Subacromial Pain Syndrome | A4Medicine

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SUBACROMIAL PAIN SYNDROME
a4medicine.co.uk
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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 )
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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 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
) 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
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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 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 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
) 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
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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 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 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
) 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
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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 Neers Hawkins Yocums ?Tests
which detect location of RC lesion Jobes test (
empty can ) supraspinatus Pattes 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
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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
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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_f
ile/0008/77084/shoulder- pain-and-disability-inde
x-spadi1.pdf
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References

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2. Kulkarni, Rohit et al. Subacromial shoulder
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   Clinical course of pain and disability in
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