Subacromial Pain Syndrome

This condition is an umbrella term and includes conditions as impingement, subacromial bursitis, calcific tendinitis, biceps tendinitis, cuff degeneration, rotator cuff tendinopathy and cuff tear. Specialized tests as Neer , Hawkins , Empty-can test have been shown to help the clinician evaluate the shoulder. Anatomy of the shoulder is also described for reference. Role of imaging as MRI , Ultrasound and X-Ray is cited to help the clinician order further investigations. Management and the role of physiotherapy are discussed- acute tear secondary to trauma should be referred urgently. Addressing each condition alone is beyond the scope of this review but a chart with further details is planned on A4Medicine

Umbrella term ( Subacromial pain syndrome – SAPS ) for non-traumatic shoulder disorders and includes
 Impingement Subacromial bursitis Calcific tendinitis Biceps tendinitis Cuff degeneration Supraspinatus or rotator cuff tendinopathy Partial rotator cuff tear

Pain comes from the subacromial space which contains the rotator cuff tendons and subacromial space – this is separate to the main Glenohumeral joint

Presentation-Pain felt on the top and outer side of shoulder Usually unilateral Worsened by overhead activity Can cause night pain Usually full passive range of movements of the G/H jt Mainly caused by rotator cuff tendinopathy ( also called shoulder impingement )

Pathology-Mechanical explanation – Impingement- between the under-surface of the acromion and the RC tendons ( while lifting the arm )
 More emphasis placed now on role of degeneration of the RC tendons leading to tears

Rotator -cuff Rotator cuff refers to group of muscles and tendons that surround and stabilize the shoulder joint
 Principle muscles involved
○ supraspinatus → tears frequently involve supraspinatus tendon
○ infraspinatus
○ subscapularis
○ teres major
 Tear- structural failure in one or more of the RC muscles and tendons
○ can be acute ( traumatic ) or chronic
○ partial or full thickness
○ risk of tear ↑es with age

SAPS-Repetitive movements of the shoulder or hand/ wrist during work Work that requires much more prolonged strength of the upper arms Hand-arm vibration ( high vibration and / or prolonged exposure) at work Working with a poor ergonomic shoulder posture High psychosocial work load

History-Hand dominance Occupation particularly sporting history Pain history
○ location
○ radiation
○ onset
○ duration
○ exacerbating and relieving factors H/O Trauma Other jt/ msk problems Any systemic illness Red flags ( see shoulder pain initial assessment )

Examination-Examination – see shoulder initial assessment
 Specific tests- several tests exist examples
○ Tests which detect impingement

○Tests which detect location of RC lesion
 Jobe’s test ( empty can ) supraspinatus
 Patte’s test ( infraspinatus )
 Lift-off test ( subscapularis )
 Palm-up Test- long head of biceps brachii
 Drop arm test- RC tear
 No single test is sufficiently accurate to diagnose SAPS Combination of a number of tests ↑ es the post-test probablity of SAPS

○ sensitive and specific
○ diagnostic accuracy is good and comparable to conventional MRI for identification of complete ( full thickness ) RC injuries
○ Conflicting evidence in partial cuff tears and tendinopathies
○ Most valuable and cost effective if a first period of non-operative treatment fails
○ can show OA , osseous abnormalities
○ calcium deposits
○ consider two view ( AP and lateral ) views
○ if steroid inj is being considered
○ suspected bony malignancy
○ when reliable US not at hand or inconclusive
○ patients who are eligible for surgical repair
○ MRI with intra-articular contrast can show intra-articular abnormalities and partial RC injury
 BESS guidance on imaging
○ US or MRI rarely needed in primary care
○ Normal RC US does not exclude serious shoulder pathologies as tumour and glenohumeral OA
○ Presence of RC tear on imaging does always correlate with symptoms and does not imply a definite need for surgery
○ People over 65 can have asymptomatic tears

Tests Neer , Hawkins-Kennedy ,Empty can test , Painful arc

Management-Conservative treatment

○ Information- shared decision making

○ Rest ( in acute phase )

○ Exercise – gradually expanding activities

○ Physiotherapy – structured
 ♦ initially for 6 weeks
 ♦ includes postural correction , motor control retaining , stretching , strengthening of the RC and scapula muscles and manual therapy
 ♦ if improvement in 1st 6 weeks then a further 6 weeks therapy is justified

○ Analgesia

○ Corticosterod injection- subacromial
 ♦ Not more than 2 
( evidence emerging that ↑ risk tendon damage with frequent injections )
 ♦ Effect in long term is not clear
 If patient asking for return to work or sport could pragmatically be advised to rest from aggravating activities for 6 weeks
 Acute calcific tendinopathy- can be very painful and can mimic malignant pain ( consider early referral ) An acute tear secondary 
to trauma needs 
urgent referral and 
should be seen in the next available OP clinic