From the Guidelines
Treatment for shoulder impingement should prioritize non-operative care, with surgery considered only after failure of conservative measures. This approach is supported by recent high-level evidence, including a 2021 umbrella review of level 1 evidence published in the BMJ 1. The review highlights the importance of seeking high-level evidence to support surgery and notes that non-operative care is often equivalent to surgical interventions.
Non-Operative Treatment Options
Non-operative treatment for shoulder impingement typically includes:
- Rest from aggravating activities
- Ice application for 15-20 minutes several times daily to reduce inflammation
- Over-the-counter NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (220-500mg twice daily) for pain and inflammation
- Physical therapy, focusing on stretching and strengthening exercises for the rotator cuff and scapular muscles, typically 2-3 sessions weekly for 6-8 weeks
- Manual therapy techniques to improve joint mobility
Role of Surgery
Surgery, such as arthroscopic subacromial decompression, may be considered for patients with pure subacromial shoulder impingement whose symptoms fail to resolve with adequate non-operative treatment, as recommended by national clinical guidelines 1. However, the evidence base for the effectiveness of these procedures is limited and of low quality, emphasizing the need for careful consideration and further research.
Corticosteroid Injections
For persistent pain, corticosteroid injections into the subacromial space can provide temporary relief, though usually limited to 2-3 injections per year. The use of these injections should be judicious and based on individual patient needs.
Rehabilitation
Rehabilitation plays a crucial role in the treatment of shoulder impingement, both after conservative treatments and following surgery. A comprehensive rehabilitation program can help reduce inflammation, strengthen supporting muscles, improve biomechanics, and prevent further injury.
From the Research
Treatment Options for Shoulder Impingement
The treatment options for shoulder impingement can be broadly categorized into conservative and surgical methods.
- Conservative treatment includes:
- Exercise therapy: Studies have shown that exercise therapy is an effective treatment for shoulder impingement syndrome 2, 3, 4.
- Physical therapy: Manual physical therapy has been found to be as effective as corticosteroid injections in improving shoulder function and reducing pain 5.
- Corticosteroid injections: While corticosteroid injections can provide temporary pain relief, they may not be as effective as physical therapy in the long term 5, 6.
- Surgical treatment includes:
- Arthroscopic subacromial decompression: This procedure has been found to be effective in improving shoulder function and reducing pain, but it may not be more effective than conservative treatment in all cases 3, 6, 4.
- Acromioplasty: This procedure involves removing bone spurs from the acromion and has been found to be effective in improving shoulder function and reducing pain 6.
Comparison of Treatment Options
Studies have compared the effectiveness of different treatment options for shoulder impingement.
- A systematic review and meta-analysis found that physical therapy combined with subacromial cortisone injection is a first-line treatment, while acromioplasty with physical therapy is best if nonoperative interventions fail 6.
- Another study found that conservative treatment was superior to surgical treatment in terms of return to work and reduction of pain and functional impairment 3.
- A review of seven randomized controlled trials found that the evidence on the effectiveness of surgical or conservative treatment of shoulder impingement is limited, but there is moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement 4.
Recommendations
Based on the available evidence, the following recommendations can be made:
- Conservative treatment, including exercise therapy and physical therapy, should be considered as the first line of treatment for shoulder impingement 2, 3, 4.
- Corticosteroid injections may be considered for temporary pain relief, but their use should be limited due to potential side effects and lack of long-term effectiveness 5, 6.
- Surgical treatment, including arthroscopic subacromial decompression and acromioplasty, may be considered if conservative treatment fails, but the decision to undergo surgery should be made on a case-by-case basis, taking into account the individual patient's symptoms and preferences 3, 6, 4.