As a 61‑year‑old man (83 kg, 5 ft 8 in) with a one‑year history of right‑shoulder impingement now having mild stiffness, occasional nocturnal discomfort, slight loss of motion but no pain on movement, should I receive a hyaluronic‑acid (hyaluronic sodium) intra‑articular injection or start a supervised exercise/physiotherapy program for definitive treatment?

Treatment Recommendation for Chronic Shoulder Impingement

You should start with a structured exercise and physiotherapy program rather than hyaluronic acid injection for your shoulder impingement. 1

Rationale for Exercise-Based Treatment

Your clinical presentation—mild stiffness, occasional nocturnal pain, slight motion loss but no pain with movement—indicates a chronic impingement syndrome that has already improved spontaneously from moderate to mild severity. This pattern strongly favors conservative management as first-line therapy.

Why Exercise is Preferred

• Randomized controlled trials demonstrate that regular moderate-level exercise does not exacerbate shoulder pain or accelerate pathological processes, and strongly indicate that increasing physical activity reduces pain and improves function in patients with joint disease. 1

• Exercise programs should target pain control, flexibility improvement, and muscle strength/endurance enhancement, specifically addressing the rotator cuff and scapular stabilizers that are compromised in impingement. 1

• At age 61, you fall into the demographic where impingement is predominantly related to rotator cuff dysfunction rather than structural instability, making rehabilitation particularly effective. 1

Why Hyaluronic Acid is NOT Recommended for Your Condition

The evidence for hyaluronic acid in shoulder impingement is weak and contradictory:

• The American Academy of Orthopaedic Surgeons states there is insufficient evidence to recommend for or against injectable viscosupplementation for glenohumeral osteoarthritis, with only one industry-supported level IV study supporting its use. 1

• Hyaluronic acid has shown benefit primarily in glenohumeral osteoarthritis, not impingement syndrome. 1, 2 Your description suggests impingement (subacromial pathology) rather than glenohumeral joint arthritis.

• When hyaluronic acid was studied for persistent shoulder pain from various etiologies including rotator cuff tears, the primary endpoint (pain improvement at 13 weeks) was not achieved, with benefits limited to patients with documented osteoarthritis. 2

• Studies showing positive results used hyaluronic acid for adhesive capsulitis or osteoarthritis 3, 4, 5, not impingement syndrome specifically.

Recommended Treatment Algorithm

Phase 1: Conservative Management (8-12 weeks minimum)

Initiate supervised physiotherapy focusing on:

• Scapular stabilization exercises to restore normal shoulder mechanics 1
• Rotator cuff strengthening, particularly external rotators 1
• Posterior capsule stretching to improve internal rotation deficit 1
• Postural correction exercises 1

Pain management during rehabilitation:

• Acetaminophen as needed for mild pain 1
• Topical NSAIDs (methyl salicylate or capsaicin cream) may be beneficial for localized pain without systemic side effects 1
• Avoid prolonged oral NSAID use given your age and associated GI/renal risks 1

Phase 2: If Conservative Management Fails (After 3-6 Months)

Consider corticosteroid injection (NOT hyaluronic acid):

• Intra-articular or subacromial corticosteroid injection provides short-term pain relief and may facilitate participation in physical therapy 1
• This is supported by guideline evidence as an option when oral medications and physical therapy provide inadequate relief 1
• Infiltration therapy has considerable value in managing impingement pain 6

Phase 3: Persistent Symptoms Despite Optimal Conservative Care

• Consider advanced imaging (MRI without contrast) to evaluate for full-thickness rotator cuff tear or other structural pathology 1
• Surgical consultation for possible arthroscopic decompression only if pain remains resistant to conservative therapy for 6-12 months 6

Critical Pitfalls to Avoid

• Do not pursue hyaluronic acid injection without documented glenohumeral osteoarthritis on imaging. The evidence does not support its use for impingement syndrome. 1, 2

• Do not skip the exercise phase. Your spontaneous improvement from moderate to mild symptoms suggests your condition is responsive to conservative measures, and formal rehabilitation will likely accelerate recovery. 1

• Do not assume "no pain with movement" means no pathology. Nocturnal pain and motion restriction indicate ongoing rotator cuff involvement requiring specific rehabilitation. 1

• Avoid prolonged immobilization. Early mobilization through guided exercise prevents the stiffness progression that characterizes chronic impingement. 4

Expected Outcomes

With structured physiotherapy, approximately 80% of patients with impingement syndrome achieve good to excellent results with conservative management. 6 Given that your symptoms have already improved without formal intervention, supervised rehabilitation should yield substantial functional gains and pain reduction within 8-12 weeks. 1