Pain relieving strategies are initiated, to improve exercise compliance. Michener et al. 2004 in a high quality systematic review suggest that therapeutic exercises when combined with joint mobilization are superior to individual interventions. Thus low Grade oscillatory mobilizations are indicated not only for their analgesic effect via pain gate stimulation but also for improving therapeutic relationship thereby influencing treatment compliance (Hengeveld and Banks 2005). Although there is inconclusive evidence to support the use of electrotherapy, medications and cryotherapy; a high quality RCT concluded that subacromial injections when combined with exercise provide successful long term outcomes in shoulder impingement (Crawshaw et al. 2010). Despite the possibility of minor adverse effects, local injections are indicated for Mrs X based on their anti-inflammatory and analgesic action providing symptomatic relief thereby improving exercise tolerance.

Shoulder girdle muscle setting exercises can be used for their analgesic effect and to prevent disuse muscle atrophy (Kolby and Kisner 2007). Activation of the proximal kinetic chain focussing on trunk control, core strengthening and modification of dysfunctional posture is a prerequisite for optimum muscle activation in the distal chain (Kibler et al. 2000). The rationale of shoulder impingement rehabilitation is to correct the scapular dyskinesia thereby providing a stable base for the rotator cuff muscles (Ellenbecker and Cools 2010). Closed chain (CC) exercises are integral early in the rehabilitation since they are functional, reduce sheer stresses, improve joint proprioception and cause co- contraction of the force couples at the shoulder girdle leading to rotator cuff activation with minimal deltoid recruitment (Kibler and Livingston 2001).

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