What is the recommended treatment for a patient with subacromial impingement syndrome and intact muscle strength, who tested positive on Hawkins and Neer tests?

Treatment for Subacromial Impingement Syndrome with Positive Hawkins and Neer Tests

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

Diagnostic Significance

Positive Hawkins and Neer tests with intact muscle strength indicate subacromial impingement syndrome (SAIS), likely involving the supraspinatus tendon. These tests are highly sensitive (92% and 88% respectively) but not specific (25% and 33% respectively) for impingement. 2

Treatment Algorithm

First-Line Treatment (0-6 weeks)

1. Exercise Therapy

   • Specific, low-intensity, high-frequency exercises
   • Combine eccentric training with attention to relaxation and posture
   • Include stretching and treatment of myofascial trigger points 1, 3

2. Pain Management

   • NSAIDs (oral or topical) for pain and inflammation
   • Acetaminophen as an alternative if NSAIDs are contraindicated 1

3. Activity Modification

   • Reduce activities that exacerbate pain
   • Avoid overhead movements that stress the affected area 1

Second-Line Treatment (if inadequate response after 4-6 weeks)

1. Subacromial Corticosteroid Injection

   • A single subacromial injection of corticosteroid with local anesthetic
   • Provides short-term pain relief and enables more effective exercise therapy 3, 4
   • Continue exercise program alongside injection therapy 1

2. Diagnostic Imaging

   • Ultrasound is recommended as first imaging choice after 6 weeks of persistent symptoms
   • Used primarily to exclude rotator cuff tears 1, 3

Third-Line Treatment (if minimal improvement after 8-12 weeks)

1. Specialized Rehabilitation

   • Consider referral to specialized rehabilitation unit for chronic, treatment-resistant cases 3

2. Consider Additional Modalities

   • Extracorporeal shock wave therapy (ESWT) may be considered, particularly for calcific tendinitis 2, 3

Evidence-Based Outcomes

Exercise therapy has demonstrated superior outcomes compared to other interventions. A randomized controlled trial comparing exercise therapy to platelet-rich plasma (PRP) injections found that exercise therapy was more effective in reducing pain and improving shoulder abduction and function, particularly in the first three months of treatment. 5

Another study showed that patients receiving a combination of physical therapy and subacromial corticosteroid injection had significantly higher functional scores (Constant scores) at six weeks compared to physical therapy alone. 4

Important Considerations

• Avoid Strict Immobilization: This is not recommended and may lead to stiffness and prolonged recovery 3

• Surgical Referral: Consider only if minimal improvement after 3-6 months of well-managed conservative treatment 1

• 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 1

• Prognosis: Over 90% of cases have good outcomes with appropriate conservative management, making non-operative approaches the clear first choice 1