Case of the Month #34: Shoulder Pain by Dr Sunil Dasari

How do you manage impingement syndrome?

Identification of the condition early before the onset of degenerative changes is the key. Complications that may arise predominantly result from structural damage within the subacromial space, altered biomechanics, or avoidance of use with subsequent atrophy. Potential pathologies that may result include rotator cuff tendonitis or tear, bicipital tendonitis or tear, or adhesive capsulitis.
 

• Physiotherapy: It is the most important treatment for shoulder impingement syndrome. Stretching exercises for improving range of movement are initiated. The combination of exercise with other conservative therapy lead to greater improvements in pain score compared to either treatment alone.

  Without known structural damage, non-operative therapies with a controlled exercise programme, non-steroidal anti-inflammatory drugs (NSAIDs), and subacromial injections are considered the treatment of choice for the first 3 to 6 months of treatment.¹

  Patient education should focus on the importance of not only adherence to physical therapy and a home exercise programme but also activity modifications, such as discontinuing overhead activities until the pain improves.⁴ 

• Pharmacologic interventions: Non-steroidal Anti-inflammatory (NSAID) like Ibuprofen and Naproxen are prescribed to help with the pain. Injections: Sub-acromion steroid injection to suppress the inflammation and improve range of movement. Physiotherapy plus localised injection resulted in a maximised treatment effect compared to just localised injection.⁵ 

• Surgery: If the conservative treatment fails. Subacromial decompression or arthroscopic shoulder decompression to create more space for the rotator cuff. A systematic review of randomised controlled trials comparing surgical intervention versus conservative therapy yielded moderate evidence that surgical intervention was not more effective for reducing pain than impingement-directed physical therapy.⁶

In 60% of patients, physical therapy, NSAIDs, corticosteroid injections, and other means of
conservative therapy yield satisfactory results within two years.¹