Impingement syndrome: Temporal outcomes of nonoperative treatment

Authors: Cummins CA, Sasso LM, Nicholson D.

References: J Shoulder Elbow Surg (2009) 18, 172-177

Hypothesis: We prospectively studied patients with impingement syndrome to look at outcomes of nonoperative treatment on a temporal basis.

Materials and methods: Temporal outcomes of 100 consecutive patients treated for impingement syndrome were prospectively evaluated. All patients began a standardized, nonoperative treatment protocol consisting of a subacromial steroid injection, followed by physical therapy.

Results: Data were available on 94 patients at the final two-year follow-up assessment. Overall, 74 of 94 patients did not require surgery. In that group, the average American Shoulder and Elbow Surgeons (ASES) outcome score increased from 56 to 95, with an average decrease in the pain score from 4.8 to 0.6. Improvement was demonstrated in patient shoulder outcome scores (ASES score) and visual analog pain scores between treatment initiation and the one-year follow-up assessment (p < .0001); no improve- ment was identified past one year. Of the non-surgical patients, 22 continued to have some shoulder pain.

Conclusion: Of patients with impingement syndrome treated nonoperatively, 79% did not require surgery after two-year follow-up. Predictors of patients going on to surgical intervention included the total number of subacromial steroid/lidocaine injections and patient response to the initial subacromial injection. Of the patients not undergoing surgery, 30% continued to have some shoulder pain.

Level of evidence: Level 1; Prospective prognosis study, >80% follow-up.

"… additional shoulder diagnoses were identified in those patients who went on to surgery. Additional diagnosis may have been present in some patients who did not undergo surgery, but the significance of potential missed diagnoses in this latter segment of patients is unclear. However, our results support the concept of reeval- uating those patients who respond poorly to nonoperative treatment with advanced imaging to assess for alternative or coexisting diagnosis."
"In 14 of 20 shoulders, additional diagnoses were identified before or at the time of the surgery. Specifically, 6 had a small, full- thickness rotator cuff tear, 4 had a superior labral anterior to posterior tear with instability of the biceps tendon attach- ment site, 1 presented with pain at the acromioclavicular joint that was addressed with a distal clavicle resection, 4 had a partial biceps tear addressed surgically, adhesive capsulitis developed in 1, and a suprascapular neuropathy was diagnosed in 1 patient."

"... the findings from this investigation demonstrate significant improvement in short-term outcomes after a subacromial steroid/lidocaine injection. Specifically, patients’ levels of pain decreased on average 44%, from a pain score of 4.8 +/- 1.9 to a score of 2.7 +/- 2.1 (P < .0001) after a subacromial steroid/lidocaine injection. The results from this study also demonstrate that a patient’s response to a subacromial injection may predict his or her ultimate outcome. Those who had a poor response to a subacromial steroid/lidocaine injection were more likely to undergo surgical management."


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