful improvements were observed in patient-reported outcomes (in pain reduction and functionality).

Non-athletes don’t want to exercise their shoulder

Older patients and those patients who no longer compete at a high level or have given up sport have mixed feelings about how much exercise can help their Subacromial shoulder pain. Many do not comply to exercise programs given to them to do at home. A January 2021 study (5) notes:

• “Exercise is recommended for patients with subacromial pain.
• It has been suggested that good exercise adherence improves clinical outcomes.
• Despite this, little attention has been paid to the need for behavioral frameworks to enhance adherence to home exercise programs for patients with subacromial pain.”

In other words, patients are not adhering to the exercise program they were given. Why? In some patients we see, there is fatigue in constantly doing treatments or therapies that the patient sees as not helping.  In this study, an exercise program was introduced to the study participants, who had received conservative treatment during the past 6 months.” What did these researchers find? Recruitment (simply getting patients to participate in an exercise study) and adherence to the self-managed exercise program were both below the anticipated level. ”

Surgery or PT

A November 2025 study in the journal Cureus (6) found that in reviewing the current research: “Current evidence does not support the routine use of arthroscopic subacromial decompression over structured physical therapy for the management of stage II shoulder impingement syndrome, as both approaches yield comparable outcomes in pain reduction, functional improvement, and return to daily activities.”

Related articles 

Understanding physical therapy for subacromial shoulder pain

References

1 Tovin BJ. Prevention and treatment of swimmer’s shoulder. North American journal of sports physical therapy: NAJSPT. 2006 Nov;1(4):166. [Google Scholar]
2 Lyng KD, Andersen JD, Jensen SL, Olesen JL, Arendt‐Nielsen L, Madsen NK, Petersen KK. The influence of exercise on clinical pain and pain mechanisms in patients with subacromial pain syndrome. European Journal of Pain. 2022 Jul 19. [Google Scholar]
3 Schydlowsky P, Szkudlarek M, Madsen OR. Comprehensive supervised heavy training program versus home training regimen in patients with subacromial impingement syndrome: a randomized trial. BMC Musculoskeletal Disorders. 2022 Dec;23(1):1-6. [Google Scholar]
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5 Major DH, Grotle M, Littlewood C, Brox JI, Matre D, Gallet HV, Røe Y. Adherence to self-managed exercises for patients with persistent subacromial pain: the Ad-Shoulder feasibility study. Pilot and feasibility studies. 2021 Dec;7(1):1-3. [Google Scholar]
6 Rutt GJ, Esch C, Ballantyne M, Esch CE. Arthroscopic subacromial decompression vs. physical therapy for stage II shoulder impingement syndrome: a comparative review of functional and social impact. Cureus. 2025 Nov 4;17(11). [Google Scholar]