eMedicine Specialties > Sports Medicine > Shoulder

Shoulder Impingement Syndrome: Treatment & Medication

Author: Thomas M DeBerardino, MD, Associate Professor of Orthopaedic Surgery, University of Connecticut Health Center
Coauthor(s): Wing K Chang, MD, Musculoskeletal Spine Fellow, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center
Contributor Information and Disclosures

Updated: Aug 13, 2009

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Goals of the acute phase are to relieve pain and inflammation, prevent muscle atrophy without exacerbation, reestablish nonpainful ROM, and normalize arthrokinematics of the shoulder complex. A period of active rest should be recommended to the patient, eliminating any activity that may cause an increase in symptoms. ROM exercises may include pendulum exercises and symptom-limited active-assistive range of motion (AAROM) exercises. Joint mobilization may be included with inferior, anterior, or posterior glides in the scapular plane. Strengthening exercises should be isometric in nature, working on the external rotators, internal rotators, biceps, deltoids, and scapular stabilizers (rhomboids, trapezius, serratus anterior, latissimus dorsi, and pectoralis major).

Exercises targeting the rotator cuff muscles are extremely important. Neuromuscular control exercises also may be initiated. Modalities may be used as an adjunct and can include cryotherapy, transcutaneous electrical nerve stimulation (TENS), high-voltage galvanic stimulation, ultrasound, phonophoresis, or iontophoresis. Patient education is particularly important for the acute phase regarding activity, pathology, and avoiding overhead activity, reaching, and lifting. The general guidelines to progress from this phase are decreased pain or symptoms, increased ROM, painful arc in abduction only, and improved muscular function.

Other Treatment

Subacromial injection

During the acute to subacute phase, when pain and inflammation are predominant, a subacromial injection may be diagnostic and therapeutic as an adjunct to a rehabilitation program. Injection of 10 mL of 1% lidocaine solution (without epinephrine) into the subacromial space should relieve shoulder pain if pain and inflammation truly is originating from the supraspinatus outlet/subacromial space. Adding a low dose intermediate-acting injectable corticosteroid may provide a therapeutic effect. Betamethasone, triamcinolone, and methylprednisolone commonly are used. One mL of any of these available injectable corticosteroids mixed with 9 mL of 1% lidocaine solution (without epinephrine) commonly is used.

Technique: Have the patient sit with the arm hanging by his/her side to distract the humerus from the acromion. Identify the lateral edge of the acromion. Insert the needle at midpoint of acromion and angle slightly upward under the acromion to full length. Slowly withdraw needle while simultaneously injecting fluid in a bolus wherever resistance is not present. Continue aspirating before injecting. Sometimes a swelling caused by fluid is visible around the edge of the acromion. Occasionally, calcification occurs within the bursa and hard resistance is encountered. In this case, aspiration and infiltration with a large bore needle and local anesthetic may be helpful. Failure of this injection may necessitate surgical evaluation.

Aftercare: Patient is informed that a local reaction may occur to the corticosteroid in the next 24-72 hours once the effect of the lidocaine wears off. If this happens, the patient is recommended to apply ice (wrapped in a towel) to the affected shoulder 20 minutes on and 20 minutes off, 3 times at the beginning and end of the day. Relief of pain after one injection is usual, but the patient must be advised to maintain correct posture with retraction and depression of the shoulder and to avoid the painful arc of elevation for 1 week. Patient may resume a symptom-limited therapy program in the first week postinjection, and then resume the full course.

Adverse effects of medications may be minimized when dosed as recommended. Adverse reactions are uncommon; however, they may occur, even when the injection is administered correctly. The clinician and patient must be educated about possible reactions, and the clinician must know how to manage any related complications. Absolute contraindications include documented allergy to any corticosteroid or local anesthetics. Relative contraindications include diabetes, hypertension, immunosuppression, cardiac arrhythmias, and heart blocks.

Adverse effects of injectable corticosteroids

• Systemic effects include flushing, menstrual irregularity, impaired glucose tolerance, osteoporosis, psychological disturbance, steroid arthropathy, steroid myopathy, and immunosuppression.
• Local effects include postinjection flare.

Adverse effects of local anesthetics

• Usually, adverse effects are due to overdose and allergic reactions, which definitively can be minimized by double-checking the administered dose and inquiring about and checking on medication records for medication allergies.
• Effects of overdose and allergic reactions may be catastrophic and may include cardiac, respiratory, and cerebral compromise.

Adverse reaction to the injection: Occasionally, a patient may experience a vasovagal reaction (faint) due to pain, apprehension, or needle phobia. In such cases, treatment should consist of the following:

• Lie the patient down in the supine position. Elevate the patient's legs.
• Strongly reassure patient that recovery is fast.
• If patient briefly loses consciousness, protect the airway and give oxygen at 35% concentration.

High-intensity laser therapy¹⁴

Santamato et al evaluated the short-term effects between high-intensity laser therapy (HILT) and sonographic therapy in 70 patients with subacromial impingement syndrome.¹⁴ The patients were randomized to receive 10 treatments of HILT or ultrasound over 2 consecutive weeks. After 2 weeks, patients in the HILT group showed statistically significant improvements in pain reduction, articular movement, functionality, and muscle strength as measured by 3 outcome measure scores.¹⁴ However, further investigation is warranted, as the study was limited by its small size, lack of control or placebo groups, and follow-up period.

Recovery Phase

Rehabilitation Program

Physical Therapy

Initial goals of this phase are to normalize ROM and shoulder arthrokinematics, perform symptom-free daily activities, and improve neuromuscular control and muscle strength. ROM exercises should progress to active exercises in all planes and self-stretches, concentrating on the joint capsule, especially the posterior capsule.

Strengthening exercises should include isotonic dumbbell resistance exercises with the supraspinatus, internal rotators, external rotators, prone extension, horizontal abduction, forward flexion to 90°, upright abduction to 90°, shoulder shrugs, rows, push-ups, press-ups, and pull-downs to strengthen the scapular stabilizers. Joint mobilization and neuromuscular reeducation also should be maintained. Upper extremity ergometry exercises, trunk exercises, and general cardiovascular conditioning should be maintained for endurance. Use of modalities may be continued if necessary. Guidelines to advance from this phase are full pain-free ROM and when manual muscle strength testing is 70% of the contralateral side.

The final goal of this phase is to get the athlete back to throwing and should include improving strength, power and endurance, and sports-specific neuromuscular control. Emphasis is placed on high-speed, high-energy strengthening exercises, and eccentric exercises in diagonal patterns. Continue isotonic strengthening with increased resistance in all planes, allowing resistance in the throwing position, 90° of abduction, and 90° of external rotation. Initiate plyometrics, sports-specific exercises, proprioceptive neuromuscular facilitation, and isokinetic exercises.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The goal of this phase is to maintain a high level of training and prevent reoccurrence. Emphasis is placed on longer, more intense workouts and proper arthrokinematics of the shoulder. Analysis and modification of techniques and mechanics may reexacerbate symptoms. Make refinements in intensity and coordination. Patient education again is reemphasized, maintaining proper mechanics, strength, and flexibility and understanding the pathology. The patient also should have a good understanding of the warnings signs of early impingement and continue with a home exercise program with proper warm-up and strengthening techniques.

Surgical Intervention

In general, conservative measures are continued for at least 3-6 months or longer if the patient is improving, which is usually the case in 60-90% of patients. If the patient remains significantly disabled and has no improvement after 3 months of conservative treatment, the clinician must seek further diagnostic work-up, and reconsider other etiologies or refer for surgical evaluation.

Appropriate surgical referrals are patients with subacromial impingement syndrome refractory to 3-6 months of appropriate conservative treatment. Surgery may be particularly beneficial in patients with full unrestricted PROM, positive response to injection of lidocaine into the subacromial space, a type III acromion having a large subacromial spur and those in whom changes are noted in the rotator cuff tendon on MRI scanning. 

In a systematic review, Dorrestijn et al attempted to compare the effects of conservative and surgical treatment for subacromial impingement syndrome with regard to improvement of shoulder function and reduction of pain.¹³ Of 4 randomized controlled trials that met the investigators' criteria, 2 were of medium methodologic quality and 2 were of low methodologic quality, but there were no differences in outcome between the treatment groups. Their findings led Dorrestijn et al to note the scarcity of high-quality randomized controlled trials does not allow conclusive evidence for differences in pain outcomes and shoulder function in conservatively and surgically treated patients with subacromial impingement syndrome.¹³

• Surgical Evaluation
  • Initial examination under anesthesia (general anesthesia vs. regional block) and diagnostic arthroscopy
  • Evaluation of shoulder ROM and stability
  • In patients with limited motion, manipulation of the shoulder is performed. Diagnostic arthroscopy also may be performed, but arthroscopic subacromial decompression is generally not performed in patients with significant preoperative stiffness due to the increased risk of postoperative adhesive capsulitis
  • Document any instability
• Arthroscopic evaluation
  • Particular attention is directed to the rotator cuff, especially the supraspinatus tendon near its insertion onto the greater tuberosity
  • Visualize the subscapularis tendon.
  • Assess for labral pathology or changes suggesting glenohumeral instability.
  • A partial tearing of the supraspinatus tendon along its articular surface is a common finding in symptomatic throwing athletes. The fragmented and torn tissue is debrided, leaving all intact rotator cuff tendon. This allows a more accurate determination of the size and thickness of the tear on the articular side of the rotator cuff and may help reduce symptoms of catching and pain.
  • Following glenohumeral arthroscopy, the bursal side of the rotator cuff is then evaluated with arthroscopy
  • The bursal surface of the rotator cuff is assessed for evidence of fraying as well as the amount of clearance between the anterior inferior acromion and the supraspinatus tendon.
  • Also noted are any signs of fraying or wear changes on the undersurface of the coracoacromial ligament.
  • If no evidence of rotator cuff disruption is noted, the coracoacromial ligament is smooth with adequate space between the anterior inferior acromion and rotator cuff, then the diagnosis of subacromial impingement is unlikely. In this case, subacromial decompression is not performed.
  • In case of a small partial-thickness rotator cuff tear on the articular surface, without evidence of impingement, only glenohumeral debridement of this tear is performed. However, if the patient has changes suggestive of impingement syndrome, arthroscopic subacromial decompression (acromioplasty- resection of the anterior inferior portion of the acromion) is performed as well.
  • If following subacromial decompression, a rotator cuff repair is necessary, it may be continued with arthroscopic assistance or it may be necessary to convert the rotator cuff repair to an open procedure.
• Postoperative care
  • Postoperatively, a radiograph (supraspinatus outlet view) should be obtained to document the adequacy of the subacromial decompression. The appearance on this radiographic view should be of a type I acromial arch without any residual spurring.
  • Following subacromial decompression, the patient is placed in a sling but is encouraged to remove the sling when comfortable and begin AROM and PROM exercises. When pain has decreased significantly and ROM has returned toward normal, a program of strengthening similar to the previously mentioned conservative management may be instituted. Patients cannot begin sports-specific activities until they have full AROM in the operated shoulder and normal strength, generally a time course of approximately 3-4 months.
• Surgical Outcome
  • Results are generally good for properly selected middle-aged patients with evidence of impingement on history and physical examination and at the time of arthroscopy.
  • General consensus in the literature is that arthroscopic subacromial decompression results in a good return to the previous level of function in approximately 85-90% of patients; however, results are generally poor in young high-performance athletes who participate in overhead activities.

Medication

During the acute and subacute phases of shoulder impingement syndrome, it is appropriate to use a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) for analgesic and anti-inflammatory effects as an adjunct to the therapy program and other treatment modalities. Choices in this drug classification are extensive, so only selected examples are discussed. Patient response to differing NSAIDs may vary. For information on the full array of NSAIDs available, dosing, and schedule, please refer to the latest edition of the Physician's Desk Reference.

The major mechanism of action of NSAIDs is inhibition of the synthesis of prostaglandin (PG), specifically PGE2 via blocking of cyclo-oxygenase (COX), which is the enzyme that converts arachidonic acid into PG. PGs lower the threshold to noxious stimuli by sensitizing the nociceptors to the actions of other noxious endogenous substances (eg, bradykinin, histamine, substance P, serotonin). PGE2 causes pain and inflammation in soft tissues, is cytoprotective in the GI tract by increasing secretion of mucus and bicarbonates and decreasing secretion of gastric acids and digestive enzymes, and enhances renal salt and water excretion in the renal system by acting as a vasodilator of small arterial blood vessels.

The COX pathway is subdivided into COX1, which is responsible for PGE2 production in the GI tract and kidneys, and, COX2, which is responsible for inflammatory PG synthesis during soft tissue injury. NSAIDs serve as competitive inhibitors of COX activity, and either selectively inhibit the COX2 enzymes or nonselectively inhibit both COX1 and COX2 enzymes, making the nonselective NSAIDs potentially ulcerogenic and renal toxic.

All NSAIDs have similar adverse drug reactions, as follows:

• Hepatotoxicity: Liver function profile must be monitored in patients taking NSAIDs, periodically every 1-2 months, especially in high-risk individuals.
• Renal toxicity: Renal function profile must be monitored periodically every 1-2 months, especially in high-risk individuals.
• GI toxicity: Symptoms may include nausea, diarrhea, acid reflux, and periumbilical cramping. The physician may consider administering NSAIDs in conjunction with GI protective medications (eg, misoprostol, omeprazole, H2-blockers) and instruct patients to take NSAIDs with food. If GI symptoms persist for more than 2 weeks or if the patient has evidence of complication (eg, iron deficiency anemia, GI bleeding, unexplained weight loss, dysphagia), endoscopic evaluation is indicated
• Aplastic anemia: Monitor CBC, especially platelets, periodically for 1-2 months.
• Anaphylaxis: Inquire about and check medical records for history of allergic reactions.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are the most widely used drugs in the world, exhibiting anti-inflammatory, antipyretic, and analgesic activities. They primarily are used for treating inflammatory conditions that are musculoskeletal in origin. Numerous drugs are available in this category and all have similar drug profiles.

Ibuprofen (Ibuprin, Advil, Motrin)

An arylpropionic acid, it is the prototypical NSAID and causes less epigastric pain, GI occult blood loss, and less hepatotoxicity. Mostly indicated for rheumatoid arthritis and osteoarthritis for mild to moderate pain. Compared to other available NSAIDs, it has a short half-life.

Diclofenac sodium/potassium (Voltarem, Cataflam)

Chemical composition is heteroaryl acetic acid with a short half-life. The delayed-release enteric-coated form is diclofenac sodium and the immediate release form is diclofenac potassium. Both primarily are indicated for rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. Can cause hepatotoxicity; hence liver enzymes should be monitored in the first 8 weeks of treatment. Has a relatively low risk for bleeding GI ulcers.

Etodolac (Lodine, Lodine XL)

Indole NSAID with intermediate half-life indicated for rheumatoid arthritis and osteoarthritis. The short-acting form is approved for analgesic use comparable to aspirin/Tylenol (with codeine). Lower risk of GI complications and is especially well tolerated by elderly patients.

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Probably most potent arylpropionic acid with a long half-life. Indicated for rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, juvenile arthritis, acute gout, and mild to moderate pain. Comes in a controlled release form (also used for acute pain) and an enteric-coated form (not used for acute pain).

Oxaprozin (Daypro)

Arylpropionic acid with 40-50 h half-life. Can be administered qd.

Nabumetone (Relafen)

An alkanone NSAID with long half-life (24 h) that can be administered qd. Lower risk of GI complications and is indicated for rheumatoid arthritis and osteoarthritis.

Piroxicam (Feldene)

Enolic acid with a long half-life (50 h) that can be administered qd. Indicated for rheumatoid arthritis and osteoarthritis. Has high GI toxicity, greater than ASA.

Cyclooxygenase-2 (COX-2) inhibitors

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.

Celecoxib (Celebrex)

Selective COX-2 inhibitor, NSAID approved by the FDA on 12/31/98. Indicated for osteoarthritis and rheumatoid arthritis and moderate to severe pain. Potentially presents less GI complications and platelet aggregation problems than nonselective COX-inhibitor NSAIDs. Renal complications are comparable. Celecoxib has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.

Analgesic combinations

May offer improved relieve over either agent alone.

Tramadol 37.5 mg and acetaminophen 325 mg (Ultracet)

Centrally acting pain medication that combines tramadol hydrochloride with acetaminophen. Clinical trials demonstrated that the combination offers better pain relief over either medication alone. Indicated for the short-term (5 d or less) management of acute pain.

• Search for CME/CE on This Topic »

• Supraspinatus Tendonitis (Sports Medicine)
• Multidirectional Glenohumeral Instability (Orthopedic Surgery)
• Swimmer's Shoulder (Sports Medicine)

• Sports Injury Center
• Rotator Cuff Injury Causes
• Rotator Cuff Injury Treatment
• Hand, Wrist, Elbow, and Shoulder Center
• Rotator Cuff Injury Overview
• Repetitive Motion Injuries Overview
• Rotator Cuff Injury Symptoms

• Geriatric Physical Diagnosis: The Upper Extremities