What are the treatment options for shoulder impingement?

Treatment Options for Shoulder Impingement Syndrome

For shoulder impingement syndrome, begin with a structured conservative approach including physical therapy focused on rotator cuff and scapular strengthening combined with NSAIDs, progressing through a phased rehabilitation protocol over 12+ weeks before considering surgical intervention. 1

Initial Conservative Treatment (0-6 Weeks)

Physical Therapy Foundation

• Initiate gentle stretching and mobilization techniques with emphasis on increasing external rotation and abduction 1
• Progress to active range of motion exercises gradually while restoring proper shoulder girdle alignment 1
• Focus on strengthening the rotator cuff, periscapular muscles, and core musculature 2
• Address anterior shoulder girdle flexibility while strengthening the posterior shoulder girdle and neck 2

Pharmacologic Management

• Use acetaminophen or ibuprofen (NSAIDs) as first-line analgesics for pain relief 1, 3
• Consider a short course of oral corticosteroids when inflammation is prominent 1
• Subacromial corticosteroid injections are indicated when pain relates to injury or inflammation of the subacromial region 1, 3
• Ultrasound-guided injections provide more accurate placement and may improve outcomes compared to landmark-based techniques 1

Critical caveat: Localized drug injections used alone show worse treatment effects than when combined with exercise therapy 4. Never rely on injections as monotherapy.

Adjunctive Measures

• Apply ice packs for symptomatic relief 3
• Implement taping of the affected shoulder to reduce pain 1
• Educate patients and families on correct positioning, protection, and handling of the affected arm 1
• Enforce activity modification and rest from aggravating movements 3

Intermediate Phase Treatment (6-12 Weeks)

Advanced Strengthening Protocol

• Progress to more intensive strengthening exercises targeting rotator cuff and scapular stabilizers 1
• Address scapular dyskinesis through specific exercises, as poor scapular coordination contributes significantly to impingement 2
• Emphasize posterior shoulder musculature strengthening to counterbalance overdeveloped anterior muscles 2
• Continue flexibility work for the shoulder capsule 2

Biomechanical Correction

• Identify and correct scapular winging or dyskinesia, which is critical for successful outcomes 2, 1
• Assess and treat the entire kinetic chain, including core and spine mechanics 2
• Review and correct any abnormal movement patterns that perpetuate impingement 2

Important distinction: Secondary impingement (functional/dynamic) from rotator cuff weakness and instability is more common in younger patients and athletes, while primary impingement (structural) predominates in older adults 2, 5. This distinction is crucial for treatment planning 1.

Advanced Phase Treatment (12+ Weeks)

Return to Function

• Focus on sport-specific or work-specific activities with proper mechanics 1
• Implement a graduated throwing program for overhead athletes, emphasizing proper mechanics 2
• Ensure complete resolution of symptoms before returning to full activity 2

Treatment Efficacy Evidence

Combined treatments composed of exercise plus other therapies consistently outperform single-intervention approaches 4. Specifically, exercise combined with modalities like kinesio taping, specific exercises, or acupuncture demonstrate superior outcomes 4.

Low-level laser therapy and localized NSAID injections alone are not recommended based on poor comparative effectiveness 4.

Surgical Intervention

Indications for Surgery

• Reserve surgery for patients who fail conservative management after several months of appropriate physical therapy and analgesics 6, 3
• Consider surgery earlier in young patients or following acute traumatic rotator cuff injuries 7
• Delay decompression surgery until any associated fractures have united 6

Surgical Techniques

• Arthroscopic subacromial decompression (ASD) is preferred over open subacromial decompression 4
• ASD combined with radiofrequency or arthroscopic bursectomy shows better outcomes than open techniques 4
• Repair rotator cuff tears when present (found in over two-thirds of surgical cases) 6
• Surgical success rates reach 86.6% for post-traumatic impingement 6

Critical consideration: Exercise therapy alone may achieve similar outcomes to surgery in patients with long-term disease, so surgical decisions should be made cautiously 4. However, when surgery is indicated, perform it arthroscopically 7.

Common Pitfalls to Avoid

• Never use corticosteroid injections as standalone treatment—always combine with structured exercise therapy 4
• Avoid being overly restrictive with exercise prescription, but maintain appropriate precautions 2
• Do not overlook scapular dyskinesis assessment and treatment, as this is essential for resolution 2, 1
• Screen for and address common concurrent conditions like adhesive capsulitis or rotator cuff tendinopathy that may complicate treatment 2
• In throwing athletes, assess for spinal accessory nerve injury which can cause scapular winging 2