Rehabilitation of bilateral shoulder impingement in a calisthenics and yoga athlete: A case report

INTRODUCTION

Subacromial impingement syndrome, commonly encompassed within the broader term subacromial pain syndrome, is one of the most frequent causes of non-traumatic shoulder pain and functional limitation in physically active individuals.^[1] Repetitive overhead movements, end-range loading, and sustained weight-bearing through the upper limbs place considerable stress on the rotator cuff tendons, subacromial bursa, and surrounding soft tissues.^[1,2] Activities such as calisthenics and yoga require a combination of strength, mobility, and neuromuscular control in elevated and closed-chain positions, increasing susceptibility to subacromial pain.

The etiology of subacromial impingement is multifactorial and includes both functional and structural contributors. Functional factors include altered scapular kinematics, impaired neuromuscular control, muscle imbalance, and training overload, whereas structural contributors, such as reduced subacromial space due to acromial morphology, may predispose individuals to persistent symptoms.^[3] Differentiating these mechanisms is clinically important, as prognosis and response to conservative treatment may differ.^[1,3]

Current evidence supports structured, exercise-based physiotherapy as the first-line intervention for subacromial impingement, with outcomes comparable to surgical decompression in many cases.^[1,2] This case report presents the assessment and rehabilitation of a recreational calisthenics and yoga athlete with bilateral subacromial impingement, demonstrating contrasting outcomes between a functionally driven and a structurally constrained presentation.

CASE REPORT

A 32-year-old male recreational athlete practicing calisthenics and yoga presented to a sports physiotherapy unit with a 2-year history of bilateral anterolateral shoulder pain. Symptoms initially developed insidiously in the right shoulder following an increase in calisthenics training volume involving frequent handstands, arm balances, and overhead strength exercises. Pain in the left shoulder developed shortly thereafter, likely due to compensatory loading. The athlete discontinued calisthenics but continued yoga for approximately 2 months, after which pain during weight-bearing and end-range postures led to cessation of overhead activity. Activities of daily living, such as lifting, reaching, and side-lying sleep, were affected.

Magnetic resonance imaging performed in 2023 demonstrated a chondrolabral tear with deltoid origin strain and subacromial bursal fluid in the right shoulder and subacromial bursal fluid with a type III (hooked) acromion in the left shoulder. Previous physiotherapy had not resulted in meaningful symptom relief.

On examination, pain was reproduced at end-range active elevation and during overhead loading, with no resting pain. Activity-related pain intensity was rated as 7/10 bilaterally on the Verbal Rating Scale. Active range of motion was restricted and painful at the end range in both shoulders. Manual muscle testing revealed grade 4 strength across major shoulder and scapular muscle groups, with slightly reduced abduction strength on the left side. Neer and Hawkins– Kennedy impingement tests were positive bilaterally, and the empty can test was positive on the right side.

The Neer and Hawkins–Kennedy tests are widely used for subacromial impingement and show moderate reliability (κ ≈ 0.39–0.40) and sensitivity of 72–79% when used together, while the empty can test assesses supraspinatus involvement.^[4,5] Pain intensity was measured with the Verbal Rating Scale, which has excellent test–retest reliability (Intraclass correlation coefficient (ICC) ≈ 0.93) and good concurrent validity.^[6] Shoulder range of motion was assessed using a universal goniometer, demonstrating excellent intra- and inter-rater reliability (ICC > 0.90).^[7] Muscle strength was evaluated through Manual Muscle Testing, which has good reliability and validity for clinical grading of gross muscle strength.^[8]

Based on clinical and imaging findings, bilateral subacromial impingement syndrome was diagnosed, classified as predominantly functional on the right side and predominantly structural on the left side.^[3]

DISCUSSION

This case report highlights the clinical importance of distinguishing functional and structural contributors in subacromial impingement syndrome, particularly in physically active individuals. The contrasting outcomes between shoulders reinforce evidence suggesting that the underlying mechanism of impingement strongly influences prognosis and response to conservative rehabilitation.^[1,3]

The complete resolution of symptoms in the right shoulder is consistent with findings that functionally driven subacromial pain, characterized by neuromuscular control deficits and training-related overload, responds favorably to exercise-based physiotherapy. Current clinical guidelines emphasize scapular stabilization, rotator cuff strengthening, and graded exposure to load as central components of management.^[1,2]In contrast, the left shoulder demonstrated persistent mild symptoms despite meaningful improvements in pain, strength, and range of motion. The presence of a type III acromion is associated with reduced subacromial space and increased mechanical compression during elevation, which may limit complete symptom resolution despite adequate rehabilitation.^[9] These findings align with previous reports and underscore the importance of realistic goal setting and long-term load modification in individuals with structural constraints.^[3,9]

Manual therapy techniques were incorporated as adjuncts to exercise. Joint mobilization and mobilization with movement have demonstrated short-term benefits in pain reduction and range of motion when combined with active rehabilitation programs.^[4] The early use of Maitland mobilizations likely facilitated pain modulation and improved capsular mobility, while Mulligan mobilization with movement techniques may have contributed to the restoration of pain-free elevation by addressing positional faults and enhancing sensorimotor integration.^[4]

Adjunct electrotherapeutic modalities were used selectively during the initial phase of rehabilitation. Although their independent effectiveness remains debated, evidence suggests that they may assist in short-term pain reduction when used alongside exercise-based interventions.^[1,2] Their application in this case primarily supported patient engagement in active rehabilitation rather than serving as stand-alone treatments. From a sport-specific perspective, calisthenics and yoga demand high levels of shoulder stability, strength, and control in end-range and weight-bearing positions. Deficits in scapular control and rotator cuff endurance can substantially increase subacromial stress. The favorable outcome in the functionally driven shoulder highlights the value of early intervention and training modification, whereas the structurally constrained shoulder may require prolonged conservative management and monitoring.^[3,9]

Several limitations should be acknowledged. Outcomes reflect short-term changes only, and validated patient-reported outcome measures such as the Disabilities of the Arm, Shoulder, and Hand questionnaire were not used. Future studies should incorporate standardized patient-reported measures and longer follow-up periods to better capture recovery trajectories, particularly in individuals with structural risk factors.

CONCLUSION

An individualized 3-week multimodal physiotherapy program resulted in complete recovery in a functionally driven shoulder and clinically meaningful improvement in a structurally constrained shoulder with type III acromion. Differentiating functional and structural contributors is essential for prognosis, rehabilitation planning, and patient education in subacromial impingement syndrome.