Guideline for diagnosis and treatment of subacromial pain syndrome

Abstract

Treatment of “subacromial impingement syndrome” of the shoulder has changed drastically in the past decade. The anatomical explanation as “impingement” of the rotator cuff is not sufficient to cover the pathology. “Subacromial pain syndrome”, SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows:(1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

Effectiveness of scapula-focused approaches in patients with rotator cuff related shoulder pain: A systematic review and meta-analysis

“…Population -Adults with signs & symptoms of RCSP (inclusive of terms such as rotator cuff tendinopathy, shoulder impingement syndrome), commonly described as unilateral shoulder pain, localised around the acromion; worse with overhead activity; usually full range of shoulder movement; a combination of positive impingement tests; presence of a painful arc; reproduction or worsening of pain on resisted muscle testing; and no cervical spine involvement (4,12,21).…”

Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?

“…Operative treatment is commonly used for shoulder impingement syndrome, even though its effectiveness has not been proven in the literature (Papadonikolakis et al 2011, Diercks et al 2014, Saltychev et al 2015). The fact that the diagnosis is merely clinical also makes comparison of different studies difficult.…”

“…Nowadays, the term impingement syndrome is used to refer to a full range of rotator cuff abnormalities, being still a diagnosis based on physical examination (Papadonikolakis et al 2011). Diercks et al (2014) highlighted the need for a combination of clinical tests in the diagnosis, and suggested the use of an imaging test after prolonged symptoms (of more than 6 weeks) to rule out rotator cuff tears. Shoulder impingement is a common cause of shoulder pain (van der Windt et al 1995, Urwin et al 1998).…”

“…It has been shown that arthroscopic acromioplasty is not superior to a supervised exercise program (Ketola et al 2009, 2013, Papadonikolakis et al 2011, Diercks et al 2014, Saltychev et al 2015). However, arthroscopic acromioplasty has been increasingly used during the last decade (Paloneva et al 2015).…”

Effectiveness of low-level laser therapy in patients with subacromial impingement syndrome: a randomized, placebo controlled, prospective study

“…The most frequent cause of shoulder pain is subacromial impingement syndrome (SIS) (2) which is caused by compression of the rotator cuff, long head of the biceps tendon, and subacromial bursa between the humerus and coracoacromial arch as a result of an intrinsic or an extrinsic mechanism (3) . Treatment of SIS is primarily conservative, including analgesic and anti-inflammatory drugs, corticosteroid injections, and occupational and physiotherapy interventions (4) . Of the physical therapy interventions, low-level laser therapy (LLLT) is a relatively new physical therapy modality that is supposed to reduce pain, accelerate wound healing, and have a ameliorating effect on the inflammatory process (5) .…”