What is the best treatment approach for a patient with shoulder impingement, considering their medical history and potential comorbidities?

Shoulder Impingement Treatment

Begin with a structured 12-week conservative treatment program focused on physical therapy with progressive strengthening exercises, NSAIDs for pain control, and reserve subacromial corticosteroid injections for cases where pain significantly limits therapy participation. 1

Initial Phase (0-6 Weeks): Conservative Management

Start all patients with non-operative treatment, as outcomes are equivalent to surgery for subacromial impingement syndrome. 2 Conservative treatment succeeds in most cases and should be exhausted before considering surgical options. 3

Physical Therapy Protocol

• Initiate gentle stretching and mobilization techniques focusing specifically on increasing external rotation and abduction. 1
• Progress active range of motion exercises gradually while restoring proper shoulder alignment. 1
• Strengthen the rotator cuff, periscapular muscles, and core musculature as primary targets. 1
• Address anterior shoulder girdle flexibility deficits while simultaneously strengthening posterior shoulder girdle and neck muscles. 1

Pain Management

• Use acetaminophen or ibuprofen as first-line analgesics for pain relief. 1
• Prescribe NSAIDs at the lowest effective dose for the shortest duration necessary. 4
• Consider topical NSAIDs over systemic formulations for mild to moderate pain. 4
• Reserve short courses of oral corticosteroids for cases with significant inflammation. 1

Adjunctive Measures

• Apply local heat before exercise sessions to improve tissue extensibility. 4
• Implement taping techniques for the affected shoulder to reduce pain during activities. 1
• Educate patients on proper positioning and activity modification to avoid aggravating overhead movements. 1

Intermediate Phase (6-12 Weeks): Progressive Strengthening

This phase is critical for addressing the underlying biomechanical dysfunction that perpetuates impingement. 1

Advanced Exercise Progression

• Progress to intensive strengthening exercises targeting rotator cuff and scapular stabilizers. 1
• Emphasize posterior shoulder musculature strengthening to counterbalance overdeveloped anterior muscles. 1
• Continue flexibility work for the shoulder capsule throughout this phase. 1

Biomechanical Correction

• Identify and correct scapular dyskinesis through specific exercises—this is essential for successful outcomes. 1 Scapular winging or abnormal scapular motion patterns must be addressed, as secondary impingement from functional/dynamic causes requires different treatment than primary structural impingement. 1, 3
• Assess and treat the entire kinetic chain, including core and spine mechanics. 1
• Review and correct abnormal movement patterns that perpetuate impingement. 1

Injection Therapy (When Indicated)

• Consider subacromial corticosteroid injection only if pain significantly limits participation in physical therapy. 1 This provides short-term pain relief to facilitate exercise therapy, though benefits are temporary. 1
• Use ultrasound-guided technique for accurate placement and potentially improved outcomes. 1
• Recognize that injections are adjunctive to, not replacements for, structured rehabilitation. 5

Advanced Phase (12+ Weeks): Return to Function

Focus on sport-specific and work-specific activities with proper mechanics. 1

Functional Progression

• Implement graduated throwing programs for overhead athletes, emphasizing proper mechanics. 1
• Introduce stresses and forces via sport-specific drills and functional activities. 6
• Ensure complete resolution of symptoms before returning to full activity. 1

Critical Diagnostic Distinctions

Distinguish between primary impingement (structural causes) and secondary impingement (functional/dynamic causes), as this determines treatment planning. 1

Atypical Impingement Causes to Screen For:

• Os acromiale 3
• Subcoracoid disorders 3
• Acromioclavicular joint undersurface hypertrophy 3
• Deconditioned rotator cuff 3
• Scapular dyskinesis 3

Concurrent Conditions That Complicate Treatment:

• Screen for adhesive capsulitis or rotator cuff tendinopathy, which may coexist and require modified treatment. 1
• In throwing athletes, assess for spinal accessory nerve injury causing scapular winging. 1
• Evaluate for labral pathology if instability symptoms persist after completing physical therapy. 1

Common Pitfalls to Avoid

• Do not be overly restrictive with exercise prescription—progressive loading is necessary for recovery. 1
• Never overlook scapular dyskinesis assessment and treatment, as this is a primary cause of treatment failure. 1
• Avoid premature surgical referral, as conservative treatment outcomes match surgical decompression results. 2
• Do not focus solely on the acromion as the pain source—multiple structural and functional factors contribute. 3, 7

Surgical Consideration

Reserve arthroscopic subacromial decompression for refractory cases that fail 12+ weeks of structured conservative treatment. 7, 2 Surgery should correct all identified structural causes of mechanical impingement. 3