CLINICAL

REVIEW

Subacromial Impingement Syndrome

Indexing Metadata/Description
Title/condition: Subacromial Impingement Syndrome
Synonyms: Shoulder impingement syndrome, shoulder; rotator cuff impingement;
subacromial pain syndrome; supraspinatus impingement; impingement syndrome,
shoulder; subacromial impingement
Anatomical location/body part affected: Shoulder/subacromial bursa, rotator cuff
tendons, scapula
Areas of specialty: Orthopedic rehabilitation, sports rehabilitation, home health
Description
Subacromial impingement syndrome (SIS) is characterized byshoulder pain and altered
glenohumeral kinematics on elevation of the involved arm, especially in overhead
activities such as reaching, lifting, and throwingthat require abduction and internal

rotation(1)
SIS is the most common painful disorder of the shoulder, accounting for 44% to 65% of

all cases of shoulder pain in primary care(1)

SIS is associated with several musculoskeletal shoulder conditions, including
subacromial bursitis, rotator cuff tendinosis, partial tears of the rotator cuff tendons, and
calcific tendinitis of the biceps long head tendon. SIS involves, therefore,a spectrum of
etiological factors(1,2)
Physical therapy, corticosteroid injection, and surgeryare effective treatment
approachesfor reducing pain and disability in patients with SIS. However, high-quality
comparative research evidence is lacking to determine which of these approachesis best

Author
Rudy Dressendorfer, BScPT, PhD
Cinahl Information Systems, Glendale, CA

Reviewers
Diane Matlick, PT
Cinahl Information Systems, Glendale, CA
Amy Lombara, PT, DPT
Rehabilitation Operations Council
Glendale Adventist Medical Center,
Glendale, CA

Editor
Sharon Richman, MSPT
Cinahl Information Systems, Glendale, CA

for restoring shoulder function in the progressive stages of SIS(1,2)

ICD-9 codes
726.1 rotator cuff syndrome of shoulder and allied disorders
726.10 disorders of bursae and tendons in shoulder region (unspecified)
726.11 calcifying tendonitis of shoulder
719.41 pain in joint, shoulder region
ICD-10 codes
M75 shoulder lesions
M75.1 rotator cuff syndrome
M75.3 calcific tendonitis of shoulder
M75.4 impingement syndrome of shoulder
M75.5 bursitis of shoulder

(ICD codes are provided for the readers reference, not for billing purposes)
G-Codes
Carrying, Moving & Handling Objects G-code set
G8984, Carrying, moving & handling objects functional limitation, current status, at
therapy episode outset and at reporting intervals
G8985, Carrying, moving & handling objects functional limitation, projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to end
reporting

June 26, 2015

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright2015, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

G8986, Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end
reporting
Self Care G-code set
G8987, Self care functional limitation, current status, at therapy episode outset and at reporting intervals
G8988, Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at
discharge or to end reporting
G8989, Self care functional limitation, discharge status, at discharge from therapy or to end reporting
Other PT/OT Primary G-code set
G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at
reporting intervals
G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end
reporting
Other PT/OT Subsequent G-code set
G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at
reporting intervals
G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting
G8995, Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to
end reporting
.
G-code Modifier
Impairment Limitation Restriction
CH

0 percent impaired, limited or restricted

CI

At least 1 percent but less than 20 percent impaired, limited or restricted

CJ

At least 20 percent but less than 40 percent impaired, limited or restricted

CK

At least 40 percent but less than 60 percent impaired, limited or restricted

CL

At least 60 percent but less than 80 percent impaired, limited or restricted

CM

At least 80 percent but less than 100 percent impaired, limited or restricted

CN

100 percent impaired, limited or restricted

Source: http://www.cms.gov
.
Reimbursement: No specific issues or information regarding reimbursement have been identified
Presentation/signs and symptoms
The patient is often a past or present throwing athlete or uses/has usedthe involved arm in overhead occupational work(2)
Shoulder pain is usually unilateral. The dominant upper extremity is most often affected(1)
Shoulder pain may interfere with or impair activities of daily living (ADLs), sports, or occupational work
Pain is localized in the superior-lateral aspect of shoulder and upper arm, and seldom below elbow
Pain increases when elevating arm in abduction and inward rotation
Tenderness at point of shoulder, often at night when sleeping on affected shoulder or with arm above affected shoulder(1)
Altered shoulder mobility (usually with scapular dyskinesis) and reduced range of motion (ROM) that may interfere with
ADLs and sports(2)
Possible edema, erythema, and warmth at point of shoulder (or at arthroscopic portal sites in surgical cases)(1)
Patient may also complain of neck pain and/or upper back pain

 Postoperative patients typically present to physical therapy for shoulder rehabilitation(3)

Causes, Pathogenesis, & Risk Factors

Causes
The etiology of SIS remains debated, but appears multifactorial(1)
Shoulder pain is likely caused by impingement or compression of various soft tissues (e.g., supraspinatus tendon/muscle,
long head of the biceps tendon, coracoacromial ligament, or subacromial bursa) between the humeral greater tuberosity and
the coracoacromial arch/postero-superior glenoid(1)
Primary impingement: Increased subacromial loading due to compression between the greater tuberosity of the humerus
and the acromial arch is associated with variant anatomy of the scapula such as a curved or hooked acromion(1)
Secondary impingement: Results from rotator cuff overuse; microtrauma (friction and abrasion) to shoulder rotator tendons
(most often supraspinatus) and/or subacromial bursa(1)
Functional: work-related factors such as handling loads overhead or repetitive overhead throwing that produce
- Muscle strength imbalance with excessive superior translation of the humerus and irritation of the rotator cuff tendons(5)
- Space-occupying hypertrophy of the supraspinatus tendon(1,2)
Biomechanical changes
- Scapular dyskinesis (i.e., abnormal scapular movement) may place excessive traction on rotator cuff (especially
supraspinatus muscle). However, whethervariantposition and movement of the scapula are causative factors remains
unclear(42,46)
- Glenohumeral joint hyperlaxity
Direct trauma (e.g., fall or other blunt force)to point of shoulder
Pathogenesis
The subacromial space ranges from 1.0 to 1.5 cm and is surrounded by the head of humerus inferiorly, the anterior edge
and inferior surface of the anterior one third of acromion, as well as by the coracoacromial ligament and acromioclavicular
joint superiorly(1)
The impingement ROM is commonly described as a painful arc between 70 and 120 abduction when elevating arm in
the scapular plane(4,5)
Neer classified SIS in 3 progressive stages(6)
Stage 1: low-grade inflammation with edema and hemorrhage of the subacromial bursa and/or rotator cuff. This stage is
usually found in patients under 25 years of age
Stage 2: subacromial bursal fibrosis; rotator cuff tendinitis (typically found in patients 25 to 45 years of age)
Stage 3: chronic acromial bone spurring; tendon tearing or rupture requiring surgery (typically found in patients more
than 45 years of age)
Visual scapular dyskinesis, characterized byreduced scapular external rotation and increased upper trapezius muscle
activity, is commonly seen in patients with SIS.(46) However, biomechanical changes in shoulder forces (assessed by
functional torque ratios and torque curve analysis) that may contribute to SIS in overhead throwing athletes remain
unclear.(7) Variations in scapular position that appear abnormal may not contribute to SIS, according to an 2014
systematic review of studies that used 2-dimensional radiological measurements, 360 inclinometers, or 3-dimensional
motion and tracking devices to assess patients with or without SIS(42)
Risk factors
High-velocity overhead movements of the upper extremity, as in throwing sports(8)
Occupations that involve repetitive or sustained elevated shoulder postures (e.g., painting, welding, carpentry)(9)
Competitive swim training, especially front-crawl and butterfly strokes, and its association with hyperlaxity(10)
Scapular dyskinesis(11,47)
Poor posture
Hooked acromion(1)
No clear risk associated specifically with age or gender

Overall Contraindications/Precautions
Any of the followingwarrants referring the patient back to physician
Suspected fracture
Suspected rotator cuff tear
Catching and pseudo-locking: this presentation is atypical, suggestive of loose bodies in subacromial space
Radicular pain below the elbow
Recalcitrant/persistent pain after 2 to 3 months of conservative treatment and activity modification(4,5)
Patients who present after trauma to the involved shoulder are at high risk for developing glenohumeral adhesive capsulitis
Modify or restrict painful ADLs that may exacerbate condition, especially overhead activities
See specific Contraindications/precautions under Assessment/Plan of Care

Examination
History
History of present illness/injury
Mechanism of injury: Was the onset of SIS sudden or gradual? Is there a history of repetitive overhead activities, such as
throwing sports or work-related (e.g., painting, lifting)? Is the patients dominant arm affected? How have the symptoms
progressed since onset?
Course of treatment
- Medical management:A conservative treatment plan (pain management, exercise therapy, activity modification, patient
education, and monitoring) typically precedes surgical intervention. Document nonoperative interventions used and
dates of treatment
- Surgical management:Arthroscopic subacromial decompression (ASD) may improve function in patients with
recalcitrant SIS after an initial trial of conservative treatment.(47)Document date of surgery for SIS and procedure used
(e.g., ASD, acromioplasty), if applicable. A proposed randomized controlled trial (RCT) in Denmark may provide a
model for postoperative shoulder rehabilitation to reduce disability in patients with SIS(48,49)
- Medications for current illness/injury: Determine what medications clinician has prescribed, if any; are they being
taken as prescribed and are they effective? Nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter
pain relievers are commonly used. Moderate evidence supports a trial of immediate-release ibuprofen or 2 sessions of
corticosteroid injection for treatment of patients with SIS, based on a 2013 systematic review.(43)Authors of a trial in
Turkey found that local steroid injection (2 times with an interval of 10 days, n=45) was associated with reduced pain
at rest and during shoulder activity as compared to sham treatment(n=45). They also separately found no significant
difference between the steroid treatment and low-level lasertreatment (n=45)(50)
- Diagnostic tests completed: Plain radiographs are generally not necessary in mild acute cases; however, imaging
studies are often conducted in recalcitrant cases to evaluate for calcific deposits, sclerosis, cyst-like changes, tendon
tears, and subacromial spurring.(1,4,5) Magnetic resonance imaging (MRI) may be used if thickening of the supraspinatus
tendon is suspected(1,2)

- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative
therapies (e.g., acupuncture) and whether or not they help
- Previous therapy: Document whether patient received occupational or physical therapy for this or related
musculoskeletal conditions and what specific treatments were helpful or not helpful
Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased):
Aggravating factors may include overhead activities, throwing, and position during sleep
Body chart: Use body chart to document location and nature of symptoms. Pain is localized in the superior-lateral aspect
of shoulder, seldom below elbow
Nature of symptoms: Document nature of symptoms (e.g., constant vs. intermittent, sharp, dull, aching, burning,
numbness, tingling), 24-hour pain patterns and frequency
- Are symptoms getting better, worse, or staying the same?
- Is there associated neck pain or upper back pain?
- Pain in the shoulder may radiate into upper arm (C5 dermatome)
Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and
at the moment (specifically address if pain is present now and how much)

Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,
night); also document changes in symptoms due to weather or other external variables. Night pain is typical
Sleep disturbance: Document number of wakings/night, if any
Other symptoms: Document other symptoms patient may be experiencing that could be indicative of a need to refer to
physician (e.g., dizziness, sudden onset of upper extremity swelling, arm pain)
Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe ________________________
Medical history
Past medical history
- Previous history of same/similar diagnosis: Any prior trauma to shoulder? Previous treatments to the affected
shoulder? Are there other musculoskeletal problems (such as arthritis in the elderly)?
- Comorbid diagnoses: Ask patient about any other medical conditions being treated, including diabetes, cancer,
cardiovascular disease, pulmonary disease, complications of pregnancy, psychiatric disorders, orthopedic disorders,
obesity, thyroid disorders,etc.
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask patient about other symptoms he or she may be experiencing
Social/occupational history
Patients goals: Document the patient specific and general goals for therapy
Vocation/avocation and associated repetitive behaviors, if any: Does the patient participate in recreational or
competitive sports? Does shoulder pain restrict recreational or occupational activities?
Functional limitations/assistance with ADLs/adaptive equipment: Any difficulty with daily activities (e.g., putting on
coat, combing hair)?
Living environment: Stairs, number of floors in home, with whom patient lives, caregivers, etc. Identify if there are
barriers to independence in the home; any modifications necessary?
Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
Anthropometric characteristics: Document patients height, weight, and body mass index (BMI)
Assistive and adaptive devices: Assess need for and proper use of ambulatory assistive devices, especially in cases with
increased fall risk
Balance: Assess static and dynamic balance in standing, as indicated by patient history (e.g., if shoulder trauma was
sustained in a fall). Use Berg Balance Scale for objective measure in elderly patients, as indicated
Cardiorespiratory function and endurance: Evaluate and monitor if cardiorespiratory conditioning is part of the
treatment plan
Circulation: Assess distal radial and ulnar pulses
Functional mobility: Assess ability in transfers, standing, walking, stairs, carrying, etc. Use FIM, as indicated
Cranial/peripheral nerve integrity: Cervical screen for radicular pain. Assess motor and sensory function in radial nerve
Ergonomics/body mechanics: Assess for scapular dyskinesis, i.e., changes associated with this syndrome: altered timing
and magnitude of acromial upward rotation, excessive anterior tilting of the glenoid (due to pectoralis tightness), and loss
of maximal rotator cuff activation;(2) assess shoulder and general body mechanics in simulated lifting and loading work
tasks
Functional mobility (including transfers, etc.): Does impairment in affected arm affect mobility?
Gait/locomotion: Evaluate as indicated. Usually not applicable
Joint integrity and mobility: Assess glenohumeral joint for hyperlaxity (instability), hypomobility, and passive translatory
movements. Athletes at risk (e.g., throwers, swimmers) for shoulder impingement syndrome typically have glenohumeral
joint instability(2,5)
Muscle strength: Assess strength at shoulder and scapulothoracic joints in all directions using manual muscle testing
(MMT), especially for possible weakness (< 5/5) in isometric forward flexion, internal and external rotation, as well as
scaption and abduction. Expect strength deficits in the impingement position due to pain avoidance. Assess for serratus
anterior and lower trapezius muscle weakness(12)
Observation/inspection/palpation (including skin assessment)
Examine shoulder for edema, warmth, scars, or deformity; atrophy around shoulder suggests chronic impairment

Expect tenderness at greater tuberosity and biceps tendon (long head); tenderness and crepitus often also at
acromioclavicular joint
Observe scapulohumeral rhythm
Posture: Assess overall posture in standing. Observe for deviations in head, neck, shoulder girdle, and shoulder posture
Range of motion: ROM may be limited by pain. High-levelbaseball pitchers typically have increased active and passive
ROM in shoulder external rotation.(13) Assess for dyskinetic scapulohumeral rhythm, especially in athletes at risk (e.g.,
throwers(8) and swimmers)(10)

Reflex testing: Assess upper extremity reflexes

Self-care/activities of daily living (objective testing): Assess for functional ROM in external rotation/abduction (thumb to
C7) and internal rotation/adduction (thumb to L5)
Sensation: Scan C5 dermatome. Assess for proprioception deficits in affected shoulder
Special tests specific to diagnosis: A wide variety of physical tests can be used in SIS cases
Neers test (Neers impingement sign): Patient in seated position with examiner supporting scapula, patient forward flexes
shoulder with elbow straight and forearm pronated against examiners resistance; positive sign (reproduces pain and
patient grimaces) suggests inflammation or injury to structures in subacromial space(1)
Hawkins (Hawkins-Kennedy) test: Patient in a seated position with 90 forward shoulder flexion and 90 elbow flexion,
patient internal rotates shoulder against examiners resistance; positive if reproduces pain. In a 2008 systematic review,
meta-analysis revealed moderate sensitivity (79%) for both Neers and Hawkins tests but poor specificity (53% and 59%,
respectively), indicating high false-positive rates(14)
Drop arm sign: In a sitting or standing position, the patient fully elevates the extended arm in scaption and then slowly
reverses the motion in the same arc. Test is positive if the arm drops suddenly or the patient has severe pain(1)
A 2012 systematic review found that the Hawkins-Kennedy test and Neers sign were found more useful for ruling out
SIS, whereas the drop arm sign was more useful for ruling in SIS(15)
Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure
Insufficient evidence was foundin an 2013 Cochrane review of 33 studies (4002 shoulders in 3,852 patients) to determine
which testfor SIS is most accurate(44)

Assessment/Plan of Care
Contraindications/precautions
Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patients physician. The treatment
summary below is meant to serve as a guide, not to replace orders from a physician or a clinics specific protocols
Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regards to
modalities. Rehabilitation professionals should always use their professional judgment when using modalities
Avoid ultrasound over growth plates in pediatric/adolescent patients
Cryotherapy contraindications(16)
Raynauds syndrome
Medical instability
Cryoglobulinemia
Cold urticaria
Paroxysmal cold hemoglobinuria
Avoid applying cold over superficial nerves, areas of diminished sensation or poor circulation, or with slow-healing
wounds
Cryotherapy precautions(16)
Use caution with patients who are hypertensive as cold can cause a transient increase in blood pressure; discontinue
treatment if there is an elevation in blood pressure
Use caution with patients who are hypersensitive to cold
Avoid aggressive treatment with cold modalities over an acute wound
Use of cryotherapy with patients who have an aversion to cold may be counterproductive if being used to promote muscle
relaxation and decrease in pain
Superficial heat contraindications(16)
Decreased circulation

Decreased sensation
Acute/subacute traumatic and inflammatory conditions
Skin infections
Impaired cognition or language barrier
Malignant tumors
Tendency for hemorrhage or edema
Heat rubs
Whirlpool contraindications(16)
Severe epilepsy
Certain dermatologic conditions
Surface infections
Uncontrolled bowels
Acute rheumatoid arthritis
Venous ulcers
Tissues devitalized by x-ray therapy
Peripheral vascular disease
Decreased thermal sensation
Respiratory dysfunctions
Cardiac dysfunctions
Active bleeding
Malignancies
Previously existing fever
Acute inflammatory conditions
Whirlpool precautions (* only relevant if entire body is immersed)(16)
Impaired sensation
Confusion or impaired cognition
Recent skin grafts
Certain medications
Alcohol consumption*
Decreased strength/ROM/endurance/balance*
Urinary incontinence*
Fear of water*
Respiratory problems
Pregnancy*
Multiple sclerosis*
Poor thermal regulation*
Seasickness
Edema, when warm/hot water immersion
Electrotherapy contraindications/precautions (in some cases, when approved by the treating physician, electrotherapy
may be used under some of the circumstances listed below when benefits outweigh the perceived risk)(16)
Stimulation through or across the chest
Cardiac pacemakers
Implanted stimulators
Over carotid sinuses
Uncontrolled hypertension/hypotension
Peripheral vascular disease
Thrombophlebitis
Pregnancy
Over pharyngeal area
Diminished sensation
Acute inflammation
Seizure history

Confused patients
Immature patients
Obesity
Osteoporosis
Cancer
Used in close proximity to diathermy treatment
Therapeutic ultrasound: Evidence is lacking to support the use of therapeutic ultrasound for management of patients with
SIS(17)
Diagnosis/need for treatment: SIS/shoulder pain, weakness, and pain-restricted ROM; reduced functional capacity for
ADLs, work, and/or sport
Rule out
Acromioclavicular joint arthritis
Internal impingement (dead arm syndrome)
Labral tear
Glenohumeral joint dislocation
Thoracic outlet syndrome
Cardiac event
Coracoid impingement
Bicipital tendonitis
Primary rotator cuff tendinitis (pain on isometric strength testing outside impingement position)
Rotator cuff tear
Cervical (C5-6) radiculopathy
Glenohumeral joint arthritis
Adhesive capsulitis (passive and active ROM equally restricted)
Suprascapular nerve entrapment(17)
Prognosis
Most patients with uncomplicated SIS return to their regular activitiesin 8 to 12 weeks after either conservative
management or postoperative care(2,3,18)
The average time until return to full work duty after arthroscopic subacromial decompression for SIS was 11.1 weeks in a
retrospective study (N=166) in Belgium. Patients performing manual labor typically had a longer period of sick leave (12
weeks) than other employees (8 weeks)(18)
Long-term outcomes appear to be similar for surgical and physical therapy management of SIS, based on a 2008 Cochrane
review and a 2009 systematic review(19,20)
Results of a 2011 systematic review of 5 RCTs indicate that as an initial approach to patients with SIS, surgery does not
improve prognosis more than conservative management(3)
Referral to other disciplines:Orthopedic surgeon for suspected fracture, rotator cuff tear, pseudo-locking, and recalcitrant
cases.(4,5) Occupational therapist (OT) for disability in ADLs
Treatment summary
Manual therapy
Manual therapy does not appear more effective than other conservative interventions in the treatment of patients with SIS,
based on a 2009 systematic review of 3 RCTs(21)
Authors of a 2004 systematic review of 12 trials found that therapeutic exercise and joint mobilizations each effectively
restored function in patients with SIS, whereas ultrasound was of no benefit.(22) This review supports similar findings in a
2003 Cochrane review of 26 trials(23)

In a 2010 case study, manual therapy techniques, including thrust and nonthrust spinal mobilization and soft tissue
mobilization of the posterior and inferior glenohumeral joint, were successful at reducing patients pain and improving
functional outcomes. Manual techniques were coupled with stretching and strengthening exercises
Manual therapy coupled with therapeutic exercise may be more effective than therapeutic exercise alone in the treatment
of patients with SIS, based on an RCT (N=52) in the U.S.(24)

- Participants were randomized to Group 1, which received therapeutic exercise (6 sessions over 3 weeks) only, or
Group 2, which received a similar course of therapeutic exercise coupled with manual therapy. Results (between-group
comparisons) indicate Group 2 had significantly greater pain reduction and improvement in shoulder function
- According to a 2014 systematic review, no further high-quality studies have investigated whether combining manual
therapy with exercise therapy improves desired outcomes for patients with SIS more than exercise therapy alone(51)
Modalities
Laser therapy
- Low-level laser therapy (LLLT) in combination with a home exercise program may not offer any considerable
therapeutic advantage over a home program alone for patients with SIS, based on an RCT (N=44) in Turkey(25)
- Participants were randomized to Group 1, which received gallium-arsenide laser therapy and a 12-week home exercise
program,or Group 2, which received an 12-week home exercise program similar to group 1
- Results (between-group comparisons) at
- 2 weeks from baseline
- showed no significant differences in mean changes in night pain and Shoulder Pain and Disability Index (SPADI)
scores or in
- University of California, Los Angeles (UCLA) shoulder scale scores between the groups.
- At 12 weeks from baseline,
- Group 1 had a significantly greater reduction in night pain, but the
- UCLA shoulder scale scores and SPADI scores did not differ significantly between groups
- Authors of a RCT (N=60) in Turkey found that LLLT was not more effective than placebo LLLT for the treatment of
SIS(26)
- High-intensity laser therapy (HILT) may be more effective than ultrasound therapy in the short-termtreatment of patients
with SIS, based on an RCT (N=70) in Italy(27)
- Participants were randomized to 1 of 2 groups
- Group 1 received HILT in 10 sessions over 2 weeks
- Group 2 received therapeutic ultrasound in 10 sessions over 2 weeks
- Results (between-group comparisons; immediately after 2-week intervention period)
- Group 1 reported a significantly greater reduction in pain (VAS scores) compared to group 2
- Group 1 had significantly greater improvement in Constant-Murley Scale (CMS) scores for pain, function, strength,
and ROM
- Group 1 had significantly greater improvement in Simple Shoulder Test scores for pain and function
Pulsed electromagnetic field (PEMF) therapy
- PEMF in addition to standard conservative therapy does not appear to offer additional therapeutic benefit for patients
with SIS, based on a double-blind RCT (N=46) in Turkey(28)
Evidence is lacking to support the use of ultrasound therapy for treatment of SIS(17,20,22)
There is insufficient evidence to support phonophoresis, iontophoresis,(29) or extracorporeal shockwave therapy for
management of SIS(30)

Therapeutic exercise
A comprehensive physical-therapy-based program for shoulder rehabilitation may include four phases(2)
- The initial phase: protection, icing for pain and edema, and activity modification
- Early rehabilitation: manual therapy that includes joint and soft tissue mobilization to address shoulder joint stiffness,
muscle shortening, and scapular dyskinesis. Pendulum exercise, active assisted ROM,postural re-education
- Late rehabilitation: restoration of active ROM and glenohumeral motion, after which resistance and proprioception
retraining exercises are introduced
- The functional phase: specific exercises (see below) for high-functioning patients to further build strength and
endurance and scapulohumeral coordination exercises aimed at restoring fitness for work and sports
A 2010 systematic review of 8 RCTs found moderate evidence that exercise may effectively reduce shoulder pain and
improve function in patients with SIS (31)
Similarly, a 2014 systematic review of 10 RCTs reported moderate evidence that a program of exercise therapy is
effective for reducing pain and disability in patients with SIS over the short term(51)

Findings of a 2010 systematic review, a 2011 review of electromyographic (EMG) studies, and an RCT (N=40) in Turkey
support the use of specific shoulder exercises for reducing pain and/or improving function in patients with SIS(32,33,34)
- Stretching exercises should target the upper trapezius muscle and posterior glenohumeral capsule
- Strengthening exercises should target the rotator cuff muscles through the full/painless ROM and scapular stabilizers,
including the serratus anterior
Authors of an RCT (N=102) in Sweden found that a specific regimen of strengthening eccentric exercises for the rotator
cuff and concentric/eccentric exercises for the scapula stabilizers in combination with manual mobilization effectively
reduced pain and improved shoulder function in patients with persistent SIS(35,45)
- 95% of participants had SIS for over 6 months and failed earlier conservative treatment
- Participants were randomized to 1 of 2 groups
- Specific exercise group received 5 to 6 individualized and guided treatment sessions combined with manual
mobilization over 12 weeks
- Control group 5 to 6 nonspecific exercises for the neck and shoulder over 12 weeks
- Both groups performed home exercises twice a day for the 12 weeks
- The following significant differences on follow-up favored the specific exercise group:
- Higher CMS assessment score (24 points vs. 9 points)
- Reported successful outcome (69% vs. 24%)
- Fewer chose to undergo surgery (20% vs. 63%)
Scapular stabilization exercises
- The following shoulder exercises may target specific periscapular muscles to elicit their highest maximum voluntary
isometric contraction recruitment, based on a review of 22 EMG studies(35)
- Resisted prone shoulder extension with elbow in full extension (targets middle trapezius)
- Resisted prone horizontal abduction at 90 with full external rotation (targets middle trapezius)
- Isometric low row patient stands (with shoulder and elbow in neutral position) and applies pressure with palm
of hands facing posteriorly on immovable surface (such as a doorway), while attempting to retract and depress the
scapula (targets low trapezius and serratus anterior)
- Inferior glide patient sits with arm abducted to 90, wrist neutral position, elbow extended, and applies pressure with
fist clenched on a full supportive surface, while attempting to retract and depress the scapula (targets low trapezius and
serratus anterior)
- Push-up plus patient lies prone with hands shoulder-width apart (in push-up position) and chest on/near the floor;
then extends elbows as in standard push-up; then continues to rise up by protracting the scapula (targets serratus
anterior)
- Dynamic hug resisted horizontal flexion with both shoulders at a constant 60 of humeral elevation while hands
follow an imaginary arc until maximum protraction is attained (targets serratus anterior)
Authors of a 2012 systematic review and meta-analysis (1,162 participants with SIS) found moderate evidence that
therapeutic exercise (scapular stabilization, rotator cuff strengthening, and exercises through range to 90 abduction)
decreased pain at 6 to 12 weeks follow-up and improved patient-reported function beyond 12 weeks(40,41)
Authors of a 2014 systematic review found evidence was lacking to conclude that exercise therapy for repositioning the
scapula to an idealized normal posture improved shoulder symptoms and function patients with SIS(42)
A home exercise program may be effective in reducing pain and increasing function for individuals (working in the
construction industry) with SIS, based on an RCT (N=67 male construction workers) in the United States(9)
- Participants were randomized to 1 of 2 groups
- Intervention group received a home exercise program (stretching and strengthening) for 8 weeks
- Control group did not receive an intervention
- Results show the intervention group had significantly greater improvements in Shoulder Rating Questionnaire (SRQ)
score, shoulder satisfaction score, pain, and patient-reporteddisability
A standard upper extremity progressive concentric resistance exercise program may reduce pain and increase function in
individuals with SIS compared to no intervention, based on an RCT (N=60) in Brazil(36)
- Participants were randomized to Group 1, which received progressive resistance exercise training 2 times per week for 2
months, or to Group 2, which received no intervention and remained on a waiting list
- Results showed significantly greater improvements in the intervention group for pain (VAS), shoulder function (DASH
Outcome Measure), and quality of life (Health Survey Short-Form 36)

Evidence is lacking to support the use of eccentric-loadingexercise therapy in the treatment of patients with SIS(52)
A high-dose exercise regimen may be more effective than a low-dose regimen for patients with persistent SIS due to
supraspinatus tendon impingement, based on an RCT (N=61) in Norway(37)
- Participants were randomized to Group 1, which received high-dose exercise therapy (HDET, 11 supervised resistance
and mobility exercises 3 sets of 30 for each exercise plus ergometer cycling for about 40 minutes [spread out through
treatment session] at 70% to 80% of estimated maximum heart rate [HR]) 3 times per week for 3 months), or to Group
2, which received low-dose exercise therapy (6 of the HDET groups exercises 2 sets of 10 for each exercise plus
cycling for about 10 minutes at 70-80% of maximum HR) 3 times per week for 3 months
- The HDET group had significantly greater improvements for pain (VAS), ROM, SRQ, patient satisfaction with
outcome, and strength in shoulder abduction and external rotation. Neither group showed a significant change in the
thickness of the impinged tendon on MRI
.
Problem

Goal

Intervention

Expected Progression

Home Program

Pain and tenderness

_
_
Joint and soft tissue
swelling

Relief of pain and

tenderness
_
_
Resolve edema

Physical agents and

N/A
mechanical modalities
_
Cryotherapy for pain
and edema

Recommend a home
program for pain/
edema management
as indicated and
appropriate for each
unique patient

Poor posture

Normal posture

Functional training
_
Functional
strengthening and
scapular stabilization
exercises for upper
extremity movements
in daily activities
_
_
Patient education
_
For correct postural
alignment at rest and
during activity

Implement a home
program to address
faulty posture as
indicated

Restricted shoulder and Improve shoulder and

scapulothoracic joint
scapulothoracic joint
mobility
mobility

Progress as indicated

Manual therapy
Progress as indicated
_
Focus on resolving
posterior and inferior
shoulder capsule
hypomobility, and neck
and shoulder muscle
tightness
_
_
Physical agents and
mechanical modalities
_
Dry or moist heat to
relax muscles prior to
manual therapy

Home exercise
program
_
May provide illustrated
unassisted stretches
(for deltoids, internal
and external rotators,
scapular elevators and
rotators) and rotatorcuff strengthening
exercises

Scapular dyskinesis

Normalize scapular
kinematics

Functional training
_
Exercises to retrain
abnormal scapular

Progress as indicated

Implement a home
program to address
scapular dyskinesis as
indicated

Therapeutic exercises Progress as indicated

_
Focus on stretching the
anterior and posterior

Implement a home
program to address
shoulder weakness as
indicated

kinematics(35)
Shoulder and shoulder
girdle muscle weakness
_
_
Proprioception deficits

Improve strength at and

around the shoulder
_
_
Normal proprioception
and kinesthesis

shoulder muscles(2)
and strengthening the
rotator cuff, shoulder
adductors, and scapular
stabilizers
_
_
Resistance tubing
exercises appear
effective for activating
targeted shoulder
muscles used in
overhead activities,
such as throwing(38,39)
_
_
Posture awareness
exercises, as indicated

Reduced shoulder
function for work
or sports; risk
of disability; no
independent self-care
program

Restore functional
strength and
performance for work
or sports
_
_
Return to work or sport;
independent self-care
program

Functional training
Progress as indicated
_
Isokinetic and
plyometric exercises to
regain work or sports
fitness

Desired Outcomes/Outcome Measures

Desired outcomes
Relief of pain and tenderness
Resolved edema
Improved shoulder and scapulothoracic joint mobility and kinematics
Improved shoulder and scapulothoracic strength
Normal proprioception/kinesthesis
Restored functional strength and performance for work or sports
Independent self-care program
Outcome measures
VAS
Goniometry
MMT
Reassessment of posture, proprioception, and kinematics, as indicated

Implement a home
program to assist in
regaining the capacity
to return to work as
indicated

 Shoulder function (e.g., CMS, SRQ, Western Ontario Rotator Cuff Index, DASH Outcome Measure, Global Rating of
Change Scale)
Indicators of patient satisfaction (e.g., ADLs, return to work or sport)

Maintenance or Prevention
Continue therapeutic exercises to maintain shoulder fitness for work or sport, to promote normal kinematics, and to prevent
recurrence

Patient Education
Shoulderdoc.co.uk Web site, Subacromial Impingement, http://www.shoulderdoc.co.uk

Coding Matrix
References are rated using the following codes, listed in order of strength:
M Published meta-analysis
SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)

RV Published review of the literature

RU Published research utilization report
QI Published quality improvement report
L Legislation

C Case histories, case studies

PGR Published government report

G Published guidelines

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

References
1. Umer M, Qadir I, Azam M. Subacromial impingement syndrome. Orthop Rev (Pavia) . 2012;4(2):e18. doi:10.4081/or.2012.e18. (RV)
2. Borsa PA, Laudner KG, Sauers EL. Mobility and stability adaptations in the shoulder of the overhead athlete: a theoretical and evidence-based perspective. Sports Med.
2008;38(1):17-36. (RV)
3. Gebremariam L, Hay EM, Koes BW, Huisstede BM. Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic review.
Arch Phys Med Rehabil. 2011;92(11):1900-1913. (SR)
4. Goldberg SS, Bigliani LU. Shoulder impingement revisited: advanced concepts of pathomechanics and treatment. Instr Course Lect. 2006;55:17-27. (RV)
5. Chang WK. Shoulder impingement syndrome. Phys Med Rehabil Clin N Am. 2004;15(2):493-510. (RV)
6. Neer CSII. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77. (RV)
7. Zanca GG, Oliveira AB, Saccol MF, Ejnisman B, Matiello-Rosa SM. Functional torque ratios and torque curve analysis of shoulder rotations in overhead athletes with and
without impingement symptoms. J Sports Sci. 2011;29(15):1603-1611. (R)
8. Meister K. Injuries to the shoulder in the throwing athlete. Part one: Biomechanics/pathophysiology/classification of injury. Am J Sports Med. 2000;28(2):265-275. (R)
9. Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occup Environ Med. 2003;60(11):841-849. (R)
10. Yanai T, Hay JG. Shoulder impingement in front-crawl swimming: II. Analysis of stroking technique. Med Sci Sports Exerc. 2000;32(1):30-40. (R)
11. Kibler WB, Uhl TL, Maddux JWQ, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg.
2003;11(6):550-556. (R)
12. Cools AM, Witvrouw EE, Mahieu NN, Danneels LA. Isokinetic scapular muscle performance in overhead athletes with and without impingement symptoms. J Athl Train.
2005;40(2):104-110. (R)
13. Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal
impingement. Am J Sports Med. 2006;34(3):385-391. (R)
14. Hegedus EJ, Goode A, Campbell S. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42(2):80-92.
(SR)
15. Algunaee M, Gavin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil.
2012;93(2):229-236. (SR)
16. Michlovitz JL, Bellew JW, Nolan TP Jr, eds. Modalities for Therapeutic Intervention. 5th ed. Philadelphia, PA: FA Davis; 2012. (GI)
17. Walsworth MK, Mills JTIII, Michener LA. Diagnosing suprascapular neuropathy in patients with shoulder dysfunction: a report of 5 cases. Phys Ther. 2004;84(4):359-372. (R)
18. Luyckx L, Luyckx T, Donceel P, Debeer P. Return to work after arthroscopic subacromial decompression. Acta Orthop Belg. 2011;77(6):737-746. (R)
19. Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database Syst Rev. 2008:1. Art No: CD005619.
doi:10.1002/14651858.CD005619.pub2. (SR)
20. Kromer TO, Tautenhahn UG, de Bie RA, Staal JB, Bastiaenen CH. Effects of physiotherapy in patients with shoulder impingement syndrome: a systematic review of the
literature. J Rehabil Med. 2009;41(11):870-880. (SR)
21. Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: a systematic review. Man Ther.
2009;14(5):463-474. (SR)
22. Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther.
2004;17(2):152-164. (SR)
23. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003:2. Art No: CD004258.
doi:10.1002/14651858.CD004258.pub2. (SR)
24. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys
Ther. 2000;30(3):126-137. (RCT)
25. Bal A, Eksioglu E, Gurcay E, Gulec B, Karaahmet O, Cakci A. Low-level laser therapy in subacromial impingement syndrome. Photomed Laser Surg. 2009;27(1):31-36. (RCT)
26. Yeldan I, Cetin E, Ozdincler AR. The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome. Disabil Rehabil.
2009;31(11):935-940. (RCT)
27. Santamato A, Solfrizzi V, Panza F. Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of people with subacromial impingement
syndrome: a randomized clinical trial. Phys Ther. 2009;89(7):643-652. (RCT)

28. Aktas I, Akgun K, Cakmak B. Therapeutic effect of pulsed electromagnetic field in conservative treatment of subacromial impingement syndrome. Clin Rheumatol.
2007;26(8):1234-1239. (RCT)
29. Perron M, Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcifying tendonitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil.
1997;78(4):379-384. (RCT)
30. Hsu CJ, Wang DY, Tseng KF, Fong YC, Hsu HC, Jim YF. Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. J Shoulder Elbow Surg. 2008;17(1):55-59.
(RCT)
31. Kelly SM, Wrightson PA, Meads CA. Clinical outcomes of exercise in the management of subacromial impingement syndrome: a systematic review. Clin Rehabil.
2010;24(2):99-109. (SR)
32. Dewhurst A. An exploration of evidence-based exercises for shoulder impingement syndrome. Int Musculoskelet Med. 2010;32(3):111-116. (SR)
33. Cricchio M, Frazer C. Scapulothoracic and scapulohumeral exercises: a narrative review of electromyographic studies. J Hand Ther. 2011;24(4):322-334. (RV)
34. Baskurt Z, Baskurt F, Gelecek N, zkan MH. The effectiveness of scapular stabilization exercise in the patients with subacromial impingement syndrome. J Back Musculoskelet
Rehabil. 2011;24(3):173-179. (RCT)
35. Holmgren T, Bjrnsson Hallgren H, berg B, Adolfsson L, Johansson K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement
syndrome: randomised controlled trial. BMJ. 2012;344:e787. (RCT)
36. Lombardi I, Magri AG, Fleury AM, Da Silva AC, Natour J. Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
Arthritis Rheum. 2008;59(5):615-622. (RCT)
37. Osteras H, Torstensen TA, Haugerud L, Osteras BS. Dose-response effects of graded therapeutic exercises in patients with long-standing subacromial pain. Adv Physiother.
2009;11(4):199-209. (RCT)
38. Laudner KG, Myers JB, Pasquale MR, Bradley JP, Lephart SM. Scapular dysfunction in throwers with pathologic internal impingement. J Orthop Sports Phys Ther.
2006;36(7):485-494. (C)
39. Myers JB, Pasquale MR, Laudner KG, Sell TC, Bradley JP, Lephart SM. On-the-field resistance-tubing exercises for throwers: an electromyographic analysis. J Athl Train.
2005;40(1):15-22. (R)
40. Hanratty CE, McVeigh JG, Kerr DP, et al. The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis. Semin
Arthritis Rheum . 2012;42(3):297-316. (SR)
41. Michaleff ZA, Kamper SJ. PEDro systematic review update: the effectiveness of physiotherapy exercises in subacromial impingement syndrome. Br J Sports Med .
2013;47(14):927-28. (RV)
42. Ratcliffe E, Pickering S, McLean S, Lewis J. there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Br J Sports Med.
Advance online publication. August 2014;48(16):1251-6. doi:10.1136/bjsports-2013-092389. (SR)
43. van der Sande R, Rinkel WD, Gebremariam L, Hay EM, Koes BW, Huisstede BM. Subacromial impingement syndrome: Effectiveness of pharmaceutical
interventions-nonsteroidal anti-inflammatory drugs, corticosteroid, or other injections: A systematic review. Arch Phys Med Rehabil . 2013;94(5):961-976. doi:10.1016/
j.apmr.2012.11.041. (SR)
44. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon, or labrum that may accompany impingement.
Cochrane Database Syst Rev . April 30, 2013. Art No: CD007427. doi:10.1002/14651858.CD007427.pub2. (SR)
45. Lewis JS. A specific exercise program for patients with subacromial impingement syndrome can improve function and reduce the need for surgery. J Physiother .
2012;58(2):127. doi:10.1016/S1836-9553(12)70093-0. (RV)
46. Lopes AD, Timmons MK, Grover M, Ciconelli RM, Michener LA. Visual scapular dyskinesis: kinematics and muscle activity alterations in patients with subacromial impingement
syndrome. Arch Phys Med Rehabil . 2015;96(2):298-306. doi:10.1016/j.apmr.2014.09.029. (R)
47. Bhattacharyya R, Edwards K, Wallace AW. Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study. BMC
Musculoskelet Disord. September 29, 2014;15:324. doi:10.1186/1471-2474-15-324. (R)
48. Svendsen SW, Christiansen DH, Haahr JP, Andrea LC, Frost P. Shoulder function and work disability after decompression surgery for subacromial syndrome: a randomized
controlled trial of physiotherapy exercises and occupational medical assistance. BMC Musculoskelet Disord. June 21, 2014;15:215. doi:10.1186/1471-2474-15-215. (RCT)
49. Christiansen DH, Falla D, Frost P, Frich LH, Svendsen SW. Physiotherapy after subacromial decompression surgery: development of a standardized exercise intervention.
Physiotherapy. Advance online publication. January 21, 2015;pii:S0031-9406(15)00008-5. doi:10.1016/j.physio.2015.01.004. (RCT)
50. Kelle B, Kozanoglu E. Low-level laser and local corticosteroid injection in the treatment of subacromial impingement syndrome: a controlled clinical trial. . Clin Rehabil .
2014;28(8):762-71. (R)
51. Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BM. Subacromial impingement syndromeeffectiveness of physiotherapy and manual therapy.
Br J Sports Med. 2014;48(16):1202-08. doi:10.1136/bjsports-2012-091802. (SR)
52. Dervey E, Marshall S, Rouse S, Bernhardsson S, Camargo PR, McVeigh JG. Eccentric exercise therapy in the treatment of subacromial impingement syndrome: a critical
review. Intern J Ther Rehabil . 2014;21(7):338-45. (RV)