What treatment options are available for a patient with a positive Neers test indicating shoulder impingement?

Treatment for Shoulder Impingement with Positive Neer Test

Start with a structured conservative treatment program consisting of complete rest from aggravating activities, followed by progressive stretching and strengthening exercises targeting the rotator cuff and scapular stabilizers over 1-3 months before considering surgical intervention. 1

Initial Management Phase (First 2-4 Weeks)

Immediate Activity Modification

• Complete rest from all overhead activities and movements that reproduce pain until you are completely asymptomatic 1
• Avoid overhead pulley exercises entirely, as these encourage uncontrolled abduction and can worsen rotator cuff pathology 1

Pain Control Measures

• Use NSAIDs for acute pain management during the initial inflammatory phase 1
• Apply ice, heat, and soft tissue massage as adjunctive modalities 1
• Consider subacromial corticosteroid injection (Triamcinolone) for more severe cases with significant pain limiting function 1

Progressive Rehabilitation Phase (Weeks 2-12)

Range of Motion Restoration

• Begin aggressive stretching and mobilization focusing specifically on external rotation and abduction once acute pain subsides 1
• This prevents the development of adhesive capsulitis (frozen shoulder), which commonly complicates untreated impingement 1

Strengthening Protocol

• Initiate rotator cuff strengthening exercises only after achieving pain-free range of motion 1
• Focus equally on scapular stabilizer strengthening, as scapular dyskinesis is a primary contributor that must be addressed 2
• Progress through a functional, individualized program over 1-3 months 1

Evidence-Based Exercise Interventions

• Therapeutic exercise is the most widely studied intervention and demonstrates both short-term and long-term effectiveness for decreasing pain and reducing functional loss 3
• Upper quarter joint mobilizations combined with therapeutic exercise are more effective than exercise alone 3

When Conservative Treatment Fails

Surgical Consideration Criteria

• Surgery should only be considered after completing a full 3-month conservative treatment program without adequate symptom resolution 4
• The evidence shows moderate quality data that surgical treatment is not more effective than active exercises for reducing pain intensity 4
• Multiple randomized controlled trials demonstrate no significant difference in pain outcomes between surgical decompression and conservative management (Hedges's g = 0.01,95% CI -0.27 to 0.30) 4

Critical Clinical Distinctions

Age-Related Considerations

• In patients over 35-40 years, impingement typically relates to rotator cuff tendinopathy or tears requiring the above conservative approach 1
• In younger patients under 35 years, consider secondary impingement from rotator cuff weakness and ligamentous laxity, which responds particularly well to strengthening programs 2

Diagnostic Confirmation

• The positive Neer test has 88% sensitivity but only 33% specificity for impingement 2
• Hawkins' test adds diagnostic value with 92% sensitivity (though only 25% specificity) 2
• Consider MRI without contrast if symptoms persist beyond 6-8 weeks of conservative treatment to rule out rotator cuff tears, as this changes management 1

Common Pitfalls to Avoid

• Do not overlook scapular dyskinesis assessment and treatment, as poor scapular coordination is both cause and effect of rotator cuff pathology 1, 2
• Never rush to surgery—the majority of studies show no outcome difference between surgical decompression and conservative management, while surgery carries higher costs and complication risks 4
• Avoid allowing patients to continue overhead activities during the initial rest phase, as this perpetuates the inflammatory cycle 1

Return to Activity Criteria

• Allow return to full activities only after completing the progressive rehabilitation program over 1-3 months without evidence of symptoms 1
• Ensure pain-free range of motion in all planes, particularly abduction with external rotation 1
• Confirm adequate strength in rotator cuff and scapular stabilizers before clearing for overhead activities 1