Subacromial Pain Syndrome: Difference between revisions

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== Introduction  ==
== Introduction  ==
There has been huge debate in relation to the diagnostic labelling of non-traumatic shoulder pain related to the structures of the subacromial space. The diagnostic label Subacromial Impingment Syndrome (SIS), presenting as anterograde-lateral shoulder pain when the arm is elevated, was first introduced in 1972 by Dr Charles Neer and was based on the mechanism of structural impingement of the structures of the subacromial space, and as reflected by the literature is considered by many to be one of the most common causes of shoulder pain.<ref name=":5" /><ref name=":6">Cools AM, Michener LA. Shoulder Pain: Can One Label Satisfy Everyone and Everything? Br J Sports Med. 2017 Feb 16;51(5):416–7.</ref><ref name=":7" /> SIS has been viewed as symptomatic irritation of the subacromial structures between the coraco-acromial arch and the humeral head during elevation of the arm above the shoulder / head <ref name=":5">de Witte PB Nagels J van Arkel ER, et al. Study protocol subacromial impingement syndrome: the identification of pathophysiologic mechanisms (SISTIM). BMC Musculoskelet Disord. 2011; 12:1-12. </ref>, associated with either External (Primary or Secondary) and Internal Impingement.
There has been huge debate in relation to the diagnostic labelling of non-traumatic shoulder pain related to the structures of the subacromial space. The diagnostic label Subacromial Impingment Syndrome (SIS), presenting as anterograde-lateral shoulder pain when the arm is elevated, was first introduced in 1972 by Dr Charles Neer and was based on the mechanism of structural impingement of the structures of the subacromial space.<ref name=":5">de Witte PB Nagels J van Arkel ER, et al. Study protocol subacromial impingement syndrome: the identification of pathophysiologic mechanisms (SISTIM). BMC Musculoskelet Disord. 2011; 12:1-12. </ref><ref name=":6">Cools AM, Michener LA. Shoulder Pain: Can One Label Satisfy Everyone and Everything? Br J Sports Med. 2017 Feb 16;51(5):416–7.</ref><ref name=":7" /> SIS has been viewed as symptomatic irritation of the subacromial structures between the coraco-acromial arch and the humeral head during elevation of the arm above the shoulder / head <ref name=":5" /> and as reflected by the literature is considered by many to be one of the most common causes of shoulder pain. Neers Classification of Impingement identified four types of Shoulder Impingement identified below;
 
'''Neer Classification of Subacromial Impingement'''
 
According to Neer impingement syndrome is divided into three stages:
 
Type I: <25 years old, Reversible, Swelling, Tendonitis, No Tears, Conservative Treatment.
* Moderate pain during exercise, no loss of strength and no limitation in movement. Edema and/or hemorrhage may be present. This stage generally occurs in patients less than 25 years of age and is frequently associated with an overuse injury. At this stage the syndrome could be possibly reversible. <ref name="khan">KHAN Y, NAGY MT, MALAL J, WASEEM M, The painful shoulder: shoulder impingement syndrome. Open Orthop J Sept 2013, 6(7): 347-51</ref>
Type II: 25-40 years old, Permanent Scarring, Tendonitis, No Tears, Subacromial Decompression
* Pain is usually reported during ADL and especially during the night. loss of mobility is associated with this stage. Type II is more advanced and tends to occur in patients between 25 to 40 years of age. The pathological changes show fibrosis as well as irreversible tendon changes.<ref name="khan" />
Type III: >40 years old, Small Rotator Cuff Tear, Subacromial Decompression with Debridement/Repair
 
Type IV: >40 years old, Large Rotator Cuff Tear, Sub Acromial Decompression with Repair
 
While Neers Classification of SIS was key to understanding shoulder pathology at the time, SIS was further broken down into four subtypes associated with either External Impingement (Primary or Secondary) and Internal Impingement.
==== External Impingement ====
==== External Impingement ====
[[File:Shapes of Acromion.jpg|thumb|463x463px|Figure 1. Acromion Shapes]]
[[File:Shapes of Acromion.jpg|thumb|463x463px|Figure 1. Acromion Shapes]]
* Primary External Impingement related to structural changes, either congenital or acquired, that mechanically narrow the subacromial space such as;  bony narrowing or osteophyte formation, bony malposition after a fracture, or an increase in the volume of the subacromial soft tissues.<ref>Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am. 1972;54:41–50.</ref><ref>Leroux J-L, Codine P, Thomas E, Pocholle M, Mailhe D, Blotman F. Isokinetic evaluation of rotational strength in normal shoulders and shoulders with impingement syndrome. Clin Orthop. 1994;304:108–115</ref><ref name="af" /><ref name=":0">Bigliani LU, Levine WN. Current concepts review: Subacromial impingement syndrome. J Bone Joint Surg Am. 1997;79:1854–1868.</ref><ref name=":14">Harryman DT, Sidles JA, Clark JM, McQuade KJ, Gibb TD, Matsen FA. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am. 1990;72-a:1334–1343.</ref><ref>Morrison DS, Greenbaum BS, Einhorn A. Shoulder impingement. Orthop Clin North Am. 2000;31:285–293</ref><ref>Nicholson GP, Goodman DA, Flatow EL, Bigliani LU. The acromion: Morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg. 1996;5:1–11.</ref><ref>Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005;35:72–87.</ref><ref name="debie">DE BIE R.A., BASTIANENEN C.H.G. Effectiveness of individualized physiotherapy on pain and functioning compared to a standard exercise protocol in patients presenting with clinical signs of subacromial impingement syndrome. A randomized controlled trial. BMC Musculoskeletal Disorders. 2010 Jun 9; 11:114.Level of evicence: 1B</ref><ref name="page">Phil Page, PhD, PT, ATC, LAT, CSCS, FACSM, Shoulder Muscle Imbalance and Subacromial Impingement Syndrome in Overhead Athletes, Int J Sport Phys. Ther., 2011</ref><ref name="coaches">http://www.sbcoachescollege.com/articles/UpperCrossSyndromeShPain.html</ref>
* Primary External Impingement related to structural changes, either congenital or acquired, that mechanically narrow the subacromial space such as;  bony narrowing or osteophyte formation, bony malposition after a fracture, or an increase in the volume of the subacromial soft tissues.<ref>Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am. 1972;54:41–50.</ref><ref>Leroux J-L, Codine P, Thomas E, Pocholle M, Mailhe D, Blotman F. Isokinetic evaluation of rotational strength in normal shoulders and shoulders with impingement syndrome. Clin Orthop. 1994;304:108–115</ref><ref name="af" /><ref name=":0">Bigliani LU, Levine WN. Current concepts review: Subacromial impingement syndrome. J Bone Joint Surg Am. 1997;79:1854–1868.</ref><ref name=":14">Harryman DT, Sidles JA, Clark JM, McQuade KJ, Gibb TD, Matsen FA. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am. 1990;72-a:1334–1343.</ref><ref name=":16">Morrison DS, Greenbaum BS, Einhorn A. Shoulder impingement. Orthop Clin North Am. 2000;31:285–293</ref><ref name=":17">Nicholson GP, Goodman DA, Flatow EL, Bigliani LU. The acromion: Morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg. 1996;5:1–11.</ref><ref>Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005;35:72–87.</ref><ref name="debie">DE BIE R.A., BASTIANENEN C.H.G. Effectiveness of individualized physiotherapy on pain and functioning compared to a standard exercise protocol in patients presenting with clinical signs of subacromial impingement syndrome. A randomized controlled trial. BMC Musculoskeletal Disorders. 2010 Jun 9; 11:114.Level of evicence: 1B</ref><ref name="page">Phil Page, PhD, PT, ATC, LAT, CSCS, FACSM, Shoulder Muscle Imbalance and Subacromial Impingement Syndrome in Overhead Athletes, Int J Sport Phys. Ther., 2011</ref><ref name="coaches">http://www.sbcoachescollege.com/articles/UpperCrossSyndromeShPain.html</ref> The shape of the acromion process of the scapula or shoulder blade may play an important role in recovery and treatment from primary impingement.


* Secondary External Impingement,  
* Secondary External Impingement related to abnormal scapulothoracic kinematics, strength balance alteration resulting in functional disturbance in the centering of the humeral head, leading to an abnormal displacement of the center of rotation when the arm is elevated. Generally caused by weakness of the Rotator Cuff Muscles (functional instability) combined with a glenohumeral joint capsule and ligaments that are to loose (micro-instability). Impingement generally occurs at the coracoacromial space secondary to anterior translation of the humeral head as opposed to the Subacromial space that is seen in primary impingement. Typically occurs in younger individuals with pain is located in the anterior or anterolateral aspect of the shoulder. The symptoms are usually activity specific and involve overhand activities.<ref name=":0" /><ref name=":14" /><ref name=":16" /><ref name=":17" /><ref name=":1" /><ref name=":10" /><ref name=":11" /><ref name=":0" /><ref name=":12" /><ref name=":13" />


==== Internal Impingment ====
==== Internal Impingement ====
* commonly seen in overhead athletes, related to abnormal scapulothoracic kinematics, strength balance alteration resulting in functional disturbance in the centering of the humeral head, leading to an abnormal displacement of the center of rotation when the arm is elevated or when the arm is placed in end-range abduction and external rotation, thereby causing soft tissue entrapment.<ref name=":1">Urwin M, Symmons D, Allison T, et al.: Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998; 57: 649–55.</ref><ref name=":10">McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther. 2006;86:1075–1090.</ref><ref name=":11">Belling Sorensen AK, Jorgensen U. Secondary impingement in the shoulder. Scand J Med Sci Sports. 2000;10:266–278.</ref><ref name=":0" /><ref name=":12">Lukasiewicz AC, McClure P, Michener L, Pratt N, Sennett B. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29:574–583.</ref><ref name=":13">Belling Sorensen AK, Jorgensen U. Secondary impingement in the shoulder. Scand J Med Sci Sports. 2000;10:266–278.</ref> This positioning becomes pathologic during excessive external rotation, anterior capsular instability, scapular muscle imbalances<ref name=":12" />, and/or upon repetitive overload of the rotator cuff musculature<ref name=":13" />.These deficiencies result in poor scapulohumral control.
* Internal Glenoid Impingement is probably the most common cause of posterior shoulder painin the throwing or overhead athlete. Caused by impingement of the articular surface (intra-articular) of the Rotator Cuff (posterior edge of the supraspinatus and the anterior edge of the infraspinatus) against the posterior-superior-glenoid and glenoid labrum. Mainly seen with repetitive overhead activities, this positioning becomes pathologic during excessive external rotation, anterior capsular instability, scapular muscle imbalances<ref name=":12" />, and/or upon repetitive overload of the rotator cuff musculature <ref name=":13" /><ref name=":1">Urwin M, Symmons D, Allison T, et al.: Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998; 57: 649–55.</ref><ref name=":10">McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther. 2006;86:1075–1090.</ref><ref name=":11">Belling Sorensen AK, Jorgensen U. Secondary impingement in the shoulder. Scand J Med Sci Sports. 2000;10:266–278.</ref><ref name=":0" /><ref name=":12">Lukasiewicz AC, McClure P, Michener L, Pratt N, Sennett B. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29:574–583.</ref><ref name=":13">Belling Sorensen AK, Jorgensen U. Secondary impingement in the shoulder. Scand J Med Sci Sports. 2000;10:266–278.</ref> .These deficiencies result in poor scapulohumral control.
These definitions and descriptions of SIS are based on a hypothesis that acromial irritation leads to external abrasion of the bursa, rotator cuff or other structures within the subacromial space.<ref name=":7">Lewis J. Subacromial Impingement Syndrome: A Musculoskeletal Condition or a Clinical Illusion? Physical Therapy Reviews 2011;16:388-298.</ref> Throughout the years, the description progressed from SIS to ‘impingement related shoulder pain’, with the growing opinion that ‘impingement’ represents a cluster of symptoms and a possible mechanism for the pain, rather than a pathoanatomic diagnose itself. This remained the dominant theory for injury to structures within the subacromial space for the past 40 years, and has been the rationale to guide clinical tests, conservative treatment, surgical procedures and rehabilitation protocols,<ref name=":6" /> however the validity of this model of acromial impingement has been challenged from both a theoretical and practical perspective throughout the last decade, with suggestions that the use of SIS terminology can potentially contribute to negative expectations of physiotherapy and conservative treatment for patients, which may compromise outcome, often resulting in an increased incidence for surgery.<ref name=":8" /><ref name=":6" /><ref name=":7" /><ref name=":8">Cuff A, Littlewood C. Subacromial Impingement Syndrome - What does this mean to and for the Patient? A Qualitative Study. Musculoskeletal Science and Practice. Elsevier Ltd; 2017 Oct 17;:1–14.</ref> 


These definitions and descriptions of SIS are based on a hypothesis that acromial irritation leads to external abrasion of the bursa, rotator cuff or other structures within the subacromial space.<ref name=":7">Lewis J. Subacromial Impingement Syndrome: A Musculoskeletal Condition or a Clinical Illusion? Physical Therapy Reviews 2011;16:388-298.</ref> This has remained the dominant theory for injury to structures within the subacromial space for the past 40 years, and has been the rationale to guide clinical tests, conservative treatment, surgical procedures and rehabilitation protocols,<ref name=":6" /> however the validity of this model of acromial impingement has been challenged from both a theoretical and practical perspective throughout the last decade, with suggestions that the use of SIS terminology can potentially contribute to negative expectations of physiotherapy and conservative treatment for patients, which may compromise outcome, often resulting in an increased incidence for surgery.<ref name=":8" /><ref name=":6" /><ref name=":7" /><ref name=":8">Cuff A, Littlewood C. Subacromial Impingement Syndrome - What does this mean to and for the Patient? A Qualitative Study. Musculoskeletal Science and Practice. Elsevier Ltd; 2017 Oct 17;:1–14.</ref>
While controversy surrounding the diagnostic labelling continues to exist, with many different terms in use to describe subacromial pain and it’s pathology in the literature it has been suggested that the label of SIS does not fully explain the mechanism. Many other diagnostic labels have been proposed but it has been suggested that the term Subacromial Pain Syndrome (SAPS) best describes the pain thought to originate from structures lying between the acromion and the humeral head, most often associated with some degree of shoulder dysfunction,<ref name=":9">Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, et al. Guideline for Diagnosis and Treatment of Subacromial Pain Syndrome. Acta Orthopaedica. 2014 May 21;85(3):314–22.</ref> but does not reflect many other causes of shoulder pain located outside the subacromial space.
 
While controversy surrounding the diagnostic labelling continues to exist, with many different terms in use to describe subacromial pain and it’s pathology in the literature it has been suggested that that the term Subacromial Pain Syndrome (SAPS) best describes pain thought to originate from structures lying between the acromion and the humeral head, most often associated with some degree of shoulder dysfunction.<ref name=":9">Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, et al. Guideline for Diagnosis and Treatment of Subacromial Pain Syndrome. Acta Orthopaedica. 2014 May 21;85(3):314–22.</ref>


== Definition / Description  ==
== Definition / Description  ==
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== Clinically Relevant Anatomy ==
== Clinically Relevant Anatomy ==
The '''Subacromial Space''' is the space beneath the acromion (between the acromion and the top surface of the humeral head). This space is outlined by the acromion and the coracoid process (which are parts of the scapula), and the coraco-acromial ligament which connects the two. <ref>http://www.jointsurgery.in/shoulder-arthoscopy/anatomy-of-shoulder/</ref>[[Image:Subacromial structures.jpg|thumb|356x356px|Figure 2. Subacromial Structures ]]
The '''Subacromial Space''' is the space beneath the acromion (between the acromion and the top surface of the humeral head). This space is outlined by the acromion and the coracoid process (which are parts of the scapula), and the coraco-acromial ligament which connects the two. <ref>http://www.jointsurgery.in/shoulder-arthoscopy/anatomy-of-shoulder/</ref>[[Image:Subacromial structures.jpg|thumb|356x356px|Figure 2. Subacromial Structures ]]
<br>
The Subacromial Space measures approximately 1cm and contains the; <ref name=":14" /><ref name=":7" /><ref>Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):923-37.</ref>
The Subacromial Space measures approximately 1cm and contains the; <ref name=":14" /><ref name=":7" /><ref>Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):923-37.</ref>
* Coracoacromial Arch, composed of the Acromion, Coracoid Process and Coracoacromial Ligaments<ref name="af">KATCHINGWE AF, Phillips B, Sletten E, Plunkett SW., Comparison of Manual Therapy Techniques with Therapeutic Exercise in the Treatment of Shoulder Impingement: A Randomized Controlled Pilot Clinical Trial. The Journal of Manual Manipulative Therapy 2008;16(4): p238-¬‐247</ref>
* Coracoacromial Arch, composed of the Acromion, Coracoid Process and Coracoacromial Ligaments<ref name="af">KATCHINGWE AF, Phillips B, Sletten E, Plunkett SW., Comparison of Manual Therapy Techniques with Therapeutic Exercise in the Treatment of Shoulder Impingement: A Randomized Controlled Pilot Clinical Trial. The Journal of Manual Manipulative Therapy 2008;16(4): p238-¬‐247</ref>
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== Prevalence / Incidence  ==
== Prevalence / Incidence  ==
SIS is the most common disorder of the shoulder, accounting for 44% to 65% of all complaints of shoulder pain<ref>Bhattacharyya R, Edwards K, Wallace AW. Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study. BMC Musculoskelet Disord. 2014;15:1. </ref>.The incidence increases as the population ages<ref>Randelli P, Randelli F, Ragone V, et al. Regenerative medicine in rotator cuff injuries. BioMed Res Int. 2014;2014:129515</ref>. Peak incidence is during the sixth decade of life. The most common clinical diagnoses are rotator cuff defects (85%) and/or impingement syndromes (74%) <ref>Ostor AJ, Richards CA, Prevost AT, Speed CA, Hazleman BL: Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford) 2005; 44: 800–5.</ref>. The prevalence of rotator cuff defects rises with age. Up to 30% of persons over age 70 have a total defect, but 75% of such cases are asymptomatic.<ref>Hedtmann A: Weichteilerkrankungen der Schulter – Subakromialsyndrome. Orthopädie und Unfallchirurgie up2date 2009; 4:85–106.
SAPS is the most common disorder of the shoulder, accounting for anywhere between 44% to 65% of all complaints of shoulder pain, <ref>Bhattacharyya R, Edwards K, Wallace AW. Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study. BMC Musculoskelet Disord. 2014;15:1. </ref> with the incidence increasing with age.<ref>Randelli P, Randelli F, Ragone V, et al. Regenerative medicine in rotator cuff injuries. BioMed Res Int. 2014;2014:129515</ref> Peak incidence occurs during the sixth decade of life.<ref>Ostor AJ, Richards CA, Prevost AT, Speed CA, Hazleman BL: Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford) 2005; 44: 800–5.</ref>
</ref>


== Etiology ==
== Etiology ==
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== Clinical Presentation  ==
== Clinical Presentation  ==
[[File:SIS CP.jpg|thumb|Figure 3. Painful Arc]]
[[File:SIS CP.jpg|thumb|Figure 3. Painful Arc]]
The affected patients are generally over age 40 and suffer from persistent pain without any known preceding trauma<ref>Garving, C., Jakob, S., Bauer, I., Nadjar, R., & Brunner, U. H. (2017). Impingement Syndrome of the Shoulder, 765–777. <nowiki>https://doi.org/10.3238/arztebl.2017.0765</nowiki></ref>. Patients report pain on elevating the arm between 70 ° and 120 ° ,the “painful arc” (Figure 3), on forced movement above the head, and when lying on the affected side <ref name=":1" />. The symptoms can be acute or chronic. Most of the time it is a gradual, degenerative condition that causes impingement, rather than due to a strong external force. Therefore, patients often have difficulties with determining the exact time of the complaints.   
The affected patients are generally over age 40 and suffer from persistent pain without any known preceding trauma.<ref>Garving, C., Jakob, S., Bauer, I., Nadjar, R., & Brunner, U. H. (2017). Impingement Syndrome of the Shoulder, 765–777. <nowiki>https://doi.org/10.3238/arztebl.2017.0765</nowiki></ref> Patients report pain on elevating the arm between 70 ° and 120 °, the “Painful Arc” (Figure 3), on forced movement above the head, and when lying on the affected side.<ref name=":1" /> The symptoms may be acute or chronic. Most often it is a gradual, degenerative condition that causes "impingement", rather than due to a strong external force. Therefore, patients often have difficulties with determining the exact onset of symptoms.   
 
According to Neer impingement syndrome is divided into three stages:
* Stage I: moderate pain during exercise, no loss of strength and no limitation in movement. Edema and/or hemorrhage may be present. This stage generally occurs in patients less than 25 years of age and is frequently associated with an overuse injury. At this stage the syndrome could be possibly reversible. <ref name="khan">KHAN Y, NAGY MT, MALAL J, WASEEM M, The painful shoulder: shoulder impingement syndrome. Open Orthop J Sept 2013, 6(7): 347-51</ref>
* Stage II: pain is usually reported during ADL and especially during the night. loss of mobility is associated with this stage. Stage II is more advanced and tends to occur in patients between 25 to 40 years of age. The pathological changes show fibrosis as well as irreversible tendon changes.<ref name="khan" />
* Stage III: strong restriction in movement due to calcifications and loss of muscle strength.This stage generally occurs in patients over 50 years of age and frequently involves a tendon rupture or tear.<ref name="khan" />


== Differential Diagnosis  ==
== Differential Diagnosis  ==
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The following additional test should also be used to rule out a Rotator Cuff Tear;
The following additional test should also be used to rule out a Rotator Cuff Tear;
* [https://www.youtube.com/watch?v=JXgRBeqToik Drop Arm Test]: To test the integrity of the [[Infraspinatus]] <ref name=":3">ALGUNAEE M, GALVIN R, FAHEY T, Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Ach Phys Med Rehabil 2012, 93(2): 229-36</ref>
* [https://www.youtube.com/watch?v=JXgRBeqToik Drop Arm Test]: To test the integrity of the [[Infraspinatus]] <ref name=":3">ALGUNAEE M, GALVIN R, FAHEY T, Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Ach Phys Med Rehabil 2012, 93(2): 229-36</ref><br>
<br>
{{#ev:youtube|UErH4NUsDWQ|400}} <div class="row"><div class="col-md-6 col-md-offset-3"><div class="text-right"><ref>Physiotutors. Subacromial Pain Syndrome Cluster | SAPS. Available from: https://www.youtube.com/watch?v=UErH4NUsDWQ [last accessed 30/10/17]</ref></div></div></div>
{{#ev:youtube|UErH4NUsDWQ|400}} <div class="row"><div class="col-md-6 col-md-offset-3"><div class="text-right"><ref>Physiotutors. Subacromial Pain Syndrome Cluster | SAPS. Available from: https://www.youtube.com/watch?v=UErH4NUsDWQ [last accessed 30/10/17]</ref></div></div></div>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
Radiographs may be used to detect anatomical variants, calcific deposits or acromioclavicular joint arthritis. The three recommended views are<ref>Smith M, Sparkes V, Busse M, Enright S. Upper and Lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Physical Therapy in Sport. 2009:10, 45-50</ref>:  
Radiographs may be used to detect anatomical variants, calcific deposits or acromioclavicular joint arthritis. The three recommended views are<ref>Smith M, Sparkes V, Busse M, Enright S. Upper and Lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Physical Therapy in Sport. 2009:10, 45-50</ref>:  
* Antero-posterior view with the arm at 30 degrees external rotation: The anteroposterior view is useful for assessing the glenohumeral joint, subacromial osteophytes and sclerosis of the greater tuberosity.   
* Antero-posterior View with the arm at 30 degrees external rotation which is useful for assessing the glenohumeral joint, subacromial osteophytes and sclerosis of the greater tuberosity.   
* Outlet Y view is useful because it shows the subacromial space and can differentiate the acromial processes.  
* Outlet Y View is useful because it shows the subacromial space and can differentiate the acromial processes.  
* Axillary view is helpful in visualizing the acromion and the processus coracoideus, as well as coracoacromial ligament calcifications.
* Axillary View is helpful in visualizing the acromion and the processus coracoideus, as well as coracoacromial ligament calcifications.   
 
The size of the subacromial space can also be measured. MRI can show full or partial tears in the tendons of the rotator cuff, cracks in the capsule and inflammation to weak structures.<ref name="shoulderdoc" />
 
Ultrasonography and arthrography are being used when rotator cuff tears are suspected or in complex cases. However, arthrography is invasive and expensive, it is the best diagnostic modality.<ref name="khan" />  


The size of the subacromial space can also be measured. MRI can show full or partial tears in the tendons of the rotator cuff, cracks in the capsule and inflammation to weak structures.<ref name="shoulderdoc" /> Ultrasonography and arthrography are being used when rotator cuff tears are suspected or in complex cases. However, while arthrography is invasive and expensive, it is the best diagnostic modality.<ref name="khan" />
== Treatment/Management ==
== Treatment/Management ==
The treatment depends on age, activity level and general health of the patient. The goal is to reduce pain and regain function.Conservative treatment is used at the beginning, for several weeks to months until improvement and return to function are noticed.<ref>Rhon DI, Boyles RE, Cleland JA, Brown DL, A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomized clinical trial, BMJ Open 2011</ref>
The treatment depends on age, activity level and general health of the patient. The goal is to reduce pain and regain function. Conservative treatment is used at the beginning, for several weeks to months until improvement and return to function are noticed.<ref>Rhon DI, Boyles RE, Cleland JA, Brown DL, A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomized clinical trial, BMJ Open 2011</ref>
 
Conservative treatment consists of; rest or avoiding overhead activities, NSAID’s to reduce pain and swelling, Physical therapy management, and steroid injection in case of failure of other interventions. Cortisone is often used because of its anti-inflammatory and pain reducing effect.<ref>AKGUN K, BIRTANE M., AKARIMAK U., Is local subacromial corticosteroïd injection beneficial in subacromial impingement syndrome?, Clin Rheumatol 2004, 23(6): 496-500</ref><br>Non-conservative treatment is recommended when the conservative treatments fail to reduce the pain.<ref>http://orthoinfo.aaos.org/topic.cfm?topic=a00032</ref>


Treatment can be classified according to Neer's stages:Stage I is often treated conservatively. Pain can be relieved by applying ice (20 minutes, 3 times/day) and using NSAID’s (nonsteroidal anti-inflammatory drugs). Physical therapy is also part of the treatment.
Conservative treatment consists of; rest or avoiding overhead activities, NSAID’s to reduce pain and swelling, physical therapy management, and subacromial injection in case of failure of other interventions. Cortisone is often used because of its anti-inflammatory and pain reducing effect.<ref>AKGUN K, BIRTANE M., AKARIMAK U., Is local subacromial corticosteroïd injection beneficial in subacromial impingement syndrome?, Clin Rheumatol 2004, 23(6): 496-500</ref><br>Non-conservative treatment is considered when the conservative treatments fail to reduce the pain.<ref>http://orthoinfo.aaos.org/topic.cfm?topic=a00032</ref>
* Stage II: Surgical intervention is needed when the subacromial impingement lasts 3-6 months without significant improvement with appropriate conservative treatment.
* Stage III: may be indicated for surgery, especially when the passive range of motion of the patient is restricted. Surgery is also beneficial with type III acromion in combination with large spurs.<ref>Differential Diagnosis between common shoulder conditions, Leeds Community Healthcare, NHS Trust: www.leedscommunityhealthcare.nhs.uk/msk</ref>                                                                                                                                                                                                                                                                                                                                          


Several surgical techniques are available, depending on the character and severity of the injury:
Several surgical techniques are available, depending on the character and severity of the injury:

Revision as of 01:42, 29 January 2018

Original Editor - David Drinkard, Dorien De Strijcker

Lead Editors Dorien De Strijcker, Naomi O'Reilly, David Drinkard, Els Van Haver, Mariam Hashem, Admin, Kim Jackson, Rachael Lowe, Florence Brachotte, Amanda Ager, Kai A. Sigel, Tony Lowe, Tarina van der Stockt, Yuli Borremans, Scott Buxton, WikiSysop, Wendy Walker, Robin Tacchetti, Lisa De Donder, Ewa Jaraczewska, Lucas Villalta, 127.0.0.1, Benjamin Desmedt, Tyler Shultz, Thaisa Van Bellingen, Wanda van Niekerk, Lauren Lopez, Lucinda hampton and Jess Bell

Introduction[edit | edit source]

There has been huge debate in relation to the diagnostic labelling of non-traumatic shoulder pain related to the structures of the subacromial space. The diagnostic label Subacromial Impingment Syndrome (SIS), presenting as anterograde-lateral shoulder pain when the arm is elevated, was first introduced in 1972 by Dr Charles Neer and was based on the mechanism of structural impingement of the structures of the subacromial space.[1][2][3] SIS has been viewed as symptomatic irritation of the subacromial structures between the coraco-acromial arch and the humeral head during elevation of the arm above the shoulder / head [1] and as reflected by the literature is considered by many to be one of the most common causes of shoulder pain. Neers Classification of Impingement identified four types of Shoulder Impingement identified below;

Neer Classification of Subacromial Impingement

According to Neer impingement syndrome is divided into three stages:

Type I: <25 years old, Reversible, Swelling, Tendonitis, No Tears, Conservative Treatment.

  • Moderate pain during exercise, no loss of strength and no limitation in movement. Edema and/or hemorrhage may be present. This stage generally occurs in patients less than 25 years of age and is frequently associated with an overuse injury. At this stage the syndrome could be possibly reversible. [4]

Type II: 25-40 years old, Permanent Scarring, Tendonitis, No Tears, Subacromial Decompression

  • Pain is usually reported during ADL and especially during the night. loss of mobility is associated with this stage. Type II is more advanced and tends to occur in patients between 25 to 40 years of age. The pathological changes show fibrosis as well as irreversible tendon changes.[4]

Type III: >40 years old, Small Rotator Cuff Tear, Subacromial Decompression with Debridement/Repair

Type IV: >40 years old, Large Rotator Cuff Tear, Sub Acromial Decompression with Repair

While Neers Classification of SIS was key to understanding shoulder pathology at the time, SIS was further broken down into four subtypes associated with either External Impingement (Primary or Secondary) and Internal Impingement.

External Impingement[edit | edit source]

Figure 1. Acromion Shapes
  • Primary External Impingement related to structural changes, either congenital or acquired, that mechanically narrow the subacromial space such as; bony narrowing or osteophyte formation, bony malposition after a fracture, or an increase in the volume of the subacromial soft tissues.[5][6][7][8][9][10][11][12][13][14][15] The shape of the acromion process of the scapula or shoulder blade may play an important role in recovery and treatment from primary impingement.
  • Secondary External Impingement related to abnormal scapulothoracic kinematics, strength balance alteration resulting in functional disturbance in the centering of the humeral head, leading to an abnormal displacement of the center of rotation when the arm is elevated. Generally caused by weakness of the Rotator Cuff Muscles (functional instability) combined with a glenohumeral joint capsule and ligaments that are to loose (micro-instability). Impingement generally occurs at the coracoacromial space secondary to anterior translation of the humeral head as opposed to the Subacromial space that is seen in primary impingement. Typically occurs in younger individuals with pain is located in the anterior or anterolateral aspect of the shoulder. The symptoms are usually activity specific and involve overhand activities.[8][9][10][11][16][17][18][8][19][20]

Internal Impingement[edit | edit source]

  • Internal Glenoid Impingement is probably the most common cause of posterior shoulder painin the throwing or overhead athlete. Caused by impingement of the articular surface (intra-articular) of the Rotator Cuff (posterior edge of the supraspinatus and the anterior edge of the infraspinatus) against the posterior-superior-glenoid and glenoid labrum. Mainly seen with repetitive overhead activities, this positioning becomes pathologic during excessive external rotation, anterior capsular instability, scapular muscle imbalances[19], and/or upon repetitive overload of the rotator cuff musculature [20][16][17][18][8][19][20] .These deficiencies result in poor scapulohumral control.

These definitions and descriptions of SIS are based on a hypothesis that acromial irritation leads to external abrasion of the bursa, rotator cuff or other structures within the subacromial space.[3] Throughout the years, the description progressed from SIS to ‘impingement related shoulder pain’, with the growing opinion that ‘impingement’ represents a cluster of symptoms and a possible mechanism for the pain, rather than a pathoanatomic diagnose itself. This remained the dominant theory for injury to structures within the subacromial space for the past 40 years, and has been the rationale to guide clinical tests, conservative treatment, surgical procedures and rehabilitation protocols,[2] however the validity of this model of acromial impingement has been challenged from both a theoretical and practical perspective throughout the last decade, with suggestions that the use of SIS terminology can potentially contribute to negative expectations of physiotherapy and conservative treatment for patients, which may compromise outcome, often resulting in an increased incidence for surgery.[21][2][3][21]

While controversy surrounding the diagnostic labelling continues to exist, with many different terms in use to describe subacromial pain and it’s pathology in the literature it has been suggested that the label of SIS does not fully explain the mechanism. Many other diagnostic labels have been proposed but it has been suggested that the term Subacromial Pain Syndrome (SAPS) best describes the pain thought to originate from structures lying between the acromion and the humeral head, most often associated with some degree of shoulder dysfunction,[22] but does not reflect many other causes of shoulder pain located outside the subacromial space.

Definition / Description[edit | edit source]

Subacromial Pain Syndrome is by defined Diercks et al [22] as all non-traumatic, usually unilateral, shoulder problems that cause pain, localized around the acromion, often worsening during or subsequent to lifting of the arm. It is basically a generic term that encompasses pain associated with any lesion within a structure or structures within the Subacromial Space. As such the SAPS incorporates all conditions related to subacromial structures such as subacromial bursitis, tendinosis calcarea, rotator cuff tendinopathy, rotator cuff tears, biceps tendinopathy, or tendon cuff degeneration as a result of the controversy regarding it’s pathogenesis.[22] [23]

Clinically Relevant Anatomy[edit | edit source]

The Subacromial Space is the space beneath the acromion (between the acromion and the top surface of the humeral head). This space is outlined by the acromion and the coracoid process (which are parts of the scapula), and the coraco-acromial ligament which connects the two. [24]
Figure 2. Subacromial Structures

The Subacromial Space measures approximately 1cm and contains the; [9][3][25]

  • Coracoacromial Arch, composed of the Acromion, Coracoid Process and Coracoacromial Ligaments[7]
  • Humeral Head
  • Subacromial Bursa[26]
  • Tendons of the Rotator Cuff; Supraspinatus, Infraspinatus, Teres Minor and Subscapularis
  • Tendon of the Long Head of Biceps Brachii
  • G-H Joint Capsule

Prevalence / Incidence[edit | edit source]

SAPS is the most common disorder of the shoulder, accounting for anywhere between 44% to 65% of all complaints of shoulder pain, [27] with the incidence increasing with age.[28] Peak incidence occurs during the sixth decade of life.[29]

Etiology[edit | edit source]

There remains debate in regards to the ethiology of subacromial pain, but it is proposed that the mechanisms include intrinsic, extrinsic and combined factors including muscle imbalance and anatomical factors that may affect the subacromial space; variations in the acromial shape; the anterior slope; the angle of the acromion; and the lateral extension of the acromion over the humeral head. Osseous changes of the inferior acromio-clavicular joint or the coracoacromial ligament may also affect the subacromial space. [23]

While it is accepted that multiple factors are involved in the pathetiology, several unresolved issues remain such as: which subacromial structure is first engaged by pathology, and what are the pain-generating mechanisms? [23]

Clinical Presentation[edit | edit source]

Figure 3. Painful Arc

The affected patients are generally over age 40 and suffer from persistent pain without any known preceding trauma.[30] Patients report pain on elevating the arm between 70 ° and 120 °, the “Painful Arc” (Figure 3), on forced movement above the head, and when lying on the affected side.[16] The symptoms may be acute or chronic. Most often it is a gradual, degenerative condition that causes "impingement", rather than due to a strong external force. Therefore, patients often have difficulties with determining the exact onset of symptoms.

Differential Diagnosis[edit | edit source]

There are a variety of shoulder conditions that can initially be confused with subacromial subacromial pain syndrome [31]. A thorough physical examination should exclude other conditions such as [32]:

Physical Examination[edit | edit source]

Detailed History and clinical examination are necessary for diagnosis of SAPS. No single test alone is accurate to diagnose SAPS or sufficiently differentiate between various shoulder disorders [33][34], but using a combination of specific tests increases the post-test probability of the diagnosis of SAPS. [35][36][37][38]

The Dutch Orthopaedic Association Guidelines for diagnosis and treatment of subacromial pain syndrome recommend a combination of the following tests to aid in the diagnosis;

The combination of the Hawkins-Kennedy Test, the Painful Arc and the Infraspinatus Resistance Test have a considerably higher predictive value;[39]

  • 3 tests are positive: the probability that the patient has SAPS is (10,56)
  • 2 tests are positive: the probability that the patient has SAPS is (5,03)
  • 1 test is psitive: the probability that the patient has SAPS is (0,90)
  • 0 tests are positive: the probability that the patient has SAPS is (0,17)

The following additional test should also be used to rule out a Rotator Cuff Tear;

[41]

Diagnostic Procedures[edit | edit source]

Radiographs may be used to detect anatomical variants, calcific deposits or acromioclavicular joint arthritis. The three recommended views are[42]:

  • Antero-posterior View with the arm at 30 degrees external rotation which is useful for assessing the glenohumeral joint, subacromial osteophytes and sclerosis of the greater tuberosity.
  • Outlet Y View is useful because it shows the subacromial space and can differentiate the acromial processes.
  • Axillary View is helpful in visualizing the acromion and the processus coracoideus, as well as coracoacromial ligament calcifications.

The size of the subacromial space can also be measured. MRI can show full or partial tears in the tendons of the rotator cuff, cracks in the capsule and inflammation to weak structures.[43] Ultrasonography and arthrography are being used when rotator cuff tears are suspected or in complex cases. However, while arthrography is invasive and expensive, it is the best diagnostic modality.[4]

Treatment/Management[edit | edit source]

The treatment depends on age, activity level and general health of the patient. The goal is to reduce pain and regain function. Conservative treatment is used at the beginning, for several weeks to months until improvement and return to function are noticed.[44]

Conservative treatment consists of; rest or avoiding overhead activities, NSAID’s to reduce pain and swelling, physical therapy management, and subacromial injection in case of failure of other interventions. Cortisone is often used because of its anti-inflammatory and pain reducing effect.[45]
Non-conservative treatment is considered when the conservative treatments fail to reduce the pain.[46]

Several surgical techniques are available, depending on the character and severity of the injury:

  • Surgical Repair of torn tissues, mostly of supraspinatus muscle, long head of biceps tendon or joint capsule. Note: a rotator cuff tear is not an indication for surgery. [31]
  • Bursectomy or removal of the subacromial bursa.
  • Subacromial Decompression to increase the subacromial space by removing bony spurs or prominences on the underside of the os acromiale or the coracoacromial ligament
  • Acromioplasty to increase the subacromial space by removing a part of the acromion. Arthroscopic acromioplasty is less invasive and requires lesser rehabilitation than the open (Neer) acromioplasty.

[47][48]

Physical Therapy Management[edit | edit source]

There is strong evidence that supervised non-operative rehabilitation decreases pain in the shoulder and increases function.[26] Non-operative treatment should therefore be attempted first, assuming there is no tear that requires surgery.

Physical therapy management includes:

  • RICE therapy in the acute phase to reduce pain and swelling
  • Stability and postural correction exercises
  • Mobility Exercises
  • Strengthening Exercises
  • Stretching exercises, including capsular stretching
  • Manual therapy techniques of the shoulder
  • Acupuncture
  • Electrical stimulation
  • Ultrasound and musculoskeletal ultrasound
  • Low-level laser therapy has positive effects on all symptoms except on muscle strength[49]

When patient is presented with acute pain, it should be relieved first then strengthning exercises are implemented for prevention of future injuries. Although exercise therapy alone has proved efficient, the addition of manual therapy insures further increase in muscle strength.[50] Exercise therapy is a vital part of treatment for subacromial impingement but results showed no significant difference between home-based exercises and clinical exercise.

Strengthening exercises should include[51]:

  • Rotator Cuff strengthening such as; external rotation with thera-tubing, Horizontal abduction exercises
  • Lower and Middle Trapezius strengthening such as; Eated press up,Unilateral scapular rotation, Bilateral shoulder external rotation, Unilateral shoulder depression.
  • Strengthening of the lower part of the trapezius muscle is an important part of exercise therapy. Individuals with impingement syndrome show greater ratios of upper and lower trapezius activity than asymptomatic individuals.[52]

Soft tissue mobilization to normalize muscle spasm and other soft tissue dysfunction has been shown to be effective alongside joint mobilizations to restore motion in treatment of SAI.[52]

The motions of the rotator cuff that are emphasized for strengthening are internal rotation, external rotation and abduction. It is important to remember that the function of the rotator cuff, in addition to generating torque, is to stabilize the glenohumeral joint. Thus, stronger rotator cuff muscles result in better glenohumeral joint stabilization and less impingement. A typical initial exercise program involves the use of 4 to 8 weights, with 10 to 40 repetitions performed three to five times a week.

Patients with Stage II impingement may require a formal physical therapy program. Isometric stretches are useful in restoring range of motion. Isotonic (fixed-weight) exercises are preferable to variable weight exercises. Thus, the shoulder exercises should be done with a fixed weight rather than a variable weight such as a rubber band. Repetitions are emphasized, and a relatively light weight is used. Sometimes, sports-specific techniques are useful, particularly for strengthening the throwing motion, the serving motion or swimming motions. In addition, physical therapy modalities such as electrogalvanic stimulation, ultrasound treatment and transverse friction massages can be helpful.[53]

[54][55]


Resources[edit | edit source]

[56]

References[edit | edit source]

  1. ↑ 1.0 1.1 de Witte PB Nagels J van Arkel ER, et al. Study protocol subacromial impingement syndrome: the identification of pathophysiologic mechanisms (SISTIM). BMC Musculoskelet Disord. 2011; 12:1-12. 
  2. ↑ 2.0 2.1 2.2 Cools AM, Michener LA. Shoulder Pain: Can One Label Satisfy Everyone and Everything? Br J Sports Med. 2017 Feb 16;51(5):416–7.
  3. ↑ 3.0 3.1 3.2 3.3 Lewis J. Subacromial Impingement Syndrome: A Musculoskeletal Condition or a Clinical Illusion? Physical Therapy Reviews 2011;16:388-298.
  4. ↑ 4.0 4.1 4.2 KHAN Y, NAGY MT, MALAL J, WASEEM M, The painful shoulder: shoulder impingement syndrome. Open Orthop J Sept 2013, 6(7): 347-51
  5. ↑ Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am. 1972;54:41–50.
  6. ↑ Leroux J-L, Codine P, Thomas E, Pocholle M, Mailhe D, Blotman F. Isokinetic evaluation of rotational strength in normal shoulders and shoulders with impingement syndrome. Clin Orthop. 1994;304:108–115
  7. ↑ 7.0 7.1 KATCHINGWE AF, Phillips B, Sletten E, Plunkett SW., Comparison of Manual Therapy Techniques with Therapeutic Exercise in the Treatment of Shoulder Impingement: A Randomized Controlled Pilot Clinical Trial. The Journal of Manual Manipulative Therapy 2008;16(4): p238-¬‐247
  8. ↑ 8.0 8.1 8.2 8.3 Bigliani LU, Levine WN. Current concepts review: Subacromial impingement syndrome. J Bone Joint Surg Am. 1997;79:1854–1868.
  9. ↑ 9.0 9.1 9.2 Harryman DT, Sidles JA, Clark JM, McQuade KJ, Gibb TD, Matsen FA. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am. 1990;72-a:1334–1343.
  10. ↑ 10.0 10.1 Morrison DS, Greenbaum BS, Einhorn A. Shoulder impingement. Orthop Clin North Am. 2000;31:285–293
  11. ↑ 11.0 11.1 Nicholson GP, Goodman DA, Flatow EL, Bigliani LU. The acromion: Morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg. 1996;5:1–11.
  12. ↑ Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005;35:72–87.
  13. ↑ DE BIE R.A., BASTIANENEN C.H.G. Effectiveness of individualized physiotherapy on pain and functioning compared to a standard exercise protocol in patients presenting with clinical signs of subacromial impingement syndrome. A randomized controlled trial. BMC Musculoskeletal Disorders. 2010 Jun 9; 11:114.Level of evicence: 1B
  14. ↑ Phil Page, PhD, PT, ATC, LAT, CSCS, FACSM, Shoulder Muscle Imbalance and Subacromial Impingement Syndrome in Overhead Athletes, Int J Sport Phys. Ther., 2011
  15. ↑ http://www.sbcoachescollege.com/articles/UpperCrossSyndromeShPain.html
  16. ↑ 16.0 16.1 16.2 Urwin M, Symmons D, Allison T, et al.: Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998; 57: 649–55.
  17. ↑ 17.0 17.1 McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther. 2006;86:1075–1090.
  18. ↑ 18.0 18.1 Belling Sorensen AK, Jorgensen U. Secondary impingement in the shoulder. Scand J Med Sci Sports. 2000;10:266–278.
  19. ↑ 19.0 19.1 19.2 Lukasiewicz AC, McClure P, Michener L, Pratt N, Sennett B. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29:574–583.
  20. ↑ 20.0 20.1 20.2 Belling Sorensen AK, Jorgensen U. Secondary impingement in the shoulder. Scand J Med Sci Sports. 2000;10:266–278.
  21. ↑ 21.0 21.1 Cuff A, Littlewood C. Subacromial Impingement Syndrome - What does this mean to and for the Patient? A Qualitative Study. Musculoskeletal Science and Practice. Elsevier Ltd; 2017 Oct 17;:1–14.
  22. ↑ 22.0 22.1 22.2 Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, et al. Guideline for Diagnosis and Treatment of Subacromial Pain Syndrome. Acta Orthopaedica. 2014 May 21;85(3):314–22.
  23. ↑ 23.0 23.1 23.2 Björnsson Hallgren H. Treatment of Subacromial Pain and Rotator Cuff Tears [dissertation]. Linköping University Sweden. 2012.
  24. ↑ http://www.jointsurgery.in/shoulder-arthoscopy/anatomy-of-shoulder/
  25. ↑ Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):923-37.
  26. ↑ 26.0 26.1 Tate A.R., McClure P.W., Young I.A., Salvator R., Michener L.A., Comprehensive Impairment-based Exercise and Manual Therapy Intervention for Patients with Subacromial Impingement Syndrome: A Case Series. The Journal of Orthopaedic and Sports Physical Therapy 2010; 40(8): p474-93 (Level of evidence 4)
  27. ↑ Bhattacharyya R, Edwards K, Wallace AW. Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study. BMC Musculoskelet Disord. 2014;15:1. 
  28. ↑ Randelli P, Randelli F, Ragone V, et al. Regenerative medicine in rotator cuff injuries. BioMed Res Int. 2014;2014:129515
  29. ↑ Ostor AJ, Richards CA, Prevost AT, Speed CA, Hazleman BL: Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford) 2005; 44: 800–5.
  30. ↑ Garving, C., Jakob, S., Bauer, I., Nadjar, R., & Brunner, U. H. (2017). Impingement Syndrome of the Shoulder, 765–777. https://doi.org/10.3238/arztebl.2017.0765
  31. ↑ 31.0 31.1 https://www.aafp.org/afp/1998/0215/p667.html#sec-6
  32. ↑ Lockhart RD. Movements of the Normal Shoulder Joint and of a case with Trapezius Paralysis studied by Radiogram and Experiment in the Living. J Anat 1930; 64: 288-302
  33. ↑ Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT, Cook C. Physical Examination Tests of the Shoulder: A Systematic Review with Meta-analysis of Individual Tests. British Journal of Sports Medicine. 2007 Aug 24.
  34. ↑ Hughes PC, Taylor NF, Green RA. Most Clinical Tests Cannot Accurately Diagnose Rotator Cuff Pathology: A Systematic Review . Aust J Physiother. 2008;54(3):159–70.
  35. ↑ Murrell GA, Walton JR. Diagnosis of Rotator Cuff Tears. The Lancet. 2001 Mar 10;357(9258):769-70.
  36. ↑ Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. JBJS. 2005 Jul 1;87(7):1446-55.
  37. ↑ Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Archives of Physical Medicine and Rehabilitation. 2009 Nov 1;90(11):1898-903.
  38. ↑ MICHENER L.A., WALSWORTH M.K., DOUKAS W.C., MURPHY K.P. Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Archives of Physical Medicine and Rehabilitation. 2009 Nov; 90(11): 1898-903. Level of evicence: 1C
  39. ↑ Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. JBJS. 2005 Jul 1;87(7):1446-55. Level of Evidence 1
  40. ↑ ALGUNAEE M, GALVIN R, FAHEY T, Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Ach Phys Med Rehabil 2012, 93(2): 229-36
  41. ↑ Physiotutors. Subacromial Pain Syndrome Cluster | SAPS. Available from: https://www.youtube.com/watch?v=UErH4NUsDWQ [last accessed 30/10/17]
  42. ↑ Smith M, Sparkes V, Busse M, Enright S. Upper and Lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Physical Therapy in Sport. 2009:10, 45-50
  43. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named shoulderdoc
  44. ↑ Rhon DI, Boyles RE, Cleland JA, Brown DL, A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomized clinical trial, BMJ Open 2011
  45. ↑ AKGUN K, BIRTANE M., AKARIMAK U., Is local subacromial corticosteroïd injection beneficial in subacromial impingement syndrome?, Clin Rheumatol 2004, 23(6): 496-500
  46. ↑ http://orthoinfo.aaos.org/topic.cfm?topic=a00032
  47. ↑ Arthroscopic subacromial decompression - Dr Terry Hammond.dv Available from:https://www.youtube.com/watch?v=YLdjvpxXgnU
  48. ↑ Shoulder Arthroscopic Subacromial Decompression - Dr. Tony Jabbour Available from:https://www.youtube.com/watch?v=sLd9yBiK3RA
  49. ↑ YELDAN I., CETIN E., OZDINCLER A.R. The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome. Disability and rehabilitation. 2009; 31(11): 935–940 (Level of evidence 1b)
  50. ↑ Bang MD, Deyle GD. Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients with Shoulder Impingement Syndrome. Journal of Orthopaedic and Sports Physical Therapy. 2000;30(3):126-137 (Level of evidence 1b)
  51. ↑ Kuhn JE. Exercise in the treatment of rotator cuff impingement: A systematic review and synthesized evidence-based rehabilitation protocol. Journal fo Shoulder and Elbow Surgery. 2009;18:138-160 (Level of evidence 1a)
  52. ↑ 52.0 52.1 Smith M, Sparkes V, Busse M, Enright S. Upper and Lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Physical Therapy in Sport. 2009:10, 45-50 (Level of evidence 3b)
  53. ↑ MORRISON D.S., FROGAMENI AD, WOODWORTH P., Non-operative treatment of subacromial impingement syndrome?, J Bone Joint Surg Am 1997. 79(5): 732 (Level of evidence 2b)
  54. ↑ Manual strategy for the treatment of shoulder impingement syndrome by Ulf Pape/ look subtitles Available from:https://www.youtube.com/watch?v=9No0i7Wb2Rk
  55. ↑ Top 3 Exercises for the Rotator Cuff (using Stretch Band) Available from:https://www.youtube.com/watch?v=FkzYvxhgqQQ
  56. ↑ Sports Congress. Subacromial Pain Syndrome and Scapular Dyskinesia - Sports Medicine Congress 2016. Available from: https://www.youtube.com/watch?v=Hv5YLrIGdn8 [last accessed 30/10/17]


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