Emergency Department Treatment

The goals of treatment of impingement lesions are twofold: to reduce pain and inflammation and, more importantly, to prevent progression of the process. Regardless of the stage of impingement identified, a conservative treatment program initiated by the emergency physician should include the following:

1. Relative rest and modification of activities. However, immobilization should be avoided whenever possible. Brief periods of support with a sling may be prescribed.

2. Medication to reduce pain and inflammation. Often analgesics are required to control pain during stage 2 and 3 impingement. Nonsteroidal anti-inflammatory agents can be prescribed for a 7- to 10-day course.

3. Cryotherapy. The application of ice to the affected shoulder for 10 to 15 min two to three times per day can have analgesic effects and is thought to reduce local inflammation and edema.

4. Gentle range of motion. Two simple exercises can help the patient maintain glenohumeral motion. Pendulum swings are done with the patient slightly bent at the waist with the arm hanging freely in front of the body. Gentle arcs of motion to the level of pain tolerance can be carried out for 5 to 10 min daily. The size of the arcs should increase daily as symptoms allow. Also, having the patient walk his or her fingers up the wall to the level of pain tolerance can also help preserve glenohumeral motion.

5. Stretching and strengthening. During stage 1 impingement, stretching and strengthening may be initiated early on. Entering stage 2 and 3 impingement, stretching and strengthening are most effectively carried out under the supervision of a physical therapist. This is an important part of the treatment of impingement and is usually prescribed by the primary care physician or orthopaedist, who can monitor the patient's response to therapy.

6. Corticosteroid injections. While local corticosteroid injections into the subacromial space can be effective for pain relief, their deleterious effects on soft tissues have been well documented. These include muscular atrophy, weakness, and further tissue degeneration. Injection directly into the substance of the tendon can lead to necrosis and rupture. Even in the primary clinician's office setting, the judicious use of corticosteroids is advised, with no more than two to three injections being recommended in one specific area. While a single injection is not believed to be harmful, caution is still advised for use in the emergency department because of the potential harmful effects of repeated injections and difficulty in ensuring reliable follow-up.

FIG. 275-4. Impingement of subacromial bursa and rotator cuff.

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