Shoulder Pain

Most shoulder pain is coming from the subacromial region. Subacromial pain was initially described in 1972 by Dr. Charles Neer (Physiopedia, 2019). The subacromial space lies between the humeral head and the acromion process of the scapula. There are 4 muscles called the rotator cuff muscles. The tendons of the rotator cuff and a bursa lie in the subacromial space.

Subacromial pain has also been known as impingement, and subacromial pain syndrome have also been named bursitis, tendinopathy, partial rotator cuff tear, biceps tendinitis, tendon cuff degeneration (Diercks et al, 2014).

Image: (Wilson, 2019).

The mechanism of subacromial pain is where the structures get ‘impinged’ within the subacromial space, usually during overhead activities (Physiopedia, 2019).

There is debate about the causes of subacromial pain. They can include:

• Structural changes – bony narrowing or osteophyte formation, changes after a fracture
• Altered scapula movement (this is debated)
• Strength balance differences which would influence the movement of the humeral head
• Reduced rotator cuff strength
• Repetitive overhead activity e.g. throwing athlete, swimmers (Physiopedia, 2019).

What are the symptoms?

• Pain in the shoulder or upper arm
• Pain with overhead activities
• Pain at certain angles of shoulder movement e.g. wrist and elbow at shoulder height or reaching your hand behind your back
• Pain lying on the affected side which may disturb sleep
• Usually on one side, but can affect both

When should I see a Physiotherapist or Doctor?

• A Physiotherapist can do an assessment to determine the cause of your symptoms if you have an injury or developed shoulder pain without an unknown cause, or you have limited movement and function.
• Seek urgent medical attention if you have had a trauma, and you are unable to raise your arm, or if you have developed weakness
• Seek urgent medical attention if you had had a significant traumatic injury to rule out other injuries such as a dislocation or fracture
• You should speak to a Doctor or Physiotherapist if you have pins and needles down the arm

What can I do?

• There is good evidence that Physiotherapy is effective in treating this condition. The Dutch Orthopaedic Association Guidelines (Diercks et al, 2014) recommended for physiotherapists to consider home exercises, posture advice and soft tissue massage for trigger points in treatment of subacromial pain
• It is worth seeing a Physiotherapist for an assessment of the shoulder, as there are a few differential diagnoses (see below)
• Mobilise the shoulder as comfortable, as holding it in a fixed position can lead to stiffness
• Activity modification – there are ways to keep active and not aggravate your symptoms. Physiotherapists can give you advice regarding this
• Subacromial decompression surgery does not have strong evidence. Beard et al (2018), concluded that outcomes following arthroscopic subacromial decompression did not differ to placebo surgery. Although both were better than no treatment, the significance of this was uncertain

You can try this exercise as long as it is comfortable, and you don’t have any of the symptoms above suggesting you need to seek urgent medical attention. It’s ok to feel a stretch but if you have worsening pain, or you feel worse in the evening or next morning, see a Physiotherapist or Doctor for further advice:

Isometric external rotation – the movement will be like you are trying to do the movement on the left image (this is not the exercise). The exercise is the image on the right – stand with your forearm and hand against the wall. Push your hand in to the wall. There should be no movement. Hold for 5 seconds, repeat 5-10 times. 2 sets if comfortable.

Treatment recommendations of Subacromial Pain Syndrome (Diercks et al, 2014):

• Education and advice
• Discussion with a pharmacist or GP regarding the use of NSAIDs acutely
• Physiotherapy for strengthening at low intensity and high frequency
• Soft tissue massage to support the exercise therapy
• Consider a steroid injection for persistent symptoms
• MRI if ultrasound is inconclusive
• If a rotator cuff tear is present – surgical repair can be considered depending on age and activity level of the patient, and also dependent on symptoms and size of the tear

Differential Diagnoses around this area include:

• Rotator cuff tear
• Frozen shoulder
• Neck pain with referred neurological symptoms
• Fractures such as proximal humerus
• Acromioclavicular joint sprains
• Shoulder dislocation or subluxation

Notes for Physios:

Diagnosis of subacromial pain syndrome, notes provided by the Dutch Orthopaedic Association Guidelines (Diercks et al, 2014):

• Positive Hawkins Kennedy
• Painful Arc
• Infraspinatus (lateral rotation) strength test

Jeremy Lewis symptoms modification procedure: https://www.physio-pedia.com/Shoulder_Symptom_Modification_Procedure

Clinical Edge Podcasts provide clinicians approaches to shoulder and subacromial pain: http://www.clinicaledge.co

Although this is more related to shoulder instability, it is interesting to read about the link between reduced core stability and shoulder instability: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611703/

References:

Beard, D; Rees, J; Cook, J; Rombach, I; Cooper, C; Merritt, N; Shirkey, B, Donovan, J; Gwilym, S; Savulescu, J; Gray, A; Jepson, M; Tracey, I; Judge, A; Wartolowska, K; Carr, A. 2017. Lancet. [online]. 391 pp. 329-338. [Accessed 11^th June 2019]. Available from: http://www.ncbi.nlm.nih.gov

Diercks, R; Bron, C; Dorrestijm, O; Meskers, C; Naber, R; Ruiter, T; Willems, J; Winters, J; Jan van der Woude, H. 2014. Guidelines for Diagnosis and Treatment of Subacromial Pain Syndrome. Acts Orthopaedica. [online]. 85 (3) pp. 314-322. [Accessed 11 June 2019]. Available from: http://www.ncbi.nlm.nih.gov

Jaggi, A; Alexander, S. 2017. Rehabilitation for Shoulder Instability. Open Orthopaedics Journal. [online]. 11. pp. 957-971. [Accessed 12^th June 2019]. Available from: http://www.ncbi.nlm.nih.gov

National Health Service. 2019. Subacromial Pain Syndrome. [online]. [Accessed 5^th June 2019]. Available from: http://www.nwbh.nhs.uk

Physiopedia. 2019. Shoulder Symptom Modification Procedure. [online]. [Accessed 12^th June 2019]. Available fromL http://www.physio-pedia.com

Physiopedia. 2019. Subacromial Pain Syndrome. [online]. [Accessed 5^th June 2019]. Available from: http://www.physio-pedia.com

Wilson, C. 2019. Shoulder Impingement Syndrome. [online]. [Accessed 5^th June 2019]. Available from: http://www.shoulder-pain-explained.com