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Nonoperative Treatment

A trial of nonoperative care is implemented before surgical intervention is considered. The majority of patients with impingement syndrome can be managed conservatively. The treatment program consists of formal physical therapy, activity modification, anti-inflammatory, and the judicious use of steroid injections into the subacromial space.

By emphasizing the importance of following the rehabilitation protocol and working closely with a skilled therapist, the majority of patients should have a satisfactory result and not require surgery.

The physical therapy program includes soft tissue stretching and strengthening of the humeral head depressors. These are the internal and external rotators. Strengthening these muscles helps to depress the humeral head and decrease impingement. Passive capsular stretching is used to return the normal rolling-gliding of the glenohumeral joint. As range of motion increases, pain levels should decrease.

The scapular stabilizers should also be strengthened. These include the upper and lower trapezius, seratus anterior, and rhomboids. These muscles contribute to optimal positioning of the scapula during overhead activities. If these muscles fatigue, the scapula is no longer able to keep up with the humerus. The humeral head continues to translate anteriorly and superiorly worsening impingement symptoms. Strengthening of the deltoid muscle is counterproductive as its action promotes elevation of the humeral head.

In a recent large study based on the above therapy program, an overall 70% success rate was obtained in treating patients with chronic subacromial impingement. In this study the acromial morphology was shown to affect the outcome of conservative treatment. Patients with a Type I acromion had a 91% successful result. Patients with Types II and III had less success with 68% and 64%, respectively.

The majority of orthopedic surgeons find the occasional use of corticosteroid injections helpful in the treatment of impingement syndrome; however, several studies have shown no significant improvement when compared with placebo in terms of pain or range of motion.

A recent randomized and blinded study found patients to have decreased pain at 1 month post-injection, but no difference 3 months after injection. If used, injections should be individualized and done in conjunction with an exercise program.

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