What is the most appropriate initial management for left‑shoulder impingement identified on dynamic scanning?

Management of Left Shoulder Impingement on Dynamic Scanning

Begin with a structured 6–8 week conservative rehabilitation program focused on restoring glenohumeral range of motion, rotator cuff strengthening, and scapular stabilization before considering surgical intervention. 1

Initial Conservative Management

Pain Control

• Use acetaminophen or ibuprofen as first-line analgesics if no contraindications exist 2
• Consider subacromial corticosteroid injection for pain related to subacromial inflammation—this has shown significant pain reduction effects 2
• Grade 2 subacromial impingement on dynamic ultrasound is positively associated with initial effectiveness of subacromial corticosteroid injection, making this an appropriate early intervention for your patient 3
• Be aware that subdeltoid bursitis on imaging predicts both poor initial response and recurrence after injection, which may require alternative strategies 3

Physical Therapy Protocol

• Initiate pain relief measures BEFORE starting active physiotherapy—attempting exercises while pain is uncontrolled leads to poor outcomes 4
• Once pain is controlled, focus rehabilitation on three sequential goals: 1
  • Restore full glenohumeral range of motion through gentle stretching and mobilization, particularly external rotation and abduction 2
  • Reestablish dynamic rotator cuff stability through progressive strengthening exercises 2, 1
  • Strengthen scapular stabilizers to correct scapular dyskinesis and restore proper scapulohumeral rhythm 5, 1
• Progress to sport-specific drills and functional activities only after achieving full strength and local muscular endurance 1

Critical Pitfalls to Avoid

• Never use overhead pulleys during initial recovery—they encourage uncontrolled abduction that worsens the injury 2
• Do not proceed with physiotherapy before achieving adequate pain control through other modalities 4
• Recognize that impingement may result from factors beyond a hooked acromion, including os acromiale, subcoracoid pathology, AC joint undersurface hypertrophy, rotator cuff deconditioning, or scapular dyskinesis—address the underlying causative factor identified on your dynamic scan 5

When to Consider Surgical Intervention

• Reserve surgery for patients with pain resistant to conservative therapy for 6–8 weeks 4
• Only outlet impingement can be successfully treated by surgical decompression—ensure proper diagnosis before referral 4
• Both open and arthroscopic decompression achieve approximately 80% good-to-excellent results, with no proven superiority of one technique over the other in mid-term outcomes 4

Monitoring Response

• Patients with grade 2 impingement on dynamic ultrasound, right handedness, and bicipital groove tenderness are more likely to respond to initial conservative treatment 3
• Watch for recurrence indicators: subdeltoid bursitis and positive painful arc test predict need for repeated intervention 3
• Approximately 20% of patients show unsatisfactory results with standard treatment, often due to unaddressed muscular imbalance or altered tendon microstructure 4