What are the management options for shoulder impingement?

Management of Shoulder Impingement

Eccentric strengthening exercises should be the cornerstone of treatment for shoulder impingement, combined with activity modification and NSAIDs as needed for pain control. 1

First-Line Treatment Approach

Conservative Management (Initial 0-4 weeks)

• Activity modification and relative rest

  • Reduce activities that load the damaged tendon 1
  • May use a sling for protection to prevent further trauma and reduce pain 1

• 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
  • Consider topical NSAIDs to minimize systemic side effects 1

• Exercise therapy

  • Eccentric strengthening exercises 1-2 times daily 1
  • Gentle passive and active-assisted range of motion exercises 1
  • Focus on progressive loading protocols to gradually increase tendon tolerance 1

Progressive Phase (4-12 weeks)

• Increase intensity of eccentric exercises 1
• Add deep transverse friction massage to reduce pain in the affected area 1
• Sport-specific or activity-specific exercises for better functional outcomes 1
• Supervised physical therapy
  • Manual therapy techniques have shown superior outcomes compared to self-training programs alone 2
  • Land-based exercises are preferred over aquatic therapy 1

Advanced Treatment Options (if symptoms persist)

• Corticosteroid iontophoresis for pain and function improvement 1
• Ultrasound-guided injections may be considered 1, 3
• Therapeutic ultrasound to decrease pain and increase collagen synthesis 1
• Extracorporeal shock wave therapy (ESWT) for refractory cases, though evidence shows mixed results 1

Imaging

• Plain radiographs as first imaging study to rule out bony abnormalities 1, 4
• MRI or ultrasound for further evaluation if symptoms persist 1, 4, 5
  • MRI is currently the procedure of choice for evaluation of shoulder soft tissues 4
  • Ultrasound with appropriate expertise is excellent for rotator cuff and biceps pathology 4

Surgical Consideration

• Consider surgical treatment only if symptoms don't improve after 3-6 months of conservative treatment 5, 3
• Recent evidence shows no clinically important or statistically significant differences in outcomes between conservative versus surgical interventions for subacromial impingement syndrome 6
• Surgical options include decompression, debridement, and/or repair of injured structures 3

Treatment Monitoring

• Reassess pain and function every 4-6 weeks 1
• Adjust treatment plan if no improvement is seen after 8-12 weeks of consistent therapy 1

Common Pitfalls and Caveats

• Avoid peri-tendon corticosteroid injections as they can increase the risk of tendon rupture 1
• Don't rush to surgery - current evidence supports exhausting conservative options first 6
• Don't neglect underlying instability - shoulder impingement and instability exist on a continuum of abnormalities 7
• Clinical correlation is essential as imaging findings may exist in asymptomatic individuals 1