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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

Shoulder pain due to SAPS is very common SAPS from RC pathology including tendinopathy , calcific tendinitis and RC tears accounts for up to 70 % of all new shoulder pain problems Annual prevalence of SAP is around 7 % A BMJ paper in 2017 quotes that among shoulder complaints SAP is the most common disorder , representing 89 % of total shoulder complaints referred to GPs and physiotherapists

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
 Neer’s
 Hawkins
 Yocum’s

○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

red flags –Trauma , pain and weakness or sudden loss of ability to actively raise the arm ( this can be with or without trauma ) this may be due to an acute cuff treat Acute painful red warm joint – ? infection – needs same day referral Trauma leading to loss of rotation and abnormal shape ? Unreduced dislocation Shoulder mass or swelling ?Tumour and malignancy Symptoms suggestive of inflammatory joint disease

Imaging-not recommended in primary care can be user dependent and the accuracy of reporting can vary a normal US does not mean that serious underlying pathology as tumour and glenohumeral osteoarthritis do not exist a report of partial thickness tear is common and this may be for a patient who is asymptomatic or due to false positive reporting this is more suitable in secondary care setting where the shoulder surgeon can correlate findings in the context of patient symptoms

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

MRI- It is largely unknown if the structural changes identified by MRI affect the outcome of non-operative treatment for shoulder pain MRI is often used by shoulder specialists particularly in groups for who a surgical intervention is being considered

Referral- any red flag Calcific tendinopathy can be very painful and can often mimic malignant pain – consider an early secondary care referral for more interventional treatment persistent or significant loss of function despite 6 weeks of conservative management

Shoulder Pain Disability Index https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0008/77084/shoulder-pain-and-disability-index-spadi1.pdf

References

  1. Diercks, Ron et al. “Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association.” Acta orthopaedica vol. 85,3 (2014): 314-22. doi:10.3109/17453674.2014.920991
  2. Kulkarni, Rohit et al. “Subacromial shoulder pain.” Shoulder & elbow vol. 7,2 (2015): 135-43. doi:10.1177/1758573215576456
  3. Tangrood ZJ, Gisselman AS, Sole G, et al. Clinical course of pain and disability in patients with subacromial shoulder pain: a systematic review protocol. BMJ Open 2018;8:e019393. doi:10.1136/ bmjopen-2017-019393 https://bmjopen.bmj.com/content/bmjopen/8/5/e019393.full.pdf
  4. Commissioning guide Subacromial Shoulder Pain RCS via https://www.boa.ac.uk/uploads/assets/uploaded/f4bfe04a-0450-4eab-b9acad9dbb5d8c86.pdf
  5. Cadogan, Angela et al. “Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain.” PloS one vol. 11,12 e0167738. 9 Dec. 2016, doi:10.1371/journal.pone.0167738
  6. Kvalvaag, E., Anvar, M., Karlberg, A.C. et al. Shoulder MRI features with clinical correlations in subacromial pain syndrome: a cross-sectional and prognostic study. BMC Musculoskelet Disord 18, 469 (2017). https://doi.org/10.1186/s12891-017-1827-3 ( Abstract )
  7. Vandvik Per Olav, Lähdeoja Tuomas, Ardern Clare, Buchbinder Rachelle, Moro Jaydeep, Brox Jens Ivar et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline
  8. Rotator cuff tendinopathy / subacromial impingement syndrome : Is it time for a new method for a new method of assessment ? J S Lewis British Journal of Sports Medicine Volume 43 , Issue 4 ( Abstract )
  9. Guideline for the diagnosis and treatment of subacromial pain syndrome A multidisciplinary review by the Dutch Orthopaedic Association Acta Orthopaedica Volume 85 , 2014- Issue 3 Pages 314-322
  10. Subacromial shoulder pain BESS / BOA Patient Care Pathways Rohit Kulkarni et al British Elbow and Shoulder Society March 2015
  11. Asessment of shoulder pain for non-specialists BMJ 2016 ; 355:i5783
  12. CKS NHS Shoulder pain 

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