Shoulder Pain Management

Tendonitis, Bursitis and Impingement Syndrome

Initial treatment for these conditions may include anti-inflammatory medications, activity modification, and physical therapy. Corticosteroid injections may be necessary if physical therapy is limited by pain. Bursitis may require removal of the bursa fluid by aspiration.

Treatment Options
• NSAIDs
• Subacromial injections with cortisone and/or bupivacaine (Marcaine)
• Arthroscopy for failure of conservative therapy and impingement

Key Clinical Points
• Most patients who have impingement syndrome eventually recover.
• Morbidity associated with operative treatment has decreased with the advent of newer arthroscopic procedures to decompress the subacromial injections (Fig. 2).
• Nonoperative interventions may be appropriate before considering operative measures.
• A minimum 6-month trial of nonoperative intervention is recommended.

Figure 2: Subacromial injection. This injection is performed from the back by using the posterolateral border of the acromion as a landmark. The injection is placed into the subacromial space by advancing the needle directly under the acromion anteriorly and slightly medially. In exceptionally large individuals, the needle must be long enough to reach the anterior one third of the subacromial area, because the pathology exists anteriorly. Alternatively, lateral and anterior injection techniques can be used in injecting the subacromial space.¹

Patient Considerations

Patients with suspected partial-thickness rotator cuff tears should be treated in a similar manner to patients with impingement syndrome. Physical therapy should be advanced as inflammation and pain decrease. Therapy should first be directed at eliminating capsular contractures and regaining full motion. Posterior capsular contracture is addressed by progressive stretching in adduction and internal rotation. As the pain subsides and the stiffness resolves, attention is focused on strengthening the periscapular musculature and rotator cuff.²

The function of the rotator cuff as a dynamic stabilizer of the humeral head is improved by using a program emphasizing progressive resistive exercises involving the use of elastic bands. Rehabilitation of the periscapular musculature is crucial, as it restores normal scapulothoracic mechanics, which should minimize dynamic impingement secondary to scapulothoracic dyskinesis.²

Patients with impingement believed to be secondary to instability are also treated initially with the control of inflammation and pain. Again, attention is focused on rehabilitating the rotator cuff and periscapular muscle groups. Restoration of proper shoulder mechanics is crucial in overhead athletes.

Clinical Course

Most patients with impingement syndrome or minor rotator cuff tearing will recover and return to normal function within 6 months. It may take some patients up to 18 months to improve from the initial date of treatment. Supervised physical therapy and NSAIDs and/or analgesia are imperative. In time, the symptoms should gradually subside. The minority of patients who have persistent or increasing symptoms should be evaluated for possible surgical interventions. However, surgery should be avoided for at least 6 months.

Know When to Refer
• Patient not responding to conservative treatment after 3 to 6 months
• Traumatic glenohumeral instability
• Full-thickness rotator cuff tears
• Symptomatic os acromiale
• Spinoglenoid notch cyst (Ganglion cyst of the shoulder)
• Recalcitrant adhesive capsulitis

References