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SUBACROMIAL SHOULDER PAIN

WHAT IS SUBACROMIAL SHOULDER PAIN?

Normal anatomy of shoulder

Side view of normal anatomy of the shoulder. (Click to enlarge)

Subacromial Shoulder Pain is an umbrella term used to describe shoulder pain caused by problems in the subacromial space. The term subacromial shoulder pain is new and previously all pain in this region was given the term shoulder impingement.

The subacromial space is the space between the acromion (flat bone at top of shoulder that is connected to the shoulder blade) and the humeral head (the ball of the shoulder). The space contains one of the rotator cuff tendons (the supraspinatus) and the subacromial bursa.

Shoulder impingement is an old term that gave the impression that pain was only caused by the rotator cuff tendon and bursa being pinched between the humeral head and acromion and we now realise that this is an oversimplification, and that pain can happen with no mechanical problem.

In addition to shoulder impingement (which is relatively rare) pain can be caused by problems with the rotator cuff tendon, the subacromial bursa or both. Rotator cuff tendon problems that can cause subacromial pain include rotator cuff tendinopathy, partial thickness rotator cuff tears, and calcific tendonitis.

rotator cuff tendinopathy

Diagram demonstrating changes in the rotator cuff tendon representing tendinopathy. (Click to enlarge)

Rotator cuff tendinopathy refers to age related degnerative change in the rotator cuff tendons. This is caused by wear and tear to the tendons throughout life. Slowly the structure of the tendon changes over time and its aparance on an MRI scan can change. We dont know exactly how this condition causes pain. Theories include chemicals being released in the tendon during the wear and tear and healing pahses that can generate pain. Others belive that muslce weakness can result in impalance in the rotator cuff tendons as they try ot balance the ball on the socket of the shoulder and this may be the cause of pain.

Subacromial bursitis is the main bursal problem.

WHAT ARE THE SYMPTOMS OF SUBACROMIAL SHOULDER PAIN?

subacromial shoulder painPatients with subacromial shoulder pain mostly complain of pain on the outside of the shoulder over the deltoid muscle. The pain can sometimes radiate down the arm to the elbow. Pain is usually not a problem when resting but patients often describe pain when lifting the arm forward or out to the side above shoulder height. Some patients experience pain laying on the affected shoulder at night. Reaching for things in a high cupboard or up on a shelf can often trigger the pain.

WHAT IS THE TREATMENT FOR SUBACROMIAL SHOULDER PAIN?

The first line of treatment should be non-operative. Over the counter pain killers and anti-inflammatories can help with pain and inflammation. Most patients with shoulder pain tend to rest their shoulder to avoid pain and this can quickly lead to weakness of the rotator cuff muscles, so it is important to exercise the shoulder to improve strength and posture for long term control of symptoms.

The British Elbow & Shoulder Society have produced a patient resource for patients with subacromial shoulder pain. This provides information and a good home exercise program to help rehabilitate the shoulder.

If these self-management options do not work, some patients may go on to need a subacromial steroid injections for control of pain and inflammation, and formal exercise focused physiotherapy to work on strength and posture. Patients usually require at least 12 weeks of physiotherapy to see long term improvements.

Patients with calcific tendonitis may require slightly different treatment. You can read more about this condition here.

WHAT IF NON-OPERATIVE MANAGEMENT DOESN’T WORK?

In some patients who fail to improve after steroids and physiotherapy and have persistent pain, surgery may be required. Any surgery required depends on the cause of the pain.

Rotator cuff tendinopathy (pain caused by tendon problems when there is no tear) is not helped by surgery at all.

Partial thickness tears that cause persistent pain despite non-operative management may require treatment similar to a full thickness rotator cuff tear.

Patients with persistent subacromial bursitis may require an arthroscopic subacromial decompression. This operation has become less and less necessary with good physiotherapy. If you are struggling to find a good physiotherapist, please get in touch.

Nick Ferran @ Shoulder & Elbow London Ltd

Clinics in:

Chiswick – Harrow – St. Johns Wood

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