What is the best management approach for impingement syndrome?

Management of Impingement Syndrome

Initial treatment for subacromial impingement syndrome should consist of a structured 3-6 month conservative program combining therapeutic exercises targeting rotator cuff and scapular stabilizers with NSAIDs, before considering any surgical intervention. 1, 2

First-Line Conservative Treatment (0-6 weeks)

Begin with therapeutic exercises and NSAIDs as the cornerstone of initial management. 1, 2

• Implement gentle stretching and mobilization techniques focusing specifically on increasing external rotation and abduction 2
• Start strengthening programs targeting rotator cuff muscles, scapular stabilizers, and periscapular muscles 1
• Address scapular dyskinesis, as poor scapular coordination is a major contributor to impingement pathology 1, 2
• Use NSAIDs (such as ibuprofen) for pain relief alongside the exercise program 1, 2, 3
• Apply ice and modify activities that provoke symptoms 4, 3

Intermediate Phase (6-12 weeks)

• Progress to more advanced strengthening exercises for rotator cuff and scapular stabilizers 2
• Gradually increase active range of motion exercises while restoring alignment 2
• Address biomechanical factors including scapular dyskinesis and rotator cuff weakness 2

Adjunctive Treatments

Consider subacromial corticosteroid injections if pain persists despite initial conservative measures, though evidence for their efficacy is conflicting. 1, 2

• Ultrasound-guided injections may provide more accurate placement and potentially better outcomes 2
• A short course of oral corticosteroids may be considered when significant inflammation is present 2
• Taping of the affected shoulder can help reduce pain 2

Advanced Phase (12+ weeks)

• Focus on return to sport or work-specific activities with proper mechanics 2
• Continue addressing any persistent scapular dyskinesis or rotator cuff weakness 2

Surgical Consideration

Surgery should only be considered after 3-6 months of unsuccessful conservative treatment, and current evidence does not support subacromial decompression as providing clinically important improvements over conservative care. 5, 1, 2

• The British Medical Journal states that subacromial decompression surgery does not provide clinically important improvements in pain, function, or quality of life compared to other treatments 1
• Systematic review evidence shows no differences in outcome between conservatively and surgically treated patients 6

Critical Clinical Pearls

Distinguish between primary impingement (structural, more common in adults) and secondary impingement (functional/dynamic, more common in younger athletes and those with rotator cuff weakness combined with ligamentous laxity). 7, 2

• Examine specifically for shoulder range of motion restrictions, particularly during abduction with external or internal rotation 7, 2
• Assess for rotator cuff weakness (present in 75% of patients) and scapular dyskinesis 7, 2
• Use Hawkins test (92% sensitive, 25% specific) and Neer test (88% sensitive, 33% specific) for diagnosis 1, 7
• Educate patients on correct positioning and handling of the affected arm 2

Common Pitfalls to Avoid

• Do not rush to surgery without completing a full 3-6 month conservative trial 1, 2
• Do not neglect scapular stabilizer strengthening, as scapular dyskinesis is a major contributor to impingement 1, 2
• Do not focus solely on pain relief without addressing underlying biomechanical factors like rotator cuff weakness and scapular dysfunction 2