Journal of Sport Rehabilitation, 2016, 25, 195  -201

http://dx.doi.org/10.1123/jsr.2014-0230
© 2016 Human Kinetics, Inc. CRITICALLY APPRAISED TOPIC

The Impact of Adding an Eccentric-Exercise Component

to the Rehabilitation Program of Patients With Shoulder
Impingement: A Critically Appraised Topic
Alison R. Valier, Ryan S. Averett, Barton E. Anderson, and Cailee E. Welch Bacon

Clinical Scenario: Shoulder pain is a common musculoskeletal complaint and is often associated with shoulder
impingement. The annual incidence of shoulder pain is estimated to be 7% of all injuries, and is the third-most-
common type of musculoskeletal pain. Initial treatment of shoulder impingement follows a conservative plan
and emphasizes rehabilitation programs as opposed to surgical interventions. Shoulder rehabilitation programs
commonly focus on strengthening the muscles of the shoulder complex and, more specifically, the rotator cuff.
The rotator cuff is a primary dynamic stabilizer of the glenohumeral joint, using both eccentric and concentric
contractions. The posterior rotator cuff, including teres minor and infraspinatus, works eccentrically to deceler-
ate the arm during overhead throwing. Exercises to strengthen the rotator cuff and the surrounding dynamic
stabilizers of the shoulder girdle vary and include activities such as internal and external rotation, full-can
lifts, and rhythmic stabilizations. Traditionally, shoulder rehabilitation programs have focused on isotonic
concentric contractions. Common strengthening exercises typically involve movements that result in shorten-
ing the muscle length while simultaneously loading the muscles. However, recent attention has been given to
eccentric exercises, which involve lengthening of the muscle during loading, for the treatment of a variety of
different tendinopathies including those of the Achilles and patellar tendons. The eccentric, or lengthening,
motion is thought to be beneficial for people who are involved in activities that place eccentric stress on their
shoulder, such as overhead throwers. Based on studies related to the Achilles tendon, eccentric exercise may
positively influence the tendon structure by increasing collagen production and decreasing neovascularization.
The changes that occur as a result of eccentric exercises may improve function, strength, and performance and
decrease pain more than concentric programs, producing better patient outcomes. Although eccentric strength
training has been shown to provide strength gains, there are no clear guidelines as to the inclusion of this form
of exercise training in shoulder rehabilitation programs for the purposes of improving function and decreasing
pain. Focused Clinical Question: Does adding an eccentric-exercise component to the rehabilitation program
of patients with shoulder impingement improve shoulder function and/or decrease pain?

Keywords: shoulder pain, rotator cuff, upper-extremity injury, functional outcomes

Clinical Scenario cuff is a primary dynamic stabilizer of the glenohumeral

joint, using both eccentric and concentric contractions.
Shoulder pain is a common musculoskeletal complaint The posterior rotator cuff, including teres minor and
and is often associated with shoulder impingement. The infraspinatus, works eccentrically to decelerate the arm
annual incidence of shoulder pain is estimated to be during overhead throwing. Exercises to strengthen the
7% of all injuries and is the third-most-common form rotator cuff and the surrounding dynamic stabilizers of
of musculoskeletal pain.1 Initial treatment of shoulder the shoulder girdle vary and include activities such as
impingement follows a conservative plan and emphasizes internal and external rotation, full-can lifts, and rhythmic
rehabilitation programs as opposed to surgical interven- stabilizations.4,5 Traditionally, shoulder rehabilitation
tions.2,3 Shoulder rehabilitation programs commonly programs have focused on isotonic concentric contrac-
focus on strengthening the muscles of the shoulder com- tions. Common strengthening exercises typically involve
plex and, more specifically, the rotator cuff.4,5 The rotator movements that result in shortening the muscle length
while simultaneously loading the muscles. However,
recent attention has been given to eccentric exercises,
The authors are with the Athletic Training Programs, A.T. Still which involve lengthening of the muscle during loading,
University, Mesa, AZ. Address author correspondence to Alison for the treatment of a variety of different tendinopathies
Valier at arsnyder@atsu.edu.

195
 196  Valier et al

including those of the Achilles and patellar tendons. component to rehabilitation programs for individuals with
The eccentric, or lengthening, motion is thought to be shoulder impingement may result in fewer requests for
beneficial for people who are involved in activities that surgical intervention. Clinicians who regularly work with
place eccentric stress on their shoulder, such as overhead shoulder-impingement patients should consider including
throwers. Based on studies related to the Achilles tendon, an eccentric-exercise component in shoulder rehabilitation
eccentric exercise may positively influence the tendon programs to help improve shoulder function, decrease
structure by increasing collagen production6 and decreas- pain levels, and reduce requests for surgical intervention.
ing neovascularization.7 The changes that occur as a result Strength of Recommendation: Due to conflicting
of eccentric exercises may improve function, strength, results of the studies included in this critically appraised
and performance and decrease pain more than concentric topic (CAT), there is grade C evidence available to sug-
programs, producing better patient outcomes.8,9 Although gest that the inclusion of an eccentric-exercise compo-
eccentric strength training has been shown to provide nent in shoulder rehabilitation programs in patients with
strength gains,8,10 there are no clear guidelines as to the shoulder impingement improves shoulder function and
inclusion of this form of exercise training in shoulder decreases pain.
rehabilitation programs for the purposes of improving
function and decreasing pain.
Search Strategy
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Focused Clinical Question Terms Used to Guide Search Strategy

Does adding an eccentric-exercise component to the • Patient/Client group: patients and shoulder impinge-
rehabilitation program of patients with shoulder impinge- ment
ment improve shoulder function and/or decrease pain? • Intervention: eccentric exercise
• Outcomes: decreased pain or improved function
Summary of Search,
“Best Evidence” Appraised, Sources of Evidence Searched
and Key Findings • PubMed
• The literature was searched for level 3 studies or • CINAHL
higher that investigated the effectiveness of shoulder • Ovid
rehabilitation programs that include an eccentric- • Cochrane Library
exercise component aimed at improving function • Proquest
and/or decreasing pain.
• Additional articles obtained through hand searching
• Two randomized trials9,11 and 1 pilot study12 were of reference lists
identified through the search.
• Additional articles obtained through searches of
• Two studies11,12 reported an increase in shoulder related article
function after a 12-week shoulder rehabilitation pro-
gram that included an eccentric-exercise component,
and 1 study did not.9 Inclusion and Exclusion Criteria
• Two studies11,12 reported a decrease in pain after
a 12-week shoulder rehabilitation program that Inclusion Criteria
included an eccentric-exercise component, and 1
• Studies that investigated shoulder rehabilitation
study did not.9
programs that include eccentric exercise as a specific
program component
Clinical Bottom Line • Studies that measured function and/or pain as pri-
mary or secondary outcomes
Through our search of the literature, we found minimal • Studies that investigated patients with shoulder
evidence to suggest that adding an eccentric-exercise impingement
component to the rehabilitation of patients with shoulder
impingement improves shoulder function and decreases • Limited to English language
pain. This review revealed that there are conflicting results • Limited to studies of level 3 evidence or higher
in the current literature regarding the incorporation of an • Limited to the last 10 years (2004–2013)
eccentric-exercise component. Some evidence suggests
that there is no impact on pain and function, while other Exclusion Criteria
evidence supports the use of eccentric exercise when
treating people with shoulder impingement. Note that • Studies that investigated postsurgical shoulder reha-
some evidence suggests that adding an eccentric-exercise bilitation programs

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 Eccentric Exercise and Shoulder Impingement   197

• Studies that did not look at eccentric exercise as a received some benefit from the strengthening program.
specific component of shoulder rehabilitation. These findings support the works of Jonsson et al12 and
Holmgren et al.11 Therefore, based on the current avail-
able evidence, there appears to be some support for the
Results of Search addition of an eccentric-exercise component to shoulder
rehabilitation programs for shoulder impingement.
Three relevant studies were identified and categorized
Other noteworthy findings from our critical appraisal
as presented in Table 1 (based on Levels of Evidence,
of the literature relate to isometric strength, successful
Centre for Evidence Based Medicine, 2011).
outcomes, and surgical intervention. Maenhout et al9
reported a small improvement in isometric strength at
Best Evidence 90° abduction in patients who experienced a heavy-load
eccentric component to their rehabilitation compared with
Through our search, the following studies were noted those who did not. However, no other significant differ-
as the best available evidence and included in the CAT ences in isometric strength were noted in the group with
(Table 2). We selected these studies because they were an eccentric-exercise component in their rehabilitation
rated as level 3 or higher evidence, investigated shoul- program. In terms of successful outcomes, the majority
der rehabilitation programs that included an eccentric- of patients in the study by Holmgren et al11 reported more
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exercise component, measured function and/or pain as successful outcomes, as determined by global rating of
a primary or secondary outcome, and included patients change, when an eccentric-exercise component was added
with shoulder impingement. to the rehabilitation protocol. Finally, both Holmgren et
al11 and Jonsson et al12 addressed future surgical interven-
tion. Holmgren et al11 reported that patients who were
Implications for Practice, exposed to an eccentric component in their rehabilitation
Education, and Future Research program selected surgery as a subsequent intervention
less frequently than those in a control group. Furthermore,
All 3 of the included studies reported that shoulder func- Jonsson et al12 noted that a high proportion of satisfied
tion improves and pain decreases when an eccentric-exer- patients (over 50% of patient population, n = 9) did not
cise component is added to the rehabilitation programs pursue surgical intervention after rehabilitation that
of patients with shoulder impingement.9,11,12 Maenhout included an eccentric-exercise component. Improvements
et al9 found no significant difference in shoulder function such as improved function, decreased pain, successful
and pain-level improvements when comparing patients outcomes, and fewer requests for surgical intervention as
who performed a heavy-load eccentric-exercise program a result of shoulder rehabilitation programs that include
compared with those who only performed traditional rota- an eccentric-exercise component may be important to
tor-cuff strengthening. Jonsson et al12 reported positive consider.
findings regarding function and pain in a small group of One challenge when considering the implementa-
satisfied patients. However, theirs was a small pilot study tion of an eccentric-exercise component in a shoulder
that did not include a control group. Holmgren et al11 rehabilitation program for patients with impingement
found significant improvement in function and decreases is determining the specific exercises to include. While
in pain, reporting that the specific exercise group, which all of the studies included in this CAT evaluated an
included an eccentric-exercise component, showed eccentric-exercise component of the shoulder rehabili-
greater improvements than the control group. While not tation program, the types of exercises differed between
a study that fit our inclusion criteria, Bernhardsson et al13 the studies. For example, Maenhout et al9 implemented a
studied the impact of a 12-week eccentric strengthening heavy-load (eg, dumbbell resistance) eccentric-exercise
program of the rotator cuff in patients with shoulder component through a full-can abduction motion in the
impingement using a single-subject study design. Pain scapular plane, whereas Holmgren et al11 incorporated
improved after the eccentric-exercise intervention in 8 2 eccentric rotator-cuff exercises, as well as concentric
out of 10 patients, and function improved in 10 out of 10 and eccentric scapula-stabilizer exercises. Jonsson et al12
patients, suggesting that most of the patients in their study eccentrically exercised the rotator cuff with the use of an
apparatus called the Ulla-sling with the goal of producing
pain. Therefore, all studies used different methods for
Table 1 Summary of Study Designs the eccentric-exercise component of the program. The
of Articles Retrieved number of times administered per day and the number
Level of Study Number of repetitions differed between the studies, as well. In
evidence design located Reference general, the studies with the most positive outcomes
administered the exercises in 3 sets of 15 repetitions
2b Randomized 2 Maenhout et al9
controlled
either 1 or 2 times per day.
Holmgren et al11 Another element of consideration when determining
trial
the eccentric-exercise protocol is pain associated with the
3 Pilot study 1 Jonsson et al12 exercise. All 3 studies specifically addressed pain as part

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Table 2 Characteristics of Included Studies

Maenhout et al9 Holmgren et al11 Jonsson et al12

198
Study Randomized controlled trial Randomized controlled trial Pilot study
design
Participants 61 patients were included in this study and randomly 97 patients met all the inclusion criteria. 51 patients (14 9 patients (4 women, 5 men) with chronic painful shoul-
assigned to either a traditional rotator-cuff-strength- women, 37 men) were assigned to a specific exercise group, der impingement syndrome were included in the study.
ening program (20 women, 10 men) or a traditional and 46 patients (22 women, 24 men) were assigned to a Patients were included if they had a long history (>1 y)
rotator-cuff strength-training program with a loaded control exercise group. of shoulder pain and were waiting for shoulder surgery.
eccentric-training component (16 women, 15 men). Patients were included if they had pain in the shoulder for Inclusion was confirmed with a clinical examination per-
Patients were included if they were over the age of 18 at least 6 mo, experienced no improvements from previous formed by an orthopedic surgeon.
with pain in the affected shoulder for at least 3 mo, multimonth treatment programs, and had positive results on Patients were excluded if they had arthritis in the acro-
positive results on 2 of 3 shoulder impingement tests, 3 of 4 impingement tests. A positive Neer impingement test mioclavicular joint and if they suffered mechanical
positive painful result on 2 of 4 resistance tests, pain- was also required for inclusion. impingement of the rotator cuff due to calcifications.
ful arc, and pain with palpation of either the supraspi- Patients were excluded if they had serious shoulder-health
natus or infraspinatus tendon. issues such as malignancy and osteoarthritis. Other reasons
Patients were excluded if they had a rupture of the for exclusion were decreased subacromial space, history
rotator cuff; history of shoulder surgery, fracture, or of shoulder fracture or surgery, frozen shoulder, shoulder
dislocation; or a traumatic onset of pain. In addition, instability, fibromyalgia, symptoms arising from the cervi-
patients who suffered from other conditions including cal spine, recent history of corticosteroid injection, or an
osteoarthritis, frozen shoulder, shoulder instability, inability to speak English.
and nerve injuries were excluded.
Intervention All participants attended 9 physiotherapy visits and All patients received a cortisone injection before engagingAll patients completed an eccentric exercise program
investigated performed a home exercise program over a span of 12 in their respective exercise programs, attended 7 physio- that targeted the rotator cuff through use of the Ulla-sling
wk. All participants performed a traditional rotator- therapy sessions, and performed a home exercise program device. Patients performed an empty-can motion that
cuff strength-training program consisting of internal over a span of 12 wk. elicited pain in a series of 3 sets of 15 repetitions, 2 times
and external rotation resisted exercise performed with The specific exercise group performed 2 rotator-cuff eccen- a day, every day, over a span of 12 wk. Increased load
an elastic band. These 2 exercises were performed tric exercises and 3 scapula-stabilizer concentric/eccentric through added weight was applied as exercises became

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once a day at home in a series of 3 sets of 10 repeti- exercises that were all done in a series of 3 sets of 15 repe- pain-free. At the conclusion of the 12 wk, participants
tions. Exercises were performed with no more pain titions 1 time a day for 8 wk. In addition, a posterior shoul- were encouraged to continue the program 2 times per
than at rest, and band resistance was increased when der stretch was performed 3 times twice a day for 30–60 s. week.
pain decreased. All strengthening and stretching exercises were repeated All participants were contacted 2 wk after initial treat-
The experimental group also completed a heavy-load once a day for the remaining weeks. Patients were educated ment to determine compliance with the protocol. Compli-
eccentric exercise twice a day in a series of 3 sets of on acceptable pain levels during exercises, and external- ance issues were addressed immediately.
10. The heavy-load eccentric exercise consisted of the load resistance was adjusted regularly using weights or
eccentric phase of full-can abduction in the scapular elastic bands based on a model for pain monitoring. At the
plane with dumbbell weight resistance. Full-can range conclusion of the 12 wk, participants were encouraged to
and resistance weight were monitored and adjusted maintain the home exercise program for an additional 2 mo.
based on presence (decreased) or absence (increased) The control exercise group was given 6 unspecified exer-
of pain. cises or movements for the shoulder and neck without the
All participants kept a journal to record sessions and use of resistance from an external load. Movement exer-
adverse events and were asked to refrain from includ- cises were repeated 10 times. Stretching exercises were
ing other strength exercises or engaging in other treat- repeated 3 times twice a day at home and every other week
ments during the study. at the physiotherapy session. The same program was com-
pleted for the 12 wk without progression.
All participants kept a journal to monitor protocol adher-
ence.
(continued)
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Table 2 (continued)
Maenhout et al9 Holmgren et al11 Jonsson et al12
Outcome Function and pain: The SPADI questionnaire was Function: The Constant-Murley shoulder score was used Function: Shoulder function was assessed with the Con-
measures used to evaluate pain and function on a 0- to 100-point to evaluate shoulder function on a scale of 0 to 100. Higher stant-Murley score.
scale. Higher scores suggest more pain and less func- scores suggest better function. Pain: A 100-mm (0 = no pain; 100 = severe pain) visual
tion. Disability and symptoms: The DASH scale was used to analogue scale (VAS) was used to measure shoulder pain
Strength: Abduction strength was measured at 0°, measure upper-extremity disability and symptoms on a during horizontal activity.
45°, and 95° of abduction in the scapular plane, and scale of 0 to 100. Lower scores indicate less disability and Satisfaction: Patients indicated whether they were satis-
internal and external strength were measured with arm fewer symptoms. fied with either a “yes” or a “no” response.
at side and elbow bent to 90° using a handheld dyna- Pain: A 100-mm (0 = no pain; 100 = severe pain) visual
mometer. Peak torque was recorded as the average of analogue scale was used to measure shoulder pain at rest, Measurements of function and pain were recorded prior
3 trials. to treatment and again at 12 and 52 wk posttreatment.
during activity, and at night in the 24 h prior to the evalua- Satisfaction was recorded once.
Global rating of improvement: Perceived improvement tion.
was rated by patients as either improved, not changed, HRQOL: HRQOL was evaluated with the EuroQol (EQ-5D
or worse. and EQ VAS).
Measurements of all variables were made at 6 and 12 Measurements were made prior to the start of treatment and
wk after the start of treatment. after the 12-wk treatment program.
Global rating of improvement: Perceived improvement
was rated by patients on a 5-point Likert scale (worse,
unchanged, small improvement, large improvement, or
recovered).
Main Function and pain: Both groups reported improve- Function: Constant-Murley score improved more in the Function: The mean Constant-Murley scores for satis-
findings ment in function and pain as reported by the SPADI specific exercise group than the control exercise group fied and unsatisfied patients were 80 and 50, respectively,
(P < .001), and these changes occurred at both 6 and (between-groups mean difference = 15 points). after 12 wk of treatment. The Constant-Murley score sig-

JSR Vol. 25, No. 2, 2016

12 wk after treatment (P < .001). Over 85% of people Disability and symptoms: Scores on the DASH improved nificantly increased in the satisfied group over the 12-wk
in both groups reported a change in SPADI score of more in the specific exercise group than the control exercise period (P < .043). The mean Constant-Murley score of
at least 10 points, which reflects clinical meaningful group (between-groups mean difference = 8 points). the satisfied group was 81 at 52 wk posttreatment.
change. Pain: The mean VAS scores for satisfied and unsatisfied
Pain: VAS ratings at night improved more in the specific
Strength: Isometric strength increased for abduction exercise group than the control exercise group (between- patients were 18 and 67, respectively, after 12 wk of treat-
at 0° (P < .001) and 45° (P < .001) scapular abduc- groups mean difference = 20 points).VAS ratings did not ment. Pain significantly decreased in the satisfied group
tion and for internal (P = .038) and external rotation differ between groups for either pain with activity or pain over the 12-wk period (P < .043). The mean VAS was 31
(P < .001) in both groups. Both groups demonstrated at rest. for the satisfied group at 52 wk posttreatment.
isometric strength improvements for abduction and Satisfaction: 5 patients were satisfied with treatment and
external rotation over the first 6 wk of treatment only, HRQOL: Scores on EQ-5D were higher in the specific
exercise group than the control exercise group (between- 4 were not. Satisfied patients withdrew from the surgical
and internal-rotation isometric-strength improvements list. One unsatisfied patient was misdiagnosed.
were noted over the 12-wk treatment period. After 12 groups mean difference = .09). No group differences were
wk of treatment, the experimental group increased noted for the EQ-VAS.
isometric strength 15% more at abduction to 90° than Global rating of improvement: Successful outcomes were
the control group, which did not improve (P = .033). reported more in the specific exercise group (69%) than the
Global rating of improvement: Ratings of perceived control exercise group (24%). Fewer patients in the specific
improvement were similar in both groups, with no one exercise group (20%) selected surgery than in the control
reporting worse health of the shoulder after treatment. exercise group (63%).

199
(continued)
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200
Table 2 (continued)
Maenhout et al9 Holmgren et al11 Jonsson et al12
Level of
evidence 2b 2b 3
Validity
score NA NA NA
Conclusion A heavy-load eccentric-exercise program resulted in An exercise program designed to focus on strengthening A painful eccentric-training program for the supraspina-
significantly improved function, pain, and isometric the rotator cuff using concentric/eccentric exercises resulted tus and deltoid muscles resulted in satisfaction in over
strength when performed over 12 wk, but these dif- in significantly improved shoulder function and decreased half of the small sample included in the study, and these
ferences were largely no different than for those who pain, especially at night, when performed over 12 wk. In satisfied individuals reported improved function and
performed a traditional rehabilitation program with no addition, this specific program resulted in higher reports of decreased pain. Those satisfied also withdrew from surgi-

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heavy-load eccentric-exercise component. The only successful outcomes and fewer surgeries than the control cal consideration. The painful eccentric-training program
difference between groups was the increase in isomet- group’s program. warrants further study with a larger sample.
ric strength during scapular abduction at 90° experi-
enced by the experimental group.
Abbreviations: SPADI, Shoulder Pain and Disability Index; DASH, Disabilities of the Arm, Shoulder, and Hand; HRQOL, health-related quality of life.
 Eccentric Exercise and Shoulder Impingement   201

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