Treatment of Subacromial Impingement Syndrome
Begin with a 3-6 month trial of therapeutic exercises combined with NSAIDs as first-line treatment, as recommended by the American Academy of Orthopaedic Surgeons, before considering any surgical intervention. 1
Initial Conservative Management (First-Line Treatment)
Therapeutic exercises and NSAIDs form the cornerstone of initial treatment and should be implemented immediately upon diagnosis. 1
Exercise Protocol
Implement a structured strengthening program targeting rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis), scapular stabilizers (rhomboids, levator scapulae, serratus anterior), and periscapular muscles. 2, 1
Frequency should be at least 7 times per week for 10-15 minutes when performing home exercises, though supervised therapy may provide superior outcomes. 3, 4
Include range of motion exercises, stretching, and progressive strengthening using elastic resistance bands, with emphasis on maintaining proper humeral head positioning during shoulder movement. 3, 4
Evidence demonstrates that exercise alone produces statistically significant reductions in pain (from mean VAS 6.6 to 3.0) and improves function in patients with impingement syndrome. 3, 4
NSAID Therapy
Administer NSAIDs concurrently with exercises as part of the initial treatment regimen. 1
Continue NSAID therapy throughout the 3-6 month conservative treatment period to reduce inflammation and facilitate more effective participation in rehabilitation exercises. 1
Enhanced Conservative Treatment (If Basic Measures Insufficient)
Manual Physical Therapy
Add manual therapy techniques if initial exercise and NSAIDs show inadequate response after 4-6 weeks. 1, 4
Manual therapy combined with supervised exercise produces superior outcomes compared to exercise alone, with pain reduction from VAS 6.7 to 2.0 (versus 6.6 to 3.0 with exercise alone). 4
Specific techniques include joint mobilization and soft tissue mobilization of the glenohumeral joint and surrounding structures, performed by experienced physical therapists. 4
Treatment frequency should be 3 times per week for 12 sessions (approximately 4 weeks) when implementing manual therapy. 4
Subacromial Corticosteroid Injections
Consider subacromial injection of local anesthetic and corticosteroid if symptoms persist despite 6-8 weeks of exercise and NSAIDs. 1, 5
The evidence for corticosteroid injections is conflicting, with five level II studies showing variable results for periods between 2-6 weeks. 1
However, injection does provide measurable benefits: pain decreases by 37.7% within 24 hours, and patients achieve significantly higher Constant scores at 6 weeks (68.4 vs 64.7) compared to physical therapy alone. 5
Injection technique: Administer 9 ml bupivacaine with 1 ml betamethasone into the subacromial space. 5
Primary benefit is enabling more effective range of motion and strengthening exercises through rapid pain reduction, rather than serving as definitive treatment. 5
Treatment Duration and Monitoring
Continue conservative treatment for a full 3-6 months before considering surgical evaluation. 1
Assess response at 3-week, 6-week, and 3-month intervals using validated outcome measures including pain scores (VAS), functional assessment (Constant score or Neer questionnaire), and range of motion measurements. 5, 3
Most patients experience significant improvement with conservative treatment alone, with 70-90% achieving good to excellent outcomes when treatment includes both exercise and adjunctive therapies. 5, 6
Surgical Consideration (Only After Failed Conservative Treatment)
Current evidence does not support subacromial decompression surgery as first-line treatment, as it fails to provide clinically important improvements in pain, function, or quality of life compared to conservative treatments. 1
Surgery should only be considered after documented failure of 3-6 months of comprehensive conservative treatment including exercises, NSAIDs, manual therapy, and corticosteroid injections. 1
Even in refractory cases, the evidence for surgical superiority over continued conservative management is lacking, with multiple studies showing no significant difference between acromioplasty with exercise versus exercise alone. 1, 3
Critical Pitfalls to Avoid
Do not proceed directly to corticosteroid injection without initiating exercise therapy, as injection alone does not address the underlying biomechanical dysfunction and provides only temporary symptom relief. 1, 5
Do not recommend surgery before completing a full 3-6 month trial of conservative treatment, as this violates evidence-based guidelines and exposes patients to unnecessary surgical risks. 1
Do not prescribe unsupervised home exercise without proper initial instruction, as supervised therapy demonstrates superior outcomes, particularly when combined with manual therapy techniques. 4
Do not neglect scapular stabilizer strengthening, as scapular dyskinesis contributes significantly to impingement pathology and must be addressed for successful treatment. 2, 7