Subacromial Pain Syndrome: A new grad physiotherapist nightmare

Nearly three years ago, I started my career as a physiotherapist armed with what I thought was enough tools in the toolkit to, at the very least, be able to effectively assess, treat and achieve a good result with a person experiencing subacromial impingement/subacromial pain syndrome/rotator cuff related pain (insert any other name you like for it, I will be calling it subacromial pain syndrome).   What I very quickly came to realise is that the numerous amounts of special tests we learnt in university couldn’t provide me the diagnosis I needed and nor could the external rotation and standing row TheraBand exercises restore our clients range of motion or alleviate their pain like I thought.  This turned my attention immediately to searching through “Research-land” for ways in which the leaders in the physiotherapy world assess, diagnose and treat subacromial pain syndrome and how I could incorporate them into my practice.  

In recent times, I have been involved in conversation with several new graduate physiotherapists and many of them have this same concern and problem when it comes to treating anterior shoulder pain.  This is a summary of the key pieces of research, information and advice that I found to be most useful as a new graduate in developing my understanding and practice when it comes to subacromial pain syndrome.

“Always assess/treat centrally first”

This piece of advice has stuck with me since I first started working as a private practice physiotherapist at Inspire Health Services and it comes from my mentor Dorothy Hawkins…she will absolutely love the name drop here.

When it comes to shoulder pain, it’s extremely important that we don’t get caught with our blinkers on and focus solely on the shoulder but assess more centrally first to determine if there is any deficiency in range of motion or motor control in the cervical or thoracic spine and the scapulothoracic joint.  The nuts and bolts as to why, my colleague Timothy Park goes into a little bit more detail in another blog but missing this component in your assessment, can really set you back in getting the best result for your client.

In the literature, shoulder guru and physiotherapist Jeremy Lewis designed the “Shoulder Symptom Modification Procedure” (SSMP) which is a great example of an assessment protocol that incorporates cervical and thoracic treatment as an assessment strategy and takes this piece of advice into consideration (Lewis, 2009).  This tool also uses several different symptom modification techniques that are extremely useful in helping to identify where the problem is in the shoulder complex and guide your treatment.

“A tight muscle is a tired muscle”

This is another piece of advice that I picked up early in my physiotherapy career and it relates to the notion that a muscle that feels tight is due to it being overworked and/or weak.  Through our subjective examination, our job as physiotherapists is to determine whether the muscle is tired and tight from being overworked (a desk worker’s pec muscles from being in an adducted/internally rotated position for long periods of time) or whether they are simply weak and don’t have the capacity to handle an increase in load.  This second category is where I believe the muscles of the rotator cuff typically land and why they can be a primary cause for subacromial pain syndrome.

The literature suggests that tightness (and weakness) of the posterior capsule and rotator cuff can lead to superior and anterior migration of the humeral head which in turn causes compression to the under surface of the supraspinatus tendon within the subacromial space. This compression causes the development of subacromial pathologies such as supraspinatus tendinopathy, degenerative supraspinatus tears and subacromial bursitis (Ellenbecker & Cools, 2010).

How do we deal this? Improve the load capacity of the rotator cuff.

Remember the primary role of the rotator cuff…

The primary role of the rotator cuff is to stabilise the glenohumeral joint by holding the head of the humerus within the glenoid – it’s not to be an external rotator! Depending upon the pathology, the classic banded external rotation exercises can actually be an aggravator for something like an under-surface supraspinatus tear. 

Focus your exercise rehab on challenging the stability of the shoulder in different ranges that don’t cause intolerable pain and are relevant to the client’s needs and lifestyle. I found this to be a lot easier to do with those who weren’t in as much pain or who had progressed past the acute stage of their rehab and much more difficult in the earlier stages.  The most useful resource I have found to date in terms of helping me with shoulder rehabilitation has been Andrew Delbridge’s graded rotator cuff loading article (Delbridge, Brindley, & Boettcher, 2019).  Andrew is an APA sports physiotherapist who in the article provides examples of specific isometric exercises that I have found to be extremely useful in the early rehabilitation of subacromial pain syndrome.

The shoulder joint, due to the various moving parts and multitude of variables that can be at play causing the pain being experienced, can be challenging for a new grad physiotherapist.  These resources and gems of advice were those that I found most useful in helping to expand my skills and knowledge on subacromial pain syndrome in the early stages of my career and a lot of them can apply to various other injuries as well. 

References
Delbridge, A., Brindley, C., & Boettcher, C. (2019). Regent Street Physio. Retrieved from https://www.regentstphysio.com.au/wp-content/uploads/2020/04/18_22_Rotator-Cuff_Sports_May-2019.pdf
Ellenbecker, T. S., & Cools, A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. British Journal of Sports Medicine, 319-327.
Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine, 259-264.