Diagnosis and Management of Subacromial Impingement Syndrome/Rotator Cuff Tendinopathy
This clinical presentation is consistent with subacromial impingement syndrome (rotator cuff tendinopathy), and initial management should consist of conservative treatment with NSAIDs, physical therapy emphasizing rotator cuff and periscapular strengthening, and activity modification for at least 2-3 months before considering surgical intervention. 1
Clinical Diagnosis
The physical examination findings are pathognomonic for subacromial impingement:
- Tenderness over the greater tuberosity indicates supraspinatus tendon involvement, the most commonly affected structure in rotator cuff impingement 1
- Positive Hawkins test (pain with passive forward flexion to 90° and internal rotation) has 92% sensitivity for impingement 1
- Positive Neer test (pain with full forward flexion between 70-120°) has 88% sensitivity for impingement 1
- Intact muscle strength suggests tendinopathy without complete rotator cuff tear 1
The mechanism involves repetitive impingement of the coracoacromial arch onto the supraspinatus tendon during abduction and internal rotation, exacerbated by hypovascularity in the region proximal to the supraspinatus insertion 1.
Initial Imaging Approach
Plain radiographs are the appropriate first-line imaging study to rule out fracture, calcific tendinitis, or bony abnormalities 1, 2. Standard views should include:
Advanced imaging is not immediately necessary unless conservative treatment fails or there is concern for complete rotator cuff tear 1. MRI without contrast becomes appropriate if symptoms persist beyond 2-3 months of conservative management 2.
Conservative Treatment Protocol
Initial conservative management should be implemented for at least 2 years, as 60% of patients achieve satisfactory results with non-operative treatment 3:
Pharmacologic Management
- NSAIDs for pain control and inflammation reduction 1
- Corticosteroid injections may be considered for acute symptom relief, though they do not change long-term outcomes 1
Physical Therapy (Primary Treatment)
- Rotator cuff strengthening exercises targeting supraspinatus, infraspinatus, teres minor, and subscapularis 1
- Periscapular muscle strengthening to optimize scapular mechanics 1
- Capsular flexibility exercises to maintain range of motion 1
- Activity modification to minimize repetitive overhead activities 1
Adjunctive Modalities
- Deep transverse friction massage may reduce pain 1
- Ultrasound therapy and iontophoresis are widely used but lack strong evidence 1
- Extracorporeal shock wave therapy (ESWT) shows promise but requires further validation 1
Surgical Consideration
Surgical referral is appropriate only if pain persists despite 2-3 months of well-managed conservative treatment 1. Surgery typically involves:
- Subacromial decompression 1, 4
- Excision of abnormal tendon tissue 1
- Longitudinal tenotomies to release scarring 1
Critical Clinical Pitfalls
Do not assume this is a complete rotator cuff tear requiring urgent surgery - intact muscle strength argues against full-thickness tear, and even complete tears can be managed conservatively in appropriate patients 5.
Do not overlook underlying glenohumeral instability - chronic anterior instability can cause secondary impingement, particularly in overhead athletes, and may require capsular reconstruction rather than isolated decompression 4.
Do not rush to surgery - the evidence level for surgical versus conservative treatment superiority remains low, and most patients improve with conservative management 3.
In skeletally immature patients (ages 11-16), consider proximal humeral epiphysiolysis (Little League shoulder) if there is a history of repetitive throwing, which requires 3 months of complete rest from throwing 1. However, the clinical presentation described (positive impingement signs) is more consistent with adult-pattern impingement.