Combination Therapies for Treating Shoulder Impingement

Shoulder impingement syndrome is one of the most common causes of shoulder pain seen in physiotherapy practice. It typically arises from irritation of the rotator cuff tendons and the subacromial bursa, often leading to pain with overhead activity, reduced range of motion, and night pain that can significantly impact quality of life.

While corticosteroid injections are frequently used to reduce inflammation and pain, their effectiveness may be short-lived and repeated use can delay tissue healing. For this reason, physiotherapists are increasingly turning to combination therapies—such as radial pressure wave therapy and LightForce® laser therapy—to address both pain modulation and tissue healing in a multimodal, evidence-informed approach.

Case Study: Joey’s Shoulder Pain

Joey, a patient presenting with an 8-month history of right shoulder pain, had already received two corticosteroid injections. The first injection provided immediate but short-lived relief (lasting around 5 days), while the second failed to deliver the same benefit. Imaging demonstrated features consistent with shoulder impingement, including bursitis and calcification within the rotator cuff tendon.

At this point, shockwave therapy (radial pressure wave) was considered. However, since shockwave is contraindicated within six weeks of a corticosteroid injection, the clinician opted to begin treatment with LightForce® laser therapy to reduce pain and stimulate tissue repair.

Treatment Approach

1. Addressing Myofascial Trigger Points

As is common with tendinopathies, Joey also presented with associated myofascial trigger points in the shoulder musculature. These were addressed first using manual therapy and radial pressure wave therapy, reducing referred pain and restoring mobility. Treating trigger points is a critical step, as they can often be the source of persistent symptoms and pain referral.

2. LightForce® Laser Therapy

The next step focused on applying photobiomodulation (PBM) therapy using a 40W LightForce® laser:

• Dual Wavelengths: One wavelength penetrates to modulate nociceptors and reduce pain transmission, while the other stimulates mitochondrial activity to enhance cellular repair.
• On-Contact Application: A silicone roller ball was used to deliver the treatment directly over the affected tendon and bursa, ensuring maximum energy transfer (up to 15% more efficient than off-contact methods).
• Tailored Parameters: The treatment was individualized based on Joey’s body type, Fitzpatrick skin type, and chronicity of the condition, ensuring safe and effective dosing.

The treatment was short—just 2 minutes and 40 seconds—but delivered a therapeutic energy dose sufficient to reduce inflammation and promote healing while allowing time in-session for exercise rehabilitation.

Clinical Outcomes

After two sessions of LightForce® laser therapy, Joey reported:

• Resolution of painful arc in shoulder abduction
• Improved sleep quality, including the ability to lie on the affected side for the first time in months
• Significant pain reduction, reporting “no pain” during daily activities

This rapid improvement highlights the role of laser therapy in modulating pain and accelerating recovery, particularly when other interventions such as corticosteroid injections have failed to deliver sustained benefit.

Why Combination Therapy Matters

Shoulder impingement is rarely the result of a single pathology. It often involves rotator cuff tendinopathy, bursitis, trigger points, and postural dysfunction. A combination approach allows clinicians to:

• Target multiple pain generators (e.g., tendon, bursa, and trigger points)
• Reduce pain quickly to facilitate exercise-based rehabilitation
• Enhance tissue healing through photobiomodulation
• Minimize reliance on corticosteroid injections, which can compromise long-term tendon health

By combining radial pressure wave therapy (to address myofascial dysfunction and stimulate tendon remodeling) with LightForce® laser therapy (to reduce pain and promote healing), clinicians can provide a comprehensive, patient-centered treatment strategy for shoulder impingement.

Key Takeaways for Clinicians

• Shockwave therapy should be delayed for at least 6 weeks post-corticosteroid injection.
• Always consider trigger point involvement in cases of tendinopathy and impingement.
• LightForce® laser therapy provides both rapid analgesia and biological stimulation for healing, making it an excellent bridge treatment when shockwave is temporarily contraindicated.
• A multimodal strategy can yield faster, longer-lasting outcomes compared to single-modality care.

Conclusion:
Joey’s case demonstrates the clinical value of combination therapies for shoulder impingement. By addressing both the symptomatic pain and the underlying pathology, radial pressure wave therapy and LightForce® laser therapy provide complementary benefits—empowering patients to regain movement, reduce pain, and return to daily life more quickly.

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