What is the treatment for shoulder impingement in an adult patient with no significant medical history?

Treatment of Shoulder Impingement

Begin with conservative management consisting of complete rest from aggravating activities, physical therapy focused on rotator cuff and scapular stabilizer strengthening, and NSAIDs, as this approach produces equivalent outcomes to surgery for shoulder impingement syndrome. 1

Initial Conservative Management (First-Line Treatment)

Immediate Activity Modification

• Mandate complete cessation of all overhead activities and movements that provoke pain until the patient achieves pain-free shoulder motion at rest and during daily activities 2, 3
• Rest period typically requires at least 6 weeks for adequate tissue recovery 3
• Specifically avoid overhead pulleys, which encourage uncontrolled abduction and can worsen rotator cuff pathology 4

Pain Control Modalities

• Ice, heat, and soft tissue massage for symptomatic relief 4, 2
• NSAIDs for acute pain management 5
• Consider intra-articular corticosteroid injections (Triamcinolone) for more severe cases, as these have demonstrated significant effects on pain reduction 4, 2

Structured Physical Therapy Protocol

Phase 1: Range of Motion Restoration

• Improve range of motion through stretching and mobilization techniques, focusing especially on external rotation and abduction 4, 2
• This focus on external rotation and abduction is critical for preventing progression to frozen shoulder and shoulder-hand-pain syndrome 4
• Pain-free motion must be achieved before advancing to strengthening exercises 2, 3

Phase 2: Strengthening Program

• Initiate rotator cuff and scapular stabilizer strengthening only after achieving pain-free motion 2, 3
• Target two critical muscle groups: rotator cuff (particularly external rotators and supraspinatus) and scapular stabilizers 3, 6
• Address the characteristic muscular imbalance pattern of weakened posterior shoulder musculature combined with overdeveloped anterior musculature 3, 6

Phase 3: Functional Progression

• Return to activities may be allowed after completing a functional, progressive, and individualized program over 1 to 3 months without evidence of symptoms 2

Additional Conservative Interventions

Electrical Stimulation

• Consider functional electrical stimulation (FES) to improve shoulder lateral rotation, which has shown significant treatment effects for pain-free lateral rotation 4
• Electrical stimulation can be used both for prevention and treatment of shoulder pain 4

Shoulder Strapping

• Consider shoulder strapping as both a preventive and therapeutic intervention 4

Surgical Intervention (Reserved for Refractory Cases)

Surgery should only be considered after failure of conservative management, as systematic reviews demonstrate no clinically important or statistically significant differences in outcomes between conservative versus surgical interventions 1

• Surgical options include arthroscopic subacromial decompression, debridement, and/or repair of injured structures 7
• All structural causes of mechanical impingement must be corrected if surgery is pursued, including os acromiale, subcoracoid disorders, acromioclavicular joint undersurface hypertrophy, or other anatomic abnormalities 8

Critical Diagnostic Considerations Before Treatment

Distinguish Primary vs. Secondary Impingement

• Secondary impingement (more common in younger patients and athletes) results from rotator cuff weakness combined with ligamentous laxity causing the humeral head to fail to maintain proper centering in the glenoid fossa 2, 3, 6
• Primary impingement occurs from structural compression of the rotator cuff against the anterolateral acromion, more common in older adults 6, 8

Key Physical Examination Findings

• Neer's test: 88% sensitive, 33% specific for impingement 2, 6
• Hawkins' test: 92% sensitive, 25% specific for impingement 2, 6
• Assess for scapular dyskinesis during active arm elevation, as this is a primary contributor that must be addressed in treatment 3, 6, 9
• Evaluate focal weakness during abduction with external or internal rotation 2, 6

Imaging When Indicated

• Plain radiographs (AP, Grashey, axillary, and/or scapular Y projections) are the initial imaging modality 2
• MRI without contrast is preferred for suspected rotator cuff pathology in patients over 35 years, with 90% sensitivity and 80% specificity 2, 3
• Ultrasound is equivalent to MRI for evaluating rotator cuff abnormalities (85% sensitivity, 90% specificity) when local expertise is available 2, 3

Common Pitfalls to Avoid

• Do not overlook scapular dyskinesis, as poor scapular coordination is a primary contributor to impingement and must be specifically addressed in the rehabilitation program 3, 6, 9
• Avoid progressing to strengthening exercises before achieving pain-free range of motion 2, 3
• Do not use overhead pulley exercises, as these encourage uncontrolled abduction and can exacerbate rotator cuff pathology 4, 2
• Recognize that lateral rotation is the factor most significantly related to onset of shoulder pain, making external rotation exercises particularly important 4