What is the recommended treatment for shoulder impingement?

Treatment for Shoulder Impingement

The recommended first-line treatment for shoulder impingement includes relative rest, analgesics such as acetaminophen, NSAIDs, and eccentric strengthening exercises, avoiding prolonged immobilization that could worsen the condition. 1

Diagnostic Assessment

• Radiography is recommended as initial imaging to rule out fractures or arthritic changes 1
• Ultrasound is highly appropriate for evaluating tendon injuries with 94% specificity for detecting tendon pathology 1
• MRI without contrast is indicated if symptoms persist after initial treatment 1

Conservative Treatment Algorithm

First-line Interventions (0-4 weeks)

• Pain management:
  • Acetaminophen (up to 4g/day) as first-line analgesic 1
  • NSAIDs at lowest effective dose for shortest duration if acetaminophen is inadequate 1
  • Topical NSAIDs for localized pain with fewer systemic side effects 1
• Activity modification:
  • Reduce activities that cause pain and overload of the affected tendon 1
  • Avoid overhead movements that exacerbate symptoms 2
• Exercise therapy:
  • Begin eccentric strengthening exercises to reverse degenerative changes 1
  • Progress gradually in intensity and volume 1
  • Focus on rotator cuff strengthening and scapular stabilization 2

Second-line Interventions (4-6 weeks if no improvement)

• Corticosteroid injections:
  • Subacromial corticosteroid injections can be used when pain is related to inflammation of the subacromial region 3
  • Effective for short-term relief in the acute phase of tendon pain 1
• Physical therapy intensification:
  • Manual therapy techniques 4
  • Progressive resistance training 2
• Orthotic support:
  • Bracing for functional support rather than immobilization 1
  • Correct biomechanical problems 1

Third-line Interventions (3-6 months if persistent symptoms)

• Advanced injection options:
  • Viscosupplementation (hyaluronic acid) injections may be considered 3
• Surgical consideration:
  • If no improvement after 3-6 months of conservative treatment 4
  • Surgical options include decompression, debridement, and/or repair of injured structures 2

Special Considerations

For Post-stroke Hemiplegic Shoulder Pain

• Botulinum toxin injections into the subscapularis and pectoralis muscles can be useful to reduce severe hypertonicity in hemiplegic shoulder muscles 3
• Suprascapular nerve blocks may be considered as an adjunctive treatment 3
• Positioning and supportive devices are reasonable for shoulder subluxation 3

For Patients with Rheumatoid Arthritis

• May require early surgical intervention to prevent tendon rupture 1
• Multiple symptomatic tendons should alert to possibility of rheumatic disease 1

For Diabetic Patients

• May respond less to conservative measures and require modified treatment approaches 1

Prognosis

• Approximately 80% of patients recover completely within 3-6 months with conservative treatment 1
• Evaluate pain and function every 2-4 weeks 1
• Progress to sport-specific or activity-specific exercises as symptoms improve 1

Common Pitfalls to Avoid

• Using overhead pulley exercises (not recommended) 3
• Prolonged immobilization, which can worsen the condition and delay recovery 1
• Delaying exercise therapy, which should be started as soon as possible to recover joint functionality 1
• Relying solely on passive treatments without addressing underlying biomechanical issues 2

The most recent evidence emphasizes the importance of active rehabilitation approaches over passive treatments, with surgical intervention reserved only for cases that fail to respond to comprehensive conservative management over 3-6 months 4, 2.