Subacromial Impingement Syndrome (SIS) / Subacromial Pain Syndrome (SAPS)
Introduction
Subacromial Impingement Syndrome (SIS), now more inclusively termed Subacromial Pain Syndrome (SAPS), remains the leading cause of shoulder pain in primary care, accounting for 44% to 65% of shoulder-related consultations (Umer et al., 2012; Yuan et al., 2022). It encompasses a spectrum of pathologies including rotator cuff tendinopathy, subacromial bursitis, and partial tears, often with overlapping symptoms.
As physiotherapists, we emphasize non-surgical management using evidence-based strategies that restore function, reduce pain, and prevent chronicity. Timely referral to physiotherapy can reduce the need for advanced imaging, injections, or surgical intervention.
Key Clinical Features
- Painful arc during shoulder elevation
- Night pain, particularly when lying on the affected side
- Tenderness over the subacromial space
- Positive signs on Hawkins-Kennedy, Neer, and painful arc tests
- Decreased strength in external rotation and abduction
Risk Factors
- Repetitive overhead activity (occupational or athletic)
- Postural dysfunction (rounded shoulders, thoracic kyphosis)
- Sleep disturbances and insomnia (Lv et al., 2024)
- Psychological components: fear-avoidance, low expectation of recovery (Chester et al., 2010)
Conservative Management: Evidence Summary
1. Exercise Therapy
A meta-analysis by Hanratty et al. (2012) concluded that structured physiotherapy focusing on rotator cuff and scapular stabilization exercises significantly improves pain and shoulder function. Programs incorporating eccentric loading, neuromuscular control, and postural correction outperform general exercise protocols.
2. Manual Therapy and Neuromobilization
Combining manual therapy with exercises improves short-term outcomes and patient satisfaction. Techniques include soft tissue release, joint mobilization, and neural glides.
3. Lifestyle Modification and Sleep Education
A 2024 Mendelian randomization study demonstrated that genetic predisposition to short sleep duration and insomnia is associated with a 53–66% increased risk of SIS (Lv et al., 2024). We educate patients on ergonomics, posture, and sleep hygiene as integral parts of care.
4. Shockwave Therapy
Effective particularly for calcific tendinopathy, ESWT has shown positive results in pain reduction and calcium deposit resorption (Xie et al., 2023). Its benefit for non-calcific SIS remains limited.
5. Psychological Support
Fear-avoidance behaviors and catastrophizing are barriers to recovery. Patient education and graded exposure are integrated into treatment plans.
When to Refer to Physiotherapy
- Persistent shoulder pain > 2 weeks with overhead movements
- Night pain interfering with sleep
- Decline in function or work capacity
- Suspected SIS without red flags or full-thickness rotator cuff tear
When to Consider Imaging or Injections
- Symptoms persist beyond 6 weeks with no improvement despite physiotherapy
- Suspicion of full-thickness tear or significant structural pathology
- Diagnostic uncertainty (ultrasound preferred over MRI in early phases)
Outcomes and Prognosis
With early physiotherapy, most patients demonstrate significant improvement within 6–12 weeks. Surgical intervention, including subacromial decompression, shows no superior long-term outcomes when compared to conservative care (Lähdeoja et al., 2020).
Referral Pathway
We offer evidence-informed rehabilitation programs tailored to the specific needs of each patient. Our assessments include:
- Detailed postural and functional analysis
- SPADI scoring to track progress
- Education on modifying aggravating activities and sleep habits
- Progressive exercise prescription, manual therapy, and, where indicated, shockwave therapy
Physicians may refer patients directly to our clinic by fax or by having patients contact us directly. We are happy to collaborate and share outcome updates upon request.
References
Chester, R., Smith, T. O., Hooper, L., & Dixon, J. (2010). The impact of subacromial impingement syndrome on muscle activity patterns of the shoulder complex: A systematic review of EMG studies. BMC Musculoskeletal Disorders, 11, 45. https://doi.org/10.1186/1471-2474-11-45
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.2012.01.005
Lähdeoja, T., Karjalainen, T., Jokihaara, J., et al. (2020). Subacromial decompression surgery for adults with shoulder pain: A systematic review with meta-analysis. British Journal of Sports Medicine, 54(11), 665–673. https://doi.org/10.1136/bjsports-2019-101333
Lv, Z., Cui, J., Zhang, J., & He, L. (2024). Lifestyle factors and subacromial impingement syndrome of the shoulder: potential associations in Finnish participants. BMC Musculoskeletal Disorders, 25, 220. https://doi.org/10.1186/s12891-024-07345-w
Xie, X., Ma, J., Feng, H., & Zhang, Y. (2023). Effectiveness of extracorporeal shockwave therapy for rotator cuff tendinopathy: A systematic review and meta-analysis. BMC Musculoskeletal Disorders, 24, 189. https://doi.org/10.1186/s12891-023-06345-3
Let’s Work Together
If you’d like to refer a patient or request a case discussion, please contact Noshin’s Physiotherapy. Our goal is to provide high-quality, individualized care to support your patient’s recovery and long-term outcomes.
