Subacromial Pain Syndrome
Markham physiotherapist assisting his patient in a shoulder exercise.
What is SAPS?
Subacromial pain syndrome (SAPS) is a term used to describe the role of degeneration of the rotator cuff tendons which give eventual development of tears. It is a non-traumatic, usually unilateral shoulder problem that can cause pain (localized near the acromion), which is aggravated with lifting of the arm. This umbrella term incorporates the differentials of bursitis, tendinosis calcarea, supraspinatus tendinopathy, partial tear of the rotator cuff, biceps tendinitis, and/or tendon cuff degeneration.
How to test for Subacromial Pain Syndrome?
There is no single test that can diagnose SAPS, but rather a collection of tests that can collective create a clinical picture for the practitioner. A combination of Hawkins-Kennedy test, painful arc test, infraspinatus and supraspinatus muscle strength test, and drop-arm test should be used to assess this condition.
Do you need an advanced imaging to diagnose this condition?
Advanced imaging can be used to rule out rotator cuff pathology, namely MR arthrography can be used to rule out partial RC tears, and ultrasound can be used to rule out RC tendinopathy, subacromial bursitis, biceps tendon tear, and tendinosis calcarea. However, there are conflicting reports on the efficacy of ultrasound for partial RC tears and tendinopathies.
What is Subacromial Impingement Syndrome?
Subacromial impingement syndrome (SIS) is also an umbrella term used to describe pain and dysfunction in the shoulder. It is the most common cause of pain (50%) of all shoulder pain and affects all age groups, and is most frequent in sporting activities such as hurling, racket sports, and swimming. Causes of dysfunction can include the natural anatomy of the acromioclavicular joint, osteophytes, inadequate vascularization of the area, and stenosis of the subacromial area. Other risk factors include imbalanced musculature, mechanical cuff compression, and repeated eccentric loading or motion of the humeral head in overhead activities. Primary impingement is described to be due to a mechanical cause, and secondary impingement is due to muscle imbalance and shoulder instability.
What are the symptoms of Shoulder Impingement?
The main symptoms of SIS are pain at the shoulder joint, dyskinesia, and difficulty with upper limb activities of daily living. The pain occurs gradually over a few weeks and is increased at night, and occurs with daily activities. The pain also refers to the middle humerus, which likely occurs with impingement of the supraspinatus tendon. Evaluation usually reveals palpatory sensitivity at the biceps tendon and rotator cuff tendons. Pain occurs with active motion, with resistance (especially abduction, and then internal and external rotation), and with passive range of motion. Painful arc or flexion of the shoulder at 60-120 degrees is indicative of SIS. The painful arc can additionally be used to assess the supraspinatus tendon.
How do you test for Shoulder Impingement?
Orthopedic testings for SIS include Arch pain (subacromial impingement), Hawkin’s-Kennedy’s (supraspinatus integrity and subacromial impingement), Neer test (subacromial impingement as passive flexion causes further impingement below the acromion), Yocum test (Subacromial or cuff impingement), Jobe test (supraspinatus), Empty/ full can test (supraspinatus and subacromial impingement), cross-body adduction test (infraspinatus/ supraspinatus, long head biceps, posterior joint capsule, AC joint), Hornblower’s Sign (teres minor), Lift-off (subscapularis), Apprehension test (internal impingement and AP lability), sulcus sign (multidirectional lability), Load and shift test (AP instability), and Yergason’s/ Ludington’s/ Speed’s/ Cross-over test (rupture or impingement of biceps long head tendon).
The most valid tests for impingement are the abduction arc pain or flexion of humerus (81.1%), Neer test (68.7%), and Hawkins-Kennedy test (66.3%). The combination of the 3 aforementioned tests plus the empty can test with 3 or more positive findings has a sensitivity of 75% and specificity of 74% for SIS. Thus, a battery of tests are required to successfully make a clinical diagnosis of subacromial impingement syndrome.
Who can diagnose Subacromial Impingement?
You may consult your local physiotherapist or chiropractor for a functional and orthopaedic assessment of your shoulder. In Ontario, it is not required to get a referral from your medical doctor as both professions are considered primary care providers. To book in with our Markham or Toronto therapists you can click the button below:
Treatment options for Subacromial Impingement
With SIS or SAPS you may do physiotherapy, chiropractic, or massage therapy to aid in the recovery of your shoulder. All professions may provide soft tissue therapy in combination with exercise for both short term and long term relief respectively.
Soft tissue techniques used at the Rehab Hero clinic include deep tissue therapy, sports massage, and myofascial release therapy.
Adjunct modalities including acupuncture, scraping (instrument assisted soft tissue manipulation), and shockwave may be used by the aforementioned clinicians. To book in appointment with our qualified therapists click the button below:
Exercises for Subacromial Impingement Syndrome and Subacromial Pain Syndrome
For both conditions the goal is to increase pain-free range of motion. Depending on your level of disability, completed assisted range of motion exercises can help with motor patterning and mobility. An example of an assisted range of motion exercise is the SHOULDER ABDUCTION TABLE SLIDE exercise.
Additional exercise will target the muscles of the scapula in order to take advantage of the body’s scapulohumeral rhythm. By improving scapular kinematics we can optimize space experienced in the subacromial region. This will help to offset the amount of mechanical pressure applied in impinging positions. An example of a scapular exercise is the PRONE BENCH Y-RAISE exercise.
Lastly, exercises that help to mobilize the muscles surrounding the shoulder can help to alleviate unneeded muscle guarding. Muscle guarding is a term used to describe the process of a muscle becoming hypertonic in response to an injury. This will cause a decrease in mobility and may impede the recovery process. One of the largest muscles surrounding the shoulder that may be affected is a latissimus dorsi. Not only is this the largest muscle that attaches to the shoulder, but it is also the most powerful internal rotator. As such, when this muscle becomes affected, it may increase the amount of load experienced at the rotator cuff. The LATS ACTIVE MASSAGE exercise can be used to help improve the soft tissue mobility of this muscle:
For additional exercises specific to your injury it is ALWAYS recommended to first consult your own health care team. You may consult your sports physiotherapist or chiropractor for more information. If you are in the Greater Toronto Area, you can consult a Rehab Hero clinician by clicking the button below:
Markham chiropractor Dr. David Song.
References
1. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, van der Woude H, et al. Guideline for diagnosis and treatment of subacromial pain syndrome. Acta Orthopaedica [serial on the Internet]. (2014, June), [cited November 7, 2017]; 85(3): 314-322. Available from: CINAHL Plus with Full Text.
2. EFSTRATIADIS A, MARANGOS S, KASAPAKIS E, GEORGIADOU P, PLOUTARXOU G, STASINOPOULOS D, et al. The subacromial impingement syndrome of the shoulder: The role of physiotherapist in the evaluation and treatment of the syndrome. Biology Of Exercise [serial on the Internet]. (2017, Jan), [cited November 7, 2017]; 13(1): 15-32. Available from: SPORTDiscus with Full Text.