What is the treatment for shoulder impingement?

Treatment for Shoulder Impingement Syndrome

Conservative treatment should be the first-line approach for shoulder impingement syndrome, as it produces similar outcomes to surgical intervention while allowing patients to return to work significantly earlier. 1, 2

Clinical Presentation and Diagnosis

• Pain in the anterior or anterolateral aspect of the shoulder that worsens with overhead activities is a characteristic symptom of subacromial impingement syndrome (sensitivity 88%, specificity 33%) 3
• Decreased range of motion, particularly during abduction with external or internal rotation, is a common clinical manifestation 3
• Focal weakness in the affected shoulder is present in approximately 75% of patients 3
• Hawkins' test (forcible internal rotation with the arm flexed forward at 90 degrees) is highly sensitive (92%) but not specific (25%) for impingement 3
• Diagnostic imaging may include:
  • MRI to evaluate soft tissue abnormalities in the supraspinatus tendon, subacromial bursa, and biceps tendon (sensitivity 90%, specificity 80%) 3
  • Ultrasound to detect rotator cuff abnormalities (sensitivity 85%, specificity 90%) 3, 4

Conservative Treatment Options

Physical Therapy and Exercise

• Gentle stretching and mobilization techniques focusing on increasing external rotation and abduction 4
• Active range of motion exercises should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 4
• Shoulder-specific exercises that improve muscle strength and flexibility should be considered first-line treatment 1

Medications

• If no contraindications exist, analgesics such as acetaminophen or ibuprofen can be used for pain relief 4
• For cases with inflammation, a short course of oral corticosteroids may be considered 4

Injections

• Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region (rotator cuff or bursa) 4
• Ultrasound-guided injections provide accurate placement and may improve outcomes 4

Positioning and Protection

• Healthcare staff, patients, and family should be educated on correct protection, positioning, and handling of the affected arm 4
• Taping of the affected shoulder can help reduce pain 4

Surgical Intervention

• Surgical treatment should be reserved for cases that fail to respond to conservative management 5
• Arthroscopic subacromial decompression is the most common surgical procedure 2
• Multiple systematic reviews have shown no clinically important or statistically significant differences in outcomes between conservative and surgical interventions 1
• Patients who undergo surgery experience significantly longer periods of work disability (approximately 5-7 weeks longer) compared to those treated conservatively 6, 2

Treatment Algorithm

1. Initial Phase (0-6 weeks):

   • Begin with conservative treatment including physical therapy, NSAIDs, and activity modification 1, 5
   • Focus on gentle stretching, mobilization techniques, and gradual strengthening 4
   • Consider subacromial corticosteroid injection if pain limits rehabilitation progress 4

2. Intermediate Phase (6-12 weeks):

   • Progress to more advanced strengthening exercises for rotator cuff and scapular stabilizers 3
   • Address any biomechanical factors such as scapular dyskinesis 3
   • Evaluate progress using standardized outcome measures 2

3. Advanced Phase (12+ weeks):

   • Return to sport/work-specific activities with proper mechanics 3
   • Consider surgical consultation only if significant symptoms persist despite 3+ months of appropriate conservative care 5, 2

Clinical Pearls and Pitfalls

• Distinguishing between primary impingement (structural) and secondary impingement (functional/dynamic) is crucial for appropriate treatment planning 3
• Addressing scapular dyskinesis and rotator cuff weakness is essential for successful outcomes 3
• Conservative treatment allows patients to return to work significantly earlier than surgical intervention 6, 2
• The presence of bursitis subacromialis on MRI may predict faster recovery 6
• Patients should be educated that both conservative and surgical treatments improve pain and function significantly, but surgery requires longer recovery time 2