What is the recommended treatment for subacromial pain syndrome?

Treatment of Subacromial Pain Syndrome

Start with a structured conservative approach combining physical therapy focused on scapular stabilization and rotator cuff strengthening, NSAIDs for pain control, and reserve corticosteroid injections for persistent symptoms after 4-6 weeks of initial treatment. 1, 2, 3

Initial Conservative Management (First 4-6 Weeks)

Non-Pharmacological Interventions

• Begin with therapeutic exercises as the cornerstone of treatment, specifically targeting scapular retraction exercises and progressive rotator cuff strengthening at low intensity and high frequency. 1, 3, 4

• Implement twice-weekly supervised physical therapy sessions focusing on strengthening weak shoulder girdle muscles, improving scapular movement patterns, and gradually restoring range of motion. 1

• Prescribe specific exercise components: eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points with muscle stretching. 3

• Add glenohumeral rotation exercises at gradual elevation angles to the scapular stabilization program, as this combination provides superior outcomes for reducing symptoms and improving acromiohumeral distance compared to scapular exercises alone. 4

• Apply thermal interventions (locally applied heat or cold for 15-20 minutes several times daily) to reduce inflammation. 1, 2

• Mandate consistent home exercise programs between supervised sessions, as this is crucial for recovery. 1

Pharmacological Management

• Prescribe NSAIDs alongside exercises as first-line pharmacological treatment for pain control. 2, 3

• Use acetaminophen or ibuprofen for analgesia if there are no contraindications. 2, 3

• Avoid opioids for subacromial pain syndrome, as evidence shows limited benefit for improved pain or function with long-term use in musculoskeletal conditions, with worse outcomes compared to nonopioid strategies. 5

Activity Modifications

• Restrict overhead lifting and reaching activities for approximately 4 weeks to allow inflammation to subside. 1

• Avoid sleeping on the affected shoulder and any activities that provoke pain during the recovery period. 1

Management of Persistent Symptoms (After 4-6 Weeks)

Corticosteroid Injection Protocol

• Administer subacromial corticosteroid injection when pain persists despite initial conservative measures and is thought to be related to inflammation of the subacromial region (rotator cuff or bursa). 2, 3, 6

• Use either anterior or posterior injection approach based on clinical preference, as both routes provide equivalent pain reduction and functional improvement for up to 6 months. 6

• Consider ultrasound guidance for injection, though the evidence comparing ultrasound-guided versus blind injection remains limited in terms of superior clinical outcomes. 7

• Continue exercise therapy after injection, though note that adding exercise specifically to the painful shoulder after corticosteroid injection does not appear to enhance the injection's effectiveness compared to injection alone. 8

Diagnostic Imaging

• Order ultrasound examination at 6 weeks if symptoms persist, specifically to exclude rotator cuff rupture, as this is the recommended imaging modality. 3

• Reserve other imaging modalities for cases where ultrasound findings are inconclusive or when serious underlying conditions are suspected. 5

Occupational Interventions

• Implement workplace modifications when complaints persist longer than 6 weeks, addressing repetitive occupational motions that contribute to symptoms. 5, 3

Interventions to Avoid

• Do not use massage therapy as a primary treatment, as the American College of Rheumatology/Arthritis Foundation conditionally recommends against it due to high risk of bias in studies, small patient numbers, and lack of demonstrated benefit for specific outcomes. 2

• Avoid strict immobilization and aggressive mobilization techniques, as these are not recommended. 3

• Do not consider surgical intervention (arthroscopic subacromial decompression) as a routine treatment, as high-quality evidence from 2019-2021 demonstrates that subacromial decompression provides no clinically important improvement in pain, function, or quality of life compared to placebo surgery, exercise therapy, or physiotherapy. 5

Management of Treatment-Resistant Cases

Advanced Conservative Options

• Consider shockwave therapy (ESWT) or ultrasound-guided needling (barbotage) specifically for tendinosis calcarea if present. 3

• Refer to specialized rehabilitation unit for chronic, treatment-resistant cases with pain-perpetuating behavior. 3

Surgical Considerations

• Maintain conservative treatment for 3-6 months minimum before considering any surgical evaluation, though evidence does not clearly support surgical benefits over continued conservative treatment. 2

• Recognize that there is no convincing evidence that surgical treatment for subacromial pain syndrome is more effective than conservative management. 3

• Do not operate on asymptomatic rotator cuff tears, as there is no indication for surgical treatment in these cases. 3

Important Clinical Caveats

• The diagnosis requires a combination of clinical tests, not a single examination finding. 3

• Most patients recover well without surgery when proper conservative treatment is implemented and maintained. 1

• Monitor for warning signs requiring immediate evaluation: sudden increase in pain or swelling, new arm weakness, or fever and redness around the shoulder suggesting infection. 1

• Emphasize proper shoulder mechanics and strength maintenance after recovery to prevent recurrence. 1