What is the initial treatment for impingement on dynamic maneuvers and tendinopathy in the supraspinatus and subscapularis tendons?

Initial Treatment for Supraspinatus and Subscapularis Tendinopathy with Dynamic Impingement

Begin with relative rest by avoiding overhead activities and movements that reproduce pain, combined with eccentric strengthening exercises continued for at least 3-6 months, as this constitutes the cornerstone of treatment that can reverse degenerative tendon changes. 1, 2, 3

Immediate Phase (First 2-4 Weeks)

Activity Modification

• Eliminate all overhead activities and movements that reproduce pain to prevent further tendon damage and allow healing to begin 1, 2, 3
• Reduce repetitive loading activities that cause strain on the affected tendons 2, 3

Pain Management

• Apply cryotherapy using ice through a wet towel for 10-minute periods immediately after any pain-provoking activities for acute pain relief 1, 3
• Use NSAIDs (oral or topical) for short-term pain relief only, recognizing they provide no long-term benefit and should not be relied upon as primary treatment 1, 2, 3
• Topical NSAIDs may offer pain relief with fewer systemic side effects than oral formulations 3

Progressive Loading Phase (Weeks 2-24)

Eccentric Exercise Protocol

• Initiate eccentric strengthening exercises as the primary treatment intervention, as these can reverse degenerative changes in tendon structure 1, 2, 3, 4
• Progress loading gradually to avoid symptom exacerbation—starting too aggressively will worsen symptoms 1, 3
• Continue eccentric exercises for a minimum of 3-6 months for optimal results 1, 2, 3

Adjunctive Manual Therapy

• Consider adding joint and soft tissue mobilization to supervised exercise programs, as this combination may improve functional outcomes beyond exercise alone 5

Intermediate Interventions (If Inadequate Progress at 6-12 Weeks)

Physical Modalities

• Extracorporeal shock wave therapy (ESWT) is safe and potentially effective for pain relief, though expensive 1, 2, 3
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 2, 3

Corticosteroid Injections: Use with Extreme Caution

• Corticosteroid injections should be avoided or used only with extreme caution, as they may provide acute pain relief but do not improve long-term outcomes, may inhibit healing, and can reduce tendon strength predisposing to rupture 1, 3
• Never inject corticosteroids into the tendon substance itself—only peritendinous injection may be considered, and even this should be used cautiously 1

Surgical Referral Criteria (At 3-6 Months)

When to Refer

• Pain persists despite 3-6 months of well-managed conservative treatment 1, 2, 3
• Significant functional limitations persist despite conservative measures 1

Critical Timing

• Do not delay surgical referral beyond 6 months of failed conservative treatment, as chronic tears may develop muscle atrophy and fatty degeneration that worsen surgical outcomes 1

Common Pitfalls to Avoid

• Diagnostic error: The Hawkins test (92% sensitive, 25% specific) and Neer test (88% sensitive, 33% specific) are sensitive but not specific for impingement—ensure appropriate diagnosis 6, 2
• Starting with aggressive exercises: This will worsen symptoms; progression must be gradual 1, 3
• Premature return to activities: Returning before adequate healing leads to symptom recurrence 2, 3
• Over-reliance on NSAIDs: These provide only short-term pain relief without altering long-term outcomes 1, 3
• Excessive corticosteroid use: Remember these do not improve long-term outcomes and can weaken the tendon 2, 3