What is the initial treatment for impingement shoulder?

Initial Treatment for Shoulder Impingement

The initial treatment for shoulder impingement should include gentle stretching and mobilization techniques, particularly focusing on external rotation and abduction, along with pain management using NSAIDs and activity modification. 1, 2

Conservative Management Algorithm

Step 1: Pain Management

• NSAIDs: First-line medication for pain control 2
• Local thermal interventions: Apply ice or heat for symptomatic relief 2
• Activity modification: Avoid painful overhead movements and activities that exacerbate symptoms 2

Step 2: Rehabilitation Exercises

1. Early Phase (1-2 weeks):

   • Gentle range of motion exercises 1
   • Proper positioning education to prevent further impingement 1
   • Avoid overhead pulleys which encourage uncontrolled abduction 1

2. Progressive Phase (2-6 weeks):

   • Active range of motion exercises focusing on external rotation and abduction 1
   • Gradual strengthening of rotator cuff muscles 1, 2
   • Scapular stabilization exercises 2

Step 3: Advanced Interventions (if inadequate response after 6 weeks)

• Corticosteroid injections: Consider for significant pain relief 1, 2
  • Subacromial corticosteroid injections when pain is related to inflammation of the subacromial region 1
  • Limit to 3-4 injections per year to avoid potential tendon weakening 2

Important Clinical Considerations

Assessment Priorities

• Evaluate tone, strength, soft tissue changes, and joint alignment of the shoulder girdle 1
• Differentiate between subacromial, internal, and subcoracoid impingement types 3

Treatment Efficacy

• Exercise has been shown to improve outcomes of pain, strength, range of motion, and function in patients with impingement syndrome 4
• Manual therapy combined with exercise may provide enhanced pain relief 4

Common Pitfalls to Avoid

1. Overreliance on imaging: Initial treatment should begin before advanced imaging in most cases
2. Premature surgical referral: Conservative management should be tried for at least 3 months before considering surgical options 2
3. Using overhead pulleys: These can worsen impingement by encouraging uncontrolled abduction 1
4. Excessive corticosteroid injections: Limit to 3-4 per year to prevent tendon weakening 2

Follow-up Timeline

• Initial follow-up at 1-2 weeks to assess response to treatment 2
• Clinical reassessment at 6 weeks to evaluate progress 2
• Consider surgical consultation if no improvement after 3 months of appropriate rehabilitation 2

This approach prioritizes conservative management with a focus on improving range of motion and strengthening while managing pain, which has been shown to be effective for most patients with shoulder impingement syndrome 3, 4.