What Is Conservative Treatment?

Conservative treatment of subacromial impingement syndrome (SIS) can consist of NSAIDs, corticosteroid injections (with exercise), electrotherapy, laser, ultrasound, and microwave diathermy, manual mobilizations, kinesiotherapy, acupuncture, and taping (1).

One review identified that significant improvements of symptoms were found after treatments that consist of ultrasound and laser, ultrasound hammer, acupuncture with exercise at home, kinesiology band and intra-articular mobilization with kinesiotherapy (1).

However, another review had determined that ultrasound therapy and acupuncture was no better than placebo or no treatment (2). 

Are Corticosteroid Injections Better Than Other Options?

Corticosteroid injections are more effective than placebo or no treatment in the first 8 weeks but are equivocal to NSAIDS for reducing pain in the short term (unclear long term results) (2). Oral NSAIDS were more effective than placebo in the first 1-2 weeks, and laser was more effective than placebo in the first 2-4 weeks (2). Extracorporeal shockwave therapy (high-energy) is more effective than placebo in the treatment of tendinosis calcarea, but not effective for shoulder conditions without calcium deposits (2). 

How Effective Are Rehab Exercises?

Kinesiotherapy, or exercising, often begins in the subacute or chronic phase, with relative rest recommended in the acute phase (1)(2). Exercises can include stretching, pulley assisted exercises, isometric strengthening exercises, passive exercises, closed kinetic chain exercises, plyometric exercises stabilizing the scapulae, peripheral upper limb stabilization exercises, and PNF exercises (neuromuscular control)(1). Movement within pain threshold is recommended, and should be performed at low intensity but high frequency with a focus on eccentric exercises (2). The overall goal of a rehabilitation program is to include strengthening, stabilization, stretching, and neuromuscular control for the rotator cuff and scapular muscles (1). This will allow reversal of tendon pathology and improve muscle coordination in the shoulder muscles to rehabilitate impingement (1).

Exercise therapy is more effective than no treatment in reducing pain and improving function, and has equivocal results to home exercising (2). However, exercises targeting rotator cuff muscles and scapular stabilizers are more effective than general exercise therapy. Manual joint mobilizations had shown no additional benefit to active exercising in reducing pain and improving function (2). Massage therapy (soft tissue or myofascial trigger point) was more effective than placebo or no treatment as well (2).  

What Type of Exercise Is Most Effective?

Eccentric loading of a tendon is believed to reverse the inflammatory effects and degenerative changes experienced in SIS by gradually overloading the tendon to promote an adaptive change to the tendon (3). This mechanism is called mechanotransduction (3). The recommended dosage is 3 sets of 10-15 repetitions performed 1-2 times a day, 7 days a week for 10-12 weeks (3). Most studies review also incorporated one of stretches, warm-up/ cool-down, manual therapy, scapulothoracic mobilization, rotator cuff exercises with band resistance, and scapular stabilization exercises (3). These exercises were also monitored using the Pain-Monitoring Model (Thomee, 1997), which describes pain or discomfort during exercise of a score up to 5 on the VAS to be acceptable if momentary (pain subsides immediately after exercise and if resolved by the next morning)(3). If the pain does not subside or exceeds 5 on the VAS, then exercise intensity is reduced. This application of eccentric exercises can improve patient function, pain, quality of life, strength, and satisfaction (3).

Proprioceptive neuromuscular facilitation (PNF) is an advanced form of flexibility training that is a combination of functional movements with neuromuscular facilitation techniques to improve motor response and neuromuscular control, and can be used in all phases of shoulder rehabilitation (4). A comparative study had found that PNF combined with eccentric exercises was statistically significant at reducing pain, and  improving overhead reach, endurance, and functional disability than eccentric exercises alone in patients with SIS (4). Three  PNF techniques were used and are described as the following:

1. Scapular PNF - 2 patterns, each with 3 sets of 10 repetitions

   1. Anterior elevation - Patient is side-lying with scapula was passively moved into posterior depression. They were asked to anteriorly elevate the scapula against resistance, with a diagonal movement towards their nose.

   2. Posterior depression - side-lying with instruction to move the scapulae towards the ipsilateral ischial tuberosity

2. Contract-Relax GH Flexion

   1. The affected limb was moved toward the point of limitation (active or passive), an isotonic contraction into available GH flexion was performed, followed by isometric contraction for 7-9 seconds into GH extension. The patient then relaxes for 2-3 seconds, followed by passive motion into new range of the agonist muscle for a 10-15 second stretch. This process is repeated until no further improvements are noted. This process was then repeated for GH abduction, GH internal rotation, and GH external rotation at 3 sets of 5 repetitions.

3. Active PNF flexion-abduction-external rotation diagonal movement pattern - 3 sets for 10 repetitions with manual facilitation at the end

Where Can I Learn To Do Exercises?

Your physiotherapist or chiropractor can teach you exercises to treat your subacromial impingement. Exercises will be based on a physical examination that is used to test your base line of movement tolerance. Tests such as the Hawkins Kennedy Test may be used in combination with a movement assessment during your appointment. This tests are used to determine the sensitivity of your subacromial space and bursa. Other tests may be used to rule out conditions such as supraspinatus tendinosis or rotator cuff tears.

Through physiotherapy and chiropractic you will be given a daily or weekly exercise routine that will help you reach full recovery. At the Rehab Hero clinic your Registered Massage Therapist may also provide exercises to help cope with your shoulder pain. Massage therapy will be used in combination with exercise to reduce muscle pain, muscle tension, and to increase shoulder range of motion. If outside of Toronto, the Rehab Hero clinic provides virtual online consults to help you recover using home-based exercises.

References

1. EFSTRATIADIS A, MARANGOS S, KASAPAKIS E, GEORGIADOU P, PLOUTARXOU G, STASINOPOULOS D, et al. The subacromial impingement syndrome of the shoulder: The role of physiotherapist in the evaluation and treatment of the syndrome. Biology Of Exercise [serial on the Internet]. (2017, Jan), [cited November 7, 2017]; 13(1): 15-32. Available from: SPORTDiscus with Full Text.

2. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, van der Woude H, et al. Guideline for diagnosis and treatment of subacromial pain syndrome. Acta Orthopaedica [serial on the Internet]. (2014, June), [cited November 7, 2017]; 85(3): 314-322. Available from: CINAHL Plus with Full Text.

3. Dervey E, Marshall S, Rouse S, Bernhardsson S, Camargo P, McVeigh J. Eccentric exercise therapy in the treatment of subacromial impingement syndrome: A critical review...including commentaries by Bernhardsson S, Camargo PR and McVeigh JG. International Journal Of Therapy & Rehabilitation [serial on the Internet]. (2014, July), [cited November 7, 2017]; 21(7): 338-345. Available from: CINAHL Plus with Full Text.

4. Jain A, Anandh S, Pawar A. Effectiveness of Proprioceptive Neuromuscular Facilitation as an Adjunct to Eccentric Exercises in Subacromial Impingement. Indian Journal Of Physiotherapy & Occupational Therapy [serial on the Internet]. (2017, Apr), [cited November 7, 2017]; 11(2): 141-146. Available from: CINAHL Plus with Full Text.

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