What is Subacromial Pain Syndrome (SAPS)?

Subacromial Pain Syndrome (SAPS) is one of the most common causes for shoulder pain and is used to describe pain in the top of the shoulder.1 Subacromial pain syndrome was previously referred to as shoulder or subacromial impingement but has recently changed to a more global term due to the many different structures and injuries in this region.

Subacromial impingement has been used commonly and was described as mechanical impingement of the supraspinatus and long head of the biceps tendon as they pass under the coracoacromial arch (space between the coracoid and acromion).2 Recent literature suggests that this cannot be proven without more advanced imaging techniques. Rather it has been shown that there is a role in the degeneration of tendons leading to pain being experienced in the subacromial region.2,3

SAPS is defined as all non-traumatic, usually unilateral, shoulder problems that cause pain, localized around the acromion, often worsening during or subsequent to lifting of the arm. It includes many different clinical and/or radiological names, such as bursitis, tendinosis, supraspinatus tendinopathy, partial tear of the rotator cuff, biceps tendinitis or tendon cuff degeneration.2,3

SAPS is treated non-operatively with early treatment and rehabilitation beneficial to reduce the recurrence. Treatment is focused on reducing pain and improving shoulder function through a combination of manual therapy and exercise rehabilitation to restore function and improve quality of life.4

WHAT STRUCTURES ARE INVOLVED IN SAPS?

The shoulder joint is a ball and socket joint and the most mobile joint in the body, therefore, requiring large amounts of support from the surrounding structures. The subacromial space is complex including the top of the humerus, the shoulder joint, ligaments and the acromion which is the top of the shoulder blade.5,6 Within the subacromial space is the bicep tendon, rotator cuff tendons and bursa which are all inclusive of subacromial pain syndrome. As these structures in the shoulder become compressed it leads to pain, limited range of motion and functional impairment.5,6 

WHAT CAUSES SAPS?

SAPS can occur for a number of reasons due to the numerous structures impacting the shoulder and subacromial space.

Several factors can contribute to SAPS including:

• Repetitive overhead movements such as throwing, lifting or reaching

• Poor posture or poor movement patterns

• Muscular imbalances

• Muscle weakness

Anatomical factors such as the positioning of the shoulder within the joint and scapular can contribute or predispose a person to SAPS. Mechanical factors such as shoulder kinematics and movement of the structures around the shoulder could impact the space in the subacromial region and tendons. A previous injury to the rotator cuff or stability of the shoulder is a likely cause of SAPS due to tendon and muscle structures around the shoulder impacting the subacromial region.5 Muscle imbalances can also likely be a cause due to the muscles around the shoulder blade providing stabilisation to the shoulder. If these muscles are weak it also contributes to having poor posture.6

Poor and inefficient shoulder movements are common to contribute to the cause of subacromial impingement. When assessing the shoulder, our physiotherapist will likely look at the neck and mid-back as these are regularly restricted and can also contribute to the pain. The shoulder blade (scapula) also needs to sit and move correctly for the shoulder joint to work efficiently. By strengthening the muscles which stabilise the shoulder blade will likely improve this movement and decrease symptoms.7

Anything that leads to the structures which pass through the subacromial space becoming irritated and inflamed can cause impingement-related pain. Inflammation can lead to swelling of the tissues in the small space and when we move our arm up or out to the side, these tissues get pinched between the bones, causing pain.2,3 Any of the above-mentioned structures of the rotator cuff tendons, bicep tendon and bursa can become inflamed. However, there is rarely just one tissue solely responsible. For example if the tendon of a rotator cuff muscle is inflamed, there is every chance the bursa will also be inflamed.4,5

WHAT ARE THE SIGNS AND SYMPTOMS?

Signs and symptoms of shoulder impingement include 1,2,3,4:

• Pain with arm movements (movements in front and out to the side)

• Pain with shoulder rotation

• Pain radiating to the upper arm

• Reduced shoulder range of motion

• Weakness and loss of strength in the shoulder

• Painful clicking or popping sensations during shoulder movements

• Discomfort or pain during rest, including the night leading to reduced sleep

MANAGEMENT AND REHABILITATION:

Physiotherapy offers a comprehensive and conservative approach to managing SAPS. A thorough assessment of the shoulder and surrounding structures will be conducted on the initial examination. This will allow testing to be completed and a diagnosis to be made. A combination of five different tests will be completed and 3 or more positive results will confirm a diagnosis of subacromial pain syndrome (SAPS).6,7

With the various structures in this space, by combining the testing the reliability and validity of the assessment is increased, confirming the diagnosis of SAPS. SAPS is a common shoulder injury contributing to large amounts of pain, discomfort and decreased quality of life. Literature shows that physiotherapy can provide major benefits to help with shoulder pain and function.6,9

The main objectives of physiotherapy interventions are to reduce pain, improve shoulder function, restore range of motion, and address underlying contributing factors.8 Physiotherapy management involves strengthening muscles in safe and effective  movements to provide relief to the subacromial joint.

Physiotherapists may employ various techniques to manage pain effectively which can include soft tissue massage, dry needling and manual therapy techniques such as joint mobilisations.9,10 Exercise therapy is a significant part of physiotherapy management for SAPS which aims to strengthen the rotator cuff muscles, improve scapular stability and enhance shoulder mobility. 11

Therefore, through a combination of using hands on techniques, progressive exercises and lifestyle changes you can expect to see positive changes quite quickly. The end goal of ensuring your pain doesn’t return is always a lengthier process and requires dedication to make sure the changes provided from your physiotherapist remain in place. 10, 11

For ongoing shoulder pain, come in and see one of our physiotherapists to provide you with the essential rehabilitation required for your shoulder pain.

REFERENCES: 

1. Senbursa, G., Baltacı, G., & Atay, A. (2007). Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy, 15(7), 915–921. https://doi.org/10.1007/s00167-007-0288-x 

2. Diercks, R., Bron, C., Dorrestijn, O., Meskers, C., Naber, R., de Ruiter, T., Willems, J., Winters, J., & van der Woude, H. J. (2014). Guideline for diagnosis and treatment of subacromial pain syndrome. Acta Orthopaedica, 85(3), 314–322. https://doi.org/10.3109/17453674.2014.920991

3. Lewis, J. S., Green, A. S., & Dekel, S. (2001). The Aetiology of Subacromial Impingement Syndrome. Physiotherapy, 87(9), 458–469. https://doi.org/10.1016/s0031-9406(05)60693-1 

4. Dickens, V. A., Williams, J. L., & Bhamra, M. S. (2005). Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study. Physiotherapy, 91(3), 159–164. https://doi.org/10.1016/j.physio.2004.10.008 

5. Michener, L. A., Walsworth, M. K., Doukas, W. C., & Murphy, K. P. (2009). Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Archives of Physical Medicine and Rehabilitation, 90(11), 1898–1903. https://doi.org/10.1016/j.apmr.2009.05.015 

6. Haik, M. N., Alburquerque-Sendín, F., Moreira, R. F. C., Pires, E. D., & Camargo, P. R. (2016). Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. British Journal of Sports Medicine, 50(18), 1124–1134. https://doi.org/10.1136/bjsports-2015-095771 

7. Reijneveld, E. A. E., Noten, S., Michener, L. A., Cools, A., & Struyf, F. (2016). Clinical outcomes of a scapular-focused treatment in patients with subacromial pain syndrome: a systematic review. British Journal of Sports Medicine, 51(5), 436–441. https://doi.org/10.1136/bjsports-2015-095460 

8. Gebremariam, L., Hay, E. M., van der Sande, R., Rinkel, W. D., Koes, B. W., & Huisstede, B. M. A. (2013). Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. British Journal of Sports Medicine, 48(16), 1202–1208. https://doi.org/10.1136/bjsports-2012-091802 

9. Hanratty, C. E., McVeigh, J. G., Kerr, D. P., Basford, J. R., Finch, M. B., Pendleton, A., & Sim, J. (2012). The Effectiveness of Physiotherapy Exercises in Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis. Seminars in Arthritis and Rheumatism, 42(3), 297–316. https://doi.org/10.1016/j.semarthrit.2012.03.015 

10. Griswold, D., Learman, K., Ickert, E., Tapp, A., & Ross, O. (2023). Dry Needling for Subacromial Pain Syndrome. A Systematic Review with Meta-analysis. Pain Medicine, 24(7). https://doi.org/10.1093/pm/pnac131 

11. Gutiérrez-Espinoza, H., Araya-Quintanilla, F., Cereceda-Muriel, C., Álvarez-Bueno, C., Martínez-Vizcaíno, V., & Cavero-Redondo, I. (2020). Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: A systematic review and meta-analysis. Physical Therapy in Sport, 41, 34–42. https://doi.org/10.1016/j.ptsp.2019.11.003