What is the initial treatment for shoulder impingement?

Initial Treatment for Shoulder Impingement

The initial treatment for shoulder impingement should consist of conservative management for 3 months, including a structured rehabilitation program, pain control with NSAIDs, and activity modification before considering surgical intervention. 1

Conservative Management Approach

Pain Management

• NSAIDs: First-line medication for pain control

  • Use the lowest effective dose for the shortest duration 1, 2
  • Starting dose of naproxen: 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as needed 2
  • Initial total daily dose should not exceed 1250 mg, with subsequent daily doses not exceeding 1000 mg 2
  • Use with caution in elderly patients and those with renal impairment 2

• Local Thermal Interventions:

  • Apply heat or cold for symptomatic relief 1
  • Can be used as adjunct to medication therapy

• Corticosteroid Injections:

  • Consider for significant pain when related to subacromial inflammation 1
  • Limit to no more than 3-4 injections per year to avoid potential tendon weakening 1
  • Note: While providing short-term relief, consider potential adverse effects on tendon biology and healing capacity 1

Rehabilitation Protocol

Implement a phased rehabilitation approach:

1. Phase 1:

   • Pain control measures
   • Gentle range of motion exercises
   • Proper positioning education
   • Isometric exercises if pain-free 1

2. Phase 2:

   • Progressive ROM exercises
   • Light strengthening of rotator cuff and periscapular muscles
   • Scapular stabilization exercises 1

3. Phase 3:

   • Progressive resistance training
   • Advanced scapular stabilization
   • Activity-specific training 1

Activity Modification

• Avoid painful movements 1
• Modify daily activities to prevent exacerbation of symptoms

Follow-up and Evaluation

• Initial follow-up: 1-2 weeks after treatment initiation to assess response 1
• Clinical reassessment: At 6 weeks to evaluate progress 1
• Rehabilitation progress evaluation: At 3 months 1
  • Consider imaging or surgical consultation if symptoms worsen or do not improve after 3 months of conservative management 1

Imaging Considerations

• Ultrasound: Recommended as initial diagnostic tool for suspected rotator cuff injuries 1

  • Cost-effective and comparable accuracy to MRI for full-thickness tears
  • Allows dynamic assessment of the shoulder

• MRI without contrast: Consider if ultrasound results are inconclusive or symptoms persist despite conservative management 1

Evidence Comparison and Clinical Implications

Recent evidence strongly supports conservative management as the first-line treatment for shoulder impingement. Multiple studies have shown no significant differences in outcomes between conservative and surgical interventions 3, 4. Conservative treatment also allows patients to return to work significantly earlier than those who undergo surgery 4.

Common Pitfalls and Caveats

• Dosing errors with NSAIDs: Always use the lowest effective dose for the shortest duration to minimize adverse effects 2
• Overuse of corticosteroid injections: Limit to 3-4 per year to avoid tendon weakening 1
• Inadequate rehabilitation: Ensure proper progression through all phases of rehabilitation
• Premature surgical referral: Remember that a full 3-month trial of conservative management is recommended before considering surgical options 1
• Neglecting special populations: Use caution with NSAIDs in elderly patients and those with renal impairment 2

By following this structured approach to conservative management, most patients with shoulder impingement can achieve significant improvement without requiring surgical intervention.