What is the treatment for Subacromial Impingement Syndrome?

Treatment of Subacromial Impingement Syndrome

The first-line treatment for Subacromial Impingement Syndrome (SAIS) should be non-operative management with exercise therapy, NSAIDs, and activity modification for 4-6 weeks before considering other interventions. 1

Initial Treatment (0-6 weeks)

First-Line Approach

• Exercise Therapy:

  • Specific, low-intensity, high-frequency exercises focusing on:
    • Eccentric training for rotator cuff muscles
    • Scapular stabilization exercises
    • Gentle progressive stretching and range of motion exercises 1, 2
  • Progressive strengthening has shown superior outcomes compared to non-specific exercises (mean difference of 15 points on Constant-Murley score) 2

• Pain Management:

  • NSAIDs (oral or topical) for pain and inflammation 1
  • Acetaminophen as an alternative for those who cannot tolerate NSAIDs

• Activity Modification:

  • Reduce activities that exacerbate pain
  • Avoid movements that stress the affected area 1
  • Maintain good posture during daily activities

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

Subacromial Injections

• Corticosteroid with lidocaine injection:
  • Provides significant pain reduction for up to 12 weeks 1
  • Should be combined with continued exercise therapy 1, 3
  • A single injection can decrease pain by approximately 38% within 24 hours 3
  • Note: The evidence for subacromial injections in rotator cuff tears is inconclusive 4

Continued Exercise Program

• Continue and potentially intensify the exercise program
• Supervised physical therapy may be beneficial 5
• Long-term studies show significant improvement in shoulder function with dedicated physical therapy (Penn shoulder score improvement from 59 to 81 over 2 years) 5

Treatment for Persistent Symptoms (8-12 weeks)

Additional Interventions

• Occupational interventions if symptoms persist beyond 6 weeks 6
• Specialized rehabilitation for chronic, treatment-resistant cases with pain-perpetuating behavior 6
• Hyperthermia has shown moderate evidence of effectiveness compared to exercise therapy or ultrasound in the short term 7
• For calcific tendinitis: Consider extracorporeal shock wave therapy (ESWT) or needling under ultrasound guidance (barbotage) 6

Surgical Consideration (3-6 months)

• Consider surgical consultation if minimal improvement after 3-6 months of well-managed conservative treatment 1
• Important note: There is no convincing evidence that surgical treatment for SAIS is more effective than conservative management 6
• The primary indication for rotator cuff repair is significant pain, not just the presence of a tear 4

Diagnostic Considerations

• Diagnosis requires a combination of clinical tests 6
• Positive Hawkins and Neer tests with intact muscle strength indicate SAIS (high sensitivity but low specificity) 1
• Ultrasound is recommended as first imaging choice to exclude rotator cuff tears 1
• Lidocaine injections have diagnostic utility - significant pain relief supports the diagnosis of SAIS 1

Common Pitfalls to Avoid

1. Rushing to surgical intervention before adequate trial of conservative management
2. Overreliance on corticosteroid injections without concurrent exercise therapy
3. Failure to reassess and modify treatment plan if no improvement is seen
4. Treating asymptomatic rotator cuff tears surgically (not recommended) 4, 6

Prognosis

• Most cases (>90%) have good prognosis with appropriate conservative management 1
• Patients with more severe disease, longer symptom duration, and type II or III acromion morphology may respond less favorably to conservative treatments 1
• Diabetic patients may require modified approaches 1

Progressive strengthening exercises specifically targeting the rotator cuff and scapular stabilizers have shown superior outcomes compared to non-specific exercises, with fewer patients subsequently choosing surgery (odds ratio 7.7) 2.