What is the best treatment for shoulder impingement syndrome (tennis shoulder)?

Treatment of Shoulder Impingement Syndrome (Tennis Shoulder)

The best treatment for shoulder impingement syndrome (tennis shoulder) is a structured approach beginning with conservative measures including exercise therapy and NSAIDs, with more invasive interventions reserved for those who fail to respond to initial treatment. 1, 2

Initial Conservative Management

First-Line Treatments

• Exercise Therapy

  • Implement exercises focused on external rotation and abduction 2
  • Include eccentric strengthening exercises specifically targeting the rotator cuff 2
  • Add gentle passive and active-assisted range of motion exercises 2
  • Several level II studies demonstrate exercise decreases pain and improves function in patients with rotator cuff-related symptoms 1

• Pain Management

  • Acetaminophen (up to 4g/day) as first-line analgesic 2
  • NSAIDs at lowest effective dose for shortest duration if acetaminophen is inadequate 1, 2
  • Consider topical NSAIDs to reduce tendon pain while avoiding gastrointestinal side effects 1, 2
  • Apply ice through a wet towel for 10-minute periods for acute pain relief 1

Adjunctive Measures

• Activity Modification

  • Avoid overhead activities that exacerbate symptoms 2
  • Implement technique modification for athletes to minimize repetitive stress 1
  • Use a sling temporarily for protection if needed 2

• Supportive Devices

  • Consider braces to reinforce and protect tendons during activity 1
  • While limited data supports their effectiveness, braces are safe and may help correct biomechanical problems 1

Second-Line Interventions

Corticosteroid Injections

• May be more effective than oral NSAIDs for acute phase pain relief 1
• Do not tend to alter long-term outcomes 1, 2
• Use with caution as they may inhibit healing and reduce tendon tensile strength 1
• Should be limited to no more than 2 injections 3

Physical Modalities

• Therapeutic Ultrasound

  • May decrease pain and increase collagen synthesis rate 1
  • Evidence for consistent benefit is weak 1

• Extracorporeal Shock Wave Therapy (ESWT)

  • Appears safe and potentially effective 1
  • Further research needed to clarify mechanisms and optimal treatment strategies 1

• Other Modalities

  • Iontophoresis and phonophoresis are widely used but lack well-designed RCTs 1
  • Heat application may help control pain 2
  • Soft tissue massage can help manage symptoms 2

Advanced Interventions for Persistent Cases

Imaging

• Plain radiographs should be the first imaging study to rule out bony abnormalities 2
• MRI or ultrasound for further evaluation if symptoms persist 1, 2

Surgical Options

• Consider if pain persists despite 3-6 months of well-managed conservative treatment 1
• Surgical techniques typically include:
  • Excision of abnormal tendon tissue
  • Longitudinal tenotomies to release areas of scarring and fibrosis 1

Special Considerations

For Tennis Players

• Tennis requires unique shoulder demands with high risk for overuse 4
• Focus rehabilitation on:
  • Concentric work to position and move the arm
  • Eccentric work to stabilize the shoulder
  • Effective depression of the humeral head to avoid impingement 4
  • Sport-specific exercises should be incorporated into rehabilitation 2, 5

Common Pitfalls

• Overreliance on Corticosteroids: May weaken tendon structure and predispose to rupture 1
• Neglecting Scapular Function: Rehabilitation should focus on restoration of intramuscular trapezius muscle balance 5
• Ignoring the Kinetic Chain: Shoulder rehabilitation should be integrated into kinetic chain training from initial phases 5
• Delayed Progression: Failure to advance from conservative to surgical management when appropriate can lead to prolonged disability 1

By following this structured approach, most patients with shoulder impingement syndrome can achieve significant pain relief and functional improvement, with surgery reserved for those who fail to respond to comprehensive conservative management.