Treatment for Subacromial Impingement Syndrome
This patient should be treated with a structured 3-6 month course of physical therapy focusing on rotator cuff and scapular stabilizer strengthening, combined with NSAIDs, as this represents the evidence-based first-line treatment that avoids unnecessary surgical intervention. 1, 2
Diagnostic Confirmation
The clinical presentation confirms subacromial impingement syndrome (also termed subacromial pain syndrome):
- Positive impingement signs: Pain with passive abduction and forward flexion between 60-120° (painful arc), positive Hawkins and Neer tests 1
- Positive subacromial injection test: Complete pain relief with lidocaine injection into the subacromial space confirms the diagnosis and localizes the pain generator 3
- Intact rotator cuff strength: Rules out full-thickness rotator cuff tear 4
Initial Conservative Management Protocol
Physical Therapy (Primary Treatment)
Implement a structured exercise program twice weekly for 3-6 months minimum before considering any other interventions: 5, 1, 2
- Rotator cuff strengthening: Target supraspinatus, infraspinatus, subscapularis, and teres minor with progressive resistance exercises 2, 6
- Scapular stabilizer strengthening: Critical component since scapular dyskinesis is a major contributor to impingement pathology 1, 2
- Periscapular muscle strengthening: Addresses the mechanical dysfunction causing the painful arc 2
- Exercise specifications: Low intensity, high frequency, combining eccentric training with attention to posture 6
- Home exercise compliance: Consistent daily home program between supervised sessions is crucial for recovery 5
Pharmacologic Management
- NSAIDs: Prescribe concurrently with physical therapy as initial treatment 1, 2
- Analgesics: Use as needed for acute pain episodes 6
Activity Modifications During Recovery
- Avoid: Overhead lifting and reaching, sleeping on the affected shoulder, any activities that reproduce pain 5
- Rest period: Approximately 4 weeks from aggravating overhead activities to allow inflammation to subside 5
- Ice application: 15-20 minutes several times daily to reduce inflammation 5
Corticosteroid Injection Considerations
The evidence for subacromial corticosteroid injections is conflicting and should be reserved for persistent or recurrent symptoms after initial conservative measures: 1, 6
- Timing: Indicated only if symptoms persist despite NSAIDs and initial physical therapy efforts 6
- Evidence quality: Five level II studies show variable results lasting only 2-6 weeks, highlighting the temporary and inconsistent nature of this intervention 1, 2
- Technique: Can be performed under ultrasound guidance if used 2
What NOT to Do
Avoid surgical intervention as first-line treatment. The highest quality evidence from 2021 demonstrates that arthroscopic subacromial decompression does not provide clinically important improvements in pain, function, or quality of life compared to conservative treatment: 7, 1, 2
- Surgery timing: Should NOT be considered until after 3-6 months of failed conservative treatment 1, 2
- Evidence against surgery: Multiple high-quality reviews show no clinically important differences between arthroscopic subacromial decompression and placebo surgery 7
- Avoid: Strict immobilization and aggressive mobilization techniques 6
Follow-Up and Monitoring
- Imaging: Not needed initially; ultrasound is recommended only after 6 weeks of persistent symptoms to exclude rotator cuff rupture 6
- Occupational interventions: Consider after 6 weeks if work-related overhead activities contribute to symptoms 6
- Red flags requiring immediate evaluation: Sudden increase in pain or swelling, new arm weakness, fever, or redness around the shoulder suggesting infection 5
Prognosis
With proper conservative treatment, most patients recover well without surgery, typically within 3-6 months. 5, 1, 4 Long-term success requires maintaining proper shoulder mechanics and continuing strengthening exercises to prevent recurrence. 5