What is the treatment for shoulder impingement?

Treatment for Shoulder Impingement Syndrome

Shoulder impingement syndrome should be treated with a combination of subacromial corticosteroid injections, NSAIDs, and physical therapy as first-line treatment, with surgical intervention considered only after 3-6 months of failed conservative management. 1, 2

Diagnosis and Initial Assessment

• Pain with shoulder abduction is characteristic of subacromial pathology
• Initial imaging should include:
  • Plain radiography with anteroposterior views in internal and external rotation
  • Axillary or scapula-Y view 1
• Advanced imaging may be necessary if symptoms persist:
  • MRI shoulder without contrast (appropriateness rating 7/9)
  • MR arthrography if labral pathology is suspected (appropriateness rating 9/9)
  • Ultrasound is equally effective for evaluating rotator cuff (appropriateness rating 9/9 for suspected bursitis) 1

Treatment Algorithm

First-Line Treatment (0-3 months)

1. Medication Management

   • NSAIDs (ibuprofen, naproxen) or acetaminophen for pain relief 1
   • Subacromial corticosteroid injection - provides significant pain relief and functional improvement for up to 6 months 1, 3
     • Methylprednisolone acetate 40mg with lidocaine 1% provides more rapid pain relief compared to triamcinolone 1
     • Both anterior and posterior injection approaches are equally effective 3

2. Physical Therapy (begin immediately)

   • Gentle stretching and mobilization focusing on external rotation and abduction 1
   • Progressive strengthening of shoulder girdle muscles
   • Eccentric strengthening exercises combined with thermal therapy
   • Functional exercises to restore normal movement patterns 1

3. Important Precautions

   • Avoid overhead pulley exercises which can worsen symptoms 4, 1
   • Avoid shoulder immobilization with arm slings or wraps as it can lead to frozen shoulder 1

Second-Line Treatment (if no improvement after 3-6 months)

1. Advanced Treatment Options

   • Kinesiotaping in combination with NSAIDs (alternative when corticosteroids are contraindicated) 5
   • Suprascapular nerve blocks for refractory cases 1
   • For hemiplegic shoulder pain related to spasticity, consider botulinum toxin injections into the subscapularis and pectoralis muscles 1

2. Surgical Referral

   • Consider surgical treatment if symptoms persist despite 3-6 months of conservative management 1, 2
   • Surgical options include:
     • Arthroscopic subacromial decompression for impingement
     • Rotator cuff repair if indicated
     • Shoulder arthroplasty for advanced osteoarthritis 1

Prognosis and Expected Outcomes

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 1
• Physical therapy should begin immediately after surgery if performed, to prevent development of frozen shoulder 1
• Delaying physical therapy intervention should be avoided, as early treatment is crucial for optimal outcomes

Common Pitfalls to Avoid

1. Prolonged immobilization of the shoulder, which can lead to adhesive capsulitis
2. Overreliance on passive modalities without active rehabilitation
3. Using overhead pulley exercises which can exacerbate impingement symptoms
4. Delaying corticosteroid injection when indicated for pain relief
5. Rushing to surgery before adequate trial of conservative management (minimum 3-6 months)

The evidence strongly supports a stepwise approach to treatment, with most patients responding well to conservative measures including corticosteroid injections and physical therapy within 3-6 months 1, 2, 6.