What is the initial treatment for shoulder impingement?

Initial Treatment for Shoulder Impingement

The initial treatment for shoulder impingement should be conservative management, including rest, ice packs, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy, before considering surgical interventions. 1, 2

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Imaging: Start with standard radiographs to rule out fractures and assess bony abnormalities

  • AP views in internal and external rotation
  • Axillary or scapula-Y view 1
  • Special views like Rockwood view may help evaluate impingement 1

• Advanced imaging if radiographs are noncontributory:

  • MRI without contrast (rating 9/9) or Ultrasound (rating 9/9) are equally appropriate for evaluating suspected impingement 1
  • MRI helps detect osseous and soft tissue abnormalities that may cause or result from impingement 1

Conservative Treatment Algorithm

1. First-line interventions (0-6 weeks):

   • Rest and activity modification to avoid painful movements
   • Ice packs for pain and inflammation reduction
   • NSAIDs to reduce pain and inflammation
   • Physical therapy focusing on:
     • Rotator cuff strengthening exercises
     • Scapular stabilization
     • Flexibility and range of motion exercises 2, 3

2. Second-line interventions (if inadequate response after 4-6 weeks):

   • Corticosteroid injection into the subacromial space 3
   • Manual therapy targeting the shoulder complex 4
   • Continued physical therapy with progression of exercises

3. Persistent symptoms (3-6 months of failed conservative treatment):

   • Consider surgical referral for evaluation for arthroscopic subacromial decompression 2

Evidence for Conservative vs. Surgical Management

High-quality evidence indicates no clinically important or statistically significant differences in outcomes between conservative and surgical interventions for shoulder impingement 5. A 2020 overview of systematic reviews found that shoulder-specific exercises should be considered first-line treatment before considering surgery 5.

Important Clinical Considerations

• Therapeutic dosage: Ensure adequate duration and intensity of conservative treatment (3-6 months) before considering surgical options 2
• Exclude other pathologies: Cervical spine issues, glenohumeral instability, and acromioclavicular joint arthritis can mimic impingement symptoms 6
• Subclassification: Consider the specific type of impingement (subacromial, internal, or subcoracoid) as this may guide specific treatment approaches 6

Common Pitfalls to Avoid

• Premature surgery: Surgical intervention before adequate trial of conservative management (at least 3-6 months) is not supported by evidence 5
• Overlooking contributing factors: Weakness of rotator cuff muscles, scapular dyskinesis, and poor posture can contribute to impingement and should be addressed in therapy 3, 6
• Inadequate rehabilitation: Physical therapy should be structured and progressive, not just a few simple exercises

Remember that shoulder impingement is often a multi-factorial condition requiring comprehensive assessment and a structured approach to conservative management before considering surgical options.