What is the recommended treatment for subacromial impingement?

Treatment of Subacromial Impingement Syndrome

Exercise therapy and NSAIDs should be the first-line treatment for subacromial impingement syndrome, as surgical interventions have not demonstrated clinically important benefits over non-operative management. 1

Initial Conservative Management

First-Line Treatments

• Exercise therapy:

  • Several level II studies demonstrate beneficial effects of exercise in decreasing pain and improving function in patients with rotator cuff-related symptoms without full-thickness tears 1
  • Focus on gentle, progressive stretching exercises and range of motion exercises
  • Both supervised and home exercise programs have shown improvements in outcomes 1

• NSAIDs:

  • Recommended as first-line medication for pain and inflammation 1
  • Options include oral NSAIDs (ibuprofen, naproxen) or topical NSAIDs for localized pain
  • Acetaminophen (up to 4g/day) is an alternative if NSAIDs are contraindicated

Adjunctive Therapies

• Activity modification:

  • Reduce activities that exacerbate pain
  • Avoid movements that stress the affected area

• Physical modalities:

  • Evidence is inconclusive for the use of ice, heat, iontophoresis, massage, TENS, PEMF, or ultrasound for subacromial impingement 1
  • TENS may provide some pain relief at 12 hours and on POD 7 1

Second-Line Interventions

Corticosteroid Injections

• Subacromial corticosteroid injections show mixed results:
  • Can provide short-term pain relief and improved range of motion 2
  • One study showed significant reduction in moderate/severe pain compared to control group (3 vs 15 patients) at mean follow-up of 33 weeks 2
  • Both anterior and posterior injection approaches appear equally effective 3
  • Addition of corticosteroid injection to NSAIDs showed better outcomes than NSAIDs alone 4
  • However, evidence is conflicting, with some studies showing no significant effect 1

Alternative Interventions

• Kinesiotaping:
  • May provide similar benefits to corticosteroid injections when added to NSAID treatment 4
  • Could serve as an alternative when corticosteroids are contraindicated

Surgical Management

Indications for Surgery

• Consider surgical options only after failure of conservative management for 3-6 months
• Significant functional limitations impacting quality of life
• Evidence of progressive joint degeneration

Surgical Options

• Arthroscopic subacromial decompression:

  • Recent high-quality evidence shows that subacromial decompression does not provide clinically important improvement in pain, function, or quality of life compared with other treatments including placebo surgery 1
  • No convincing evidence that any surgical technique is better than another or than conservative interventions 5

• Arthroscopic vs. Open decompression:

  • Similar clinical outcomes for both approaches
  • Arthroscopic approach may allow quicker return to work and shorter hospital stay 1

Treatment Algorithm

1. Initial treatment (0-6 weeks):

   • Exercise therapy (supervised or home program)
   • NSAIDs or acetaminophen
   • Activity modification

2. If inadequate response after 4-6 weeks:

   • Consider subacromial corticosteroid injection
   • Continue exercise program
   • Consider kinesiotaping as alternative if corticosteroids contraindicated

3. Reassess every 4-6 weeks:

   • Adjust treatment plan if no improvement after 8-12 weeks

4. If minimal improvement after 3-6 months of well-managed conservative treatment:

   • Consider surgical consultation
   • Discuss arthroscopic subacromial decompression, understanding limited evidence for superior outcomes compared to continued conservative management

Important Considerations

• The term "subacromial impingement syndrome" has been scrutinized as a vague umbrella term; it may be better subcategorized into subacromial, internal, and subcoracoid impingement 6
• Most cases (>90%) have good prognosis with appropriate conservative management
• Even with optimal management, resolution typically requires 3-6 months
• Diabetic patients may respond less favorably to conservative measures and may require modified approaches

Common Pitfalls to Avoid

• Rushing to surgical intervention before adequate trial of conservative management
• Overreliance on corticosteroid injections without concurrent exercise therapy
• Failure to reassess and modify treatment plan if no improvement is seen
• Expecting quick resolution of symptoms, as even optimal management typically requires months

Remember that high-quality evidence from recent studies indicates that surgical interventions do not provide clinically important benefits over non-operative management for subacromial impingement syndrome.