What is subacromial pain syndrome?
Subacromial Pain Syndrome (Subacromial impingement, painful arc) is a condition in which the tissues in the subacromial space become inflamed causing pain.
It is often difficult to distinguish between bursitis, tendinitis and small rotator cuff tears in the initial stages however the treatment is the same.
The condition may be caused or made worse by the shape of the acromion. If it is “hooked” it may rub on the tendons increasing the inflammation but this is uncommon.
The tissues involved can be:
The bursa (lubricating sac) can become inflamed causing bursitis: The causes include: throwing sports and overhead activities such as painting, hanging wallpaper or washing windows. The chance of developing the condition increases with age.
The rotator cuff tendons: Causing tendinitis: This may occur when an overly aggressive training program is started by someone whose muscles are poorly conditioned (the post-Wimbledon syndrome) In younger athletes, the causes of tendinitis are similar to those of bursitis.
Calcium can be deposited in the tendons causing pain, again the chance of this increases with age.
What are the signs and symptoms?
There is usually no single acute initial episode and, at first, only minor pain and a slight loss of strength may be noticed. Loss of range of motion, especially the ability to lift the arm overhead, is often ignored for several months.
The symptoms of both conditions include
Mild to severe pain
Limited movement.
Inability to hold the arm in certain positions indicates tendinitis is present.
Recurrent episodes of tendinitis may indicate a rotator cuff tear.
The pain often has two forms
A continuous dull ache, which is often worse at night, is usually located over the lateral aspect of the shoulder joint and may extend someway down the side of the arm even as far as the elbow. Often it does not appear to be coming from the joint at all.
Sharp pain on lifting the arm is felt just below the acromion (the bony prominence at the top of the shoulder). The pain usually starts when the arm reaches horizontal and eases off if the arm can be brought all the way to vertical. This is the so called “painful arc”.
How is the diagnosis made?
The doctor will listen to the description of the symptoms and examine the shoulder. Xrays may be taken to help exclude other pathology within the shoulder.
What is the initial treatment?
We recommend watching the series of Youtube videos produced by the Physiotherapy Department at St. George’s Hospital which explain how to manage Subacromial Pain.
It is often not possible to differentiate between bursitis and tendinitis however the treatment is the same.
Avoidance of the aggravating activities.
Anti-inflammatory drugs should be used and may be all that is required.
Graduated exercises- these can be found at
British Elbow & Shoulder Society Youtube channel
British Elbow & Shoulder Society website
Local injection of local anaesthetic and steroid often settle the acute episode.
If the initial treatment doesn’t work, what’s next?
If the symptoms persist despite conservative treatment the shoulder will be re-examined to exclude a rotator cuff tear. It may be necessary to perform an arthroscopic subacromial decompression (acromioplasty) in which the undersurface of the acromion is shaved to prevent it rubbing on the rotator cuff although this is uncommon.
Pain is felt in the region of the joint. This is usually a dull pain at night, which is made worse by lying on that side. Sharp pain is felt when reaching overhead, particularly at the top of the reach. Symptoms of rotator cuff pain may also be experienced.
Arthroscopic Subacromial decompression
Anaesthetic
General Anaesthetic with an interscalene block (Fully asleep with a local anaesthetic injection into the side of the neck will numb the nerves to the shoulder for post-operative pain relief)
Operation type
Arthroscopic – 3 0.5cm incisions, one at the back, one at the side and one at the front of the shoulder
Procedure
The gleno-humeral (shoulder) joint will be inspected first followed by the subacromial bursa and the rotator cuff. A soft tissue shaving device will be used to clear any scar tissue away. A bone-shaving device will be used to shape the underside of the acromion (the bone at the top of the shoulder) and remove any excess bone. (This is the subacromial decompression). The same shaver will then be used to remove the acromioclavicular joint and the outer and of the clavicle.
Wound Closure
Small butterfly paper stitches will be used to close the wounds.
Tegaderm waterproof dressings will be placed over the top of the paper stitches.
Pain relief
The anaesthetist will discuss a nerve block which will be administered after you are asleep, this means that you will wake up with no pain in the shoulder but the arm will feel numb for up to 12 hours. You will be prescribed painkillers to start taking when you get home and we encourage you to take these regularly for at least the first few days. There will be some discomfort but this settles quite rapidly and ice packs can be used in addition if you wish.
Wound care
The dressings will be changed before you go home and these can be left alone until they are removed. Typically they can be removed 10 days after surgery just by peeling them off and you do not need to visit the doctor for this.
The dressings are showerproof and you will be given some spares in case they start to peel off.
Rehabilitation after surgery
You will wake up with a sling on your arm. This can be removed as soon as you are comfortable, typically the next day.
You should try to use the arm as normally as possible, there will be some pain, particularly above shoulder height but you should not worry about this.
Surgical Risks
Every operation has a degree of risk. It is important that you are aware of these risks before you agree to proceed with your operation.
If you decide not to proceed with surgery there is a possibility that the symptoms will settle on their own but they may continue and they may get worse. You will not damage the shoulder if you decide not to proceed with surgery.
The most common or significant risks are outlined below. A risk of 0.1% means that 1 in 1000 people will suffer the complication
- Failure of the procedure to relieve symptoms: 5%
- Superficial Infection (requiring antibiotics): 0.16%
- Deep Infection (requiring further surgery): 0.02%
- PE (Pulmonary Embolus) (Blood clot in the lung): 0.13% – Blood thinning medication is required for several months. Can rarely result in death.
- DVT (Deep Vein Thrombosis) (Blood clot in the leg): 0.14% – Blood thinning medication is required for several months. Can lead to PE
- Nerve Injury: 0.01% – Usually temporary. Can cause weakness around the shoulder with loss of function and rarely can be permanent.
- Heart attack: 0.02%
- To put these numbers in perspective
The chance of:- Getting three balls in the UK national lottery: 0.9%
- Needing emergency treatment in the next year after being injured by a can, bottle, or jar: 0.1%
- Death by an accident at home: 0.01%
- For a 50 year old man in good health the 5 year risk of dying is 0.8%
Frequently asked questions
Return to work after surgery
This is very much dependent on the type of work that you do, whether you need to drive to get to work and the type of surgery that you have had done.
You, as the patient, have the best idea of the specific demands that are required of you to do your work safely and effectively.
Having an operation with an anaesthetic often takes more out of people than they would expect. Generally it is probably worth taking at least a week off from your regular work after having had any procedure.
You should discuss expected post-operative recovery and work with the surgeon before your operation.
Driving after surgery
To be able to drive safely you should be capable of actively moving your shoulder without assistance and without damaging the surgical repair. You should be able to react normally to avoid causing injury to yourself or others due to a lack of control.
Typically this is a no more than 2 weeks after surgery.
It is a UK requirement that, unless specific dispensation has been granted by the DVLA, a driver uses both arms to control the steering wheel.
It is the responsibility of the driver to ensure that they are in control of the vehicle at all times. They should be able to demonstrate this if stopped by the police.
It is not a requirement to notify the DVLA unless the medical conditions likely to affect safe driving persist for longer than three months after the date of the surgery.
Drivers must not drive under the influence of narcotic medications or within a minimum of 24 hours after an anaesthetic.
Although it is not essential, it may be wise to discuss your return to driving with your car insurance company.
Sports after surgery
You can start simple cardio such as walking or using a static bicycle immediately following surgery. Exercises which involve the shoulder can start as soon as you feel comfortable. Typically this is a few weeks but it may take 5 months or more for high demand overhead sports (swimming, tennis etc to return to normal)