Subacromial shoulder pain

Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

Subacromial shoulder pain – A shoulder pain in search of a diagnosis

If you are reading this article you are likely someone with a job where your hands are constantly over your head, such as a home and commercial painter, landscaper, warehouse worker or you are yourself, or the parent of a swimmer or an athlete where a lot of throwing is involved. You are also likely to be someone who has had these shoulder problems explained to you as an overuse injury due to overhead motion.

Explanations are helpful. But if you have a job where you have to keep moving your hands over your head you need some type of solution. Well, at least you know why you have a lot of pain in the front of your shoulder towards the outside. You have subacromial shoulder pain. You may also have a lot of instability or looseness in your shoulder or you may feel that your shoulder is trying to lock itself up. Many times this occurs with an “on and off” frequency of looseness and tightness. You may also feel like you are losing muscle strength even to the point of dropping things out of your hand.

The situation is getting progressively worse, not better.

The difficulties in understanding subacromial shoulder pain or subacromial impingement syndrome

Frustration mounts for the patient when treatments are not helping. You did not need us to tell you that. If you are reading this article, it is likely that you have been on a course of conservative treatments for some time and you have reached a new degree of urgency in finding your solution. Sometimes the doctors are frustrated too. It almost always has to do with not getting to the true root cause of your problem. If you do not get to the root of the problem, the problem remains.

The difficulties in understanding subacromial shoulder pain are described by doctors from the Department of Orthopedics, Brigham and Women’s Hospital, and Tufts University School of Medicine writing in The Journal of the American Academy of Orthopaedic Surgeons(1).

Is it really a Swimmer’s Shoulder?

“Coach, and clinician (must) be aware of the discerning characteristics among these different injuries to ensure a proper diagnosis and treatment plan to aid the swimmer in his or her return to competition.”

Swimmer’s shoulder is a broad term often used to diagnose shoulder injury obviously in swimmers. However, research has shed light on several specific shoulder injuries that often are incurred by the competitive swimmer.

The researchers of this study conclude: “An understanding of the mechanics of the swim stroke, in combination with the complex static and dynamic properties of the shoulder, is essential to the comprehension and identification of the painful swimmer’s shoulder. It is important for the athlete, coach, and clinician to be aware of the discerning characteristics among these different injuries to ensure a proper diagnosis and treatment plan to aid the swimmer in his or her return to competition.”

What are we seeing in this image?

This illustration demonstrates shoulder impingements caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement, the structures within the glenohumeral joint themselves have impinged. These conditions can be caused by excessive shoulder instability.

This illustration demonstrates shoulder impingements as caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement the structures within the glenohumeral joint themselves are impinged. These conditions can be caused by excessive shoulder instability.

Rest, Ice, Anti-inflammatories, and Cortisone have not helped generations of American swimmers, pitchers, or patients with Subacromial shoulder pain

Swimmer’s shoulder has been a problem for a long time. In 1980 Famed orthopedic surgeon Frank Jobe, the same surgeon who invented the Tommy John Surgeryjoined with Dr. Allen Richardson and Dr. H. Royer Collins from the National Athletic Health Institute, Inglewood, California to write in the American Journal of Sports Medicine (3) of the problem of swimmer’s shoulder in America’s best competitive swimmers:

These treatment options did not seem to have helped nearly two generations of swimmers or pitchers

Writing in the American Journal of Sports Medicine,(4) doctors from the Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California wrote of applying The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score to define functional and performance measures of the upper extremity in overhead athletes. To date, no study has investigated the baseline functional scores for swimmers actively competing in the sport. What the doctors were doing was to use The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score to come up with baseline measurements. They were surprised by what they found:

When the problem is not inflammation but instability

Our clinic has published numerous studies on the problems of shoulder joint instability and inflammation. Some of this research is summarized below. The simple idea is that instability causes inflammation. If you do not correct the instability you can not correct the inflammation. Anti-inflammatory medications can only make the situation worse in the long run. To treat the problems of the swimmer’s shoulder, in our opinion, the swimmer must treat the problems of instability. This, of course, can be addressed in two ways, surgical and non-surgical treatment. Let’s start exploring.

Almost 40 years later – For many, exercise and physical therapy not helpful either

Supportive therapies to the standard care outlined in the near 40 years of research we are discussing are physical therapy and core strength conditioning. Here we may offer an answer to your question, why isn’t physical therapy helping me? Let’s say it again: When the problem is not inflammation, but instability.

Here is a 2018 study from the Department of Orthopedic Surgery, Copenhagen University Hospital. (5) It may explain the ineffectiveness of your physical therapy.

Here are the learning points:

The surgical option called into question, criticism from surgeons

In 2010 Klaus Bak of the Parken’s Private Hospital, Copenhagen, Denmark wrote in the Clinical Journal of Sports Medicine: (6)

When discussing surgical options for Swimmer’s shoulder, it is best to bring in surgical opinions. In our clinic, we offer non-surgical regenerative treatments. In many patients we see, surgery can be avoided. Below we will also discuss the scenario when the shoulder is “too far gone,” and surgery will be needed.

The success of the surgery may not have been the surgery itself but rather, the placebo effect. The idea that arthroscopic surgery for shoulder impingement was a valueless procedure

The idea that arthroscopic surgery for shoulder impingement was a valueless procedure was put worth in November 2017, when one of the leading medical journals in the world, The Lancet, (7) reported the findings of 51 surgeons operating at 32 hospitals around the United Kingdom.

In this study, 313 patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were considered eligible for arthroscopic surgery. These same patients had previously completed a non-operative management program that included exercise therapy and at least one steroid injection.

The 313 patients were then divided into three groups:

  1. Arthroscopic subacromial decompression surgery group (106 patients),
  2. investigational arthroscopy surgery only (103 patients),
  3. or no treatment (104 patients)

Here are the results of the researchers:

And finally, in the study recap:

“During the past three decades, clinicians and patients with subacromial shoulder pain have accepted minimally invasive arthroscopic subacromial decompression surgery in the belief that it provides reliable relief of symptoms at low risk of adverse events and complications. However, the findings from our study suggest that surgery might not provide a clinically significant benefit over no treatment.”

In an accompanying article in The Lancet, Netherland University researchers Berend W Schreurs and Stephanie L. van der Pas wrote:(8)

“The findings send a strong message that the burden of proof now rests on those who wish to defend the standpoint that shoulder arthroscopy is more effective than non-surgical interventions. Hopefully, these findings from a well-respected shoulder research group will change daily practice. The costs of surgery are high, and although the low occurrence of complications might suggest that the surgery is benign, there is no indication for surgery without possible gain.”

In other words, don’t have a surgery that does not help.

This study was backup in 2018 when, in a landmark study, Finnish researchers showed that arthroscopic surgeries of the shoulder are useless for patients with “shoulder impingement.”

This is the simple conclusion of this groundbreaking study that appeared in the British Medical Journal, July 19, 2018 (9)

“The results of this randomized, placebo surgery controlled trial show that arthroscopic subacromial decompression provides no clinically relevant benefit over diagnostic arthroscopy in patients with shoulder impingement syndrome. The findings do not support the current practice of performing subacromial decompression in patients with shoulder impingement syndrome.”

There are times when tearing of the rotator cuff tendons are so catastrophic, because preventive treatment was delayed or anti-inflammatory treatments went on too long, that the swimmer must make a decision on whether to go through with more invasive surgery, to address the rotator cuff or to address the options surrounding a bursectomy, the surgical removal of the shoulder bursa (bursae).

  1. They are going to continue swimming
  2. How long can they allow themselves to recover in terms of months perhaps years?
  3. Is surgery likely to be of help?
  4. Will the surgery leave you with impaired strength and make itself useless to you for the goal of returning to swimming?

Doctors at the Department of Orthopaedic Surgery, University of Kentucky School of Medicine wrote this StatPearls,(10) part of the National Center for Biotechnology Information internet library.

Arthroscopic bursectomy

An arthroscopic bursectomy is usually offered as part of the overall “clean-up” or repair of the damaged shoulder joint. The bursectomy may be done during rotator cuff repair or in the context of this article, within a subacromial decompression procedure. Sometimes Arthroscopic bursectomy is performed as a stand-alone or primary procedure in the treatments of shoulder bursitis that is no longer responding to anti-inflammatory or corticosteroid management. During the surgery, if it is determined that even with the complete removal of the inflamed bursa that the shoulder is still a threat of continued impingement, then a subacromial decompression may be performed.

Some people do have good success with Arthroscopic bursectomy, but not everyone. A December 2020 study in the Journal of shoulder and elbow surgery (11) suggested that  “varying results after surgery in patients with subacromial pain syndrome have raised the question on whether there is a subgroup of patients that can benefit from surgery.” Note: As mentioned above certain surgeries remain controversial in that they can make the patient’s situation worse). In this study, the researchers found: “arthroscopic bursectomy is less effective in patients with subacromial pain syndrome with a degenerative shoulder. This finding suggests that an improved treatment effect of arthroscopic subacromial bursectomy can be expected in patients with chronic subacromial pain syndrome if intra-articular pathologies such as glenohumeral osteoarthritis are sufficiently excluded.” In other words in an unstable, degenerative shoulder, subacromial bursectomy will not be effective for many.

Non-surgical treatment addressing shoulder instability, wear and tear, and inflammation in the swimmer

At our clinic, we have provided more than 28 years of service to patients seeking non-surgical options to get them back to their sport. In this section, we will show our research and research of other clinicians in offering non-surgical solutions to “Swimmer’s Shoulder.”

Part of the reason for arthroscopic surgical failure is that it does not properly address the problems of hypermobility and shoulder instability. Possibly, because you are removing tissue in the shoulder during surgical procedures, the problem of instability becomes worse.

The problem of how to deal with this instability was reflected in a study from the Hospital for Special Surgery, published in 2018 in the journal Current Reviews in Musculoskeletal Medicine. (12)

“Swimmers may develop increased shoulder laxity over time due to repetitive use. Such excessive laxity can decrease passive shoulder stability and lead to rotator cuff muscle overload, fatigue, and subsequent injury in order to properly control the translation of the humeral head (the movement of the shoulder).

A look at physical therapy

Like the world of regenerative medicine, physical therapists seek to prevent further destruction of the swimmer’s shoulder with a rehabilitation plan.

A review published in the North American Journal of Sports Physical Therapy, (13) gives a good outline of the challenges facing physical therapists in helping the patient with a swimmer’s shoulder.

“Physical therapists involved in the treatment of competitive swimmers should focus on prevention and early treatment, addressing the impairments associated with this condition, and analyzing training methods and stroke mechanics.”

“Swimmers shoulder is a condition that may be prevented with adequate preseason screening that can identify impairments and training errors that may lead to symptoms. If a swimmer does become symptomatic during the season, the physical therapist should identify the most likely impairments or training errors and rule out any significant tissue pathology that would warrant a referral to an orthopedic surgeon. A comprehensive rehabilitation program usually includes strengthening of the rotator cuff and scapular stabilizers, stretching anterior chest musculature that may be shortened, and implementing activity modification so the athlete can still participate in the sport.”

Non-athletes don’t want to exercise their shoulder

Older patients and those patients who no longer compete at a high level or have given up sport have mixed feelings about how much exercise can help their Subacromial shoulder pain. Many do not comply to exercise programs given to them to do at home. A January 2021 study (14) notes:

In other words, patients are not adhering to the exercise program they were given. Why? In some patients we see, there is a fatigue in constantly doing treatments or therapies that the patient sees as not helping.  In this study, an exercise program was introduced to the study participants “who had received conservative treatment during the past 6 months.” What did these researchers find? Recruitment (simply getting patients to participate in an exercise study) and adherence to the self-managed exercise program were both below the anticipated level.

A look at Prolotherapy and Platelet Rich Plasma Therapy for Shoulder Instability and Pain

At our clinic, we frequently work with physical therapists who are treating athletes. For physical therapy to achieve maximum benefit in the patient with Subacromial shoulder pain, the shoulder capsule itself has to be capable of providing muscle resistance. If the tendons of the rotator cuff and the ligaments that hold the bone structure of the shoulder are compromised, as seen by excessive shoulder instability and hypermobility, including partial dislocation, the shoulder may not be able to provide the resistance needed for maximum gain.

When it comes to seeking non-surgical options in the treatment of difficult to treat or chronic shoulder pain, patients frequently find themselves researching our injection treatments of Comprehensive Prolotherapy incorporating various treatments to include Platelet Rich Plasma Therapy and Dextrose Prolotherapy.

These injection techniques stimulate the repair of injured tissue and have been cited in the research as curative for chronic pain.

Platelet Rich Plasma Therapy is an injection treatment that re-introduces your own concentrated blood platelets into areas of chronic joint and spine deterioration, more commonly referred to as PRP. There are many orthopedic surgeons now offering this treatment.

For the competitive swimmer or worker who does a physically demanding job requiring overhead movements, we utilize a more aggressive approach as demonstrated in the video.

In this video, a general demonstration of Prolotherapy and PRP treatment is given.
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:

No standard way to offer PRP treatment for shoulder impingement causes controversy

The medical literature is filled with studies suggesting the PRP treatment is effective for a myriad of shoulder problems. PRP works because it addresses damaged tendons and repairs them in a non-surgical way by rebuilding tissue on a cellular level. We are going to stress throughout this segment of our article, our more than 25 years of experience in offering regenerative medicine techniques, such as PRP and will call into question doctors and clinicians who offer this treatment after attending a weekend workshop and then announce to their patients that this treatment does not seem to be effective. We will also bring attention to “failed PRP” treatments that consist of a “single injection.”

In a new study from 2018, Doctors at The Orthopedic-Traumatology Department of Prostějov Hospital in the Czech Republic published these observations. (15)

This study aimed to explore the effects of new therapeutic procedures in patients with shoulder impingement syndrome. The primary goal of the study was to confirm the hypothesis that the application of the platelet-rich plasma (PRP) in patients with shoulder impingement syndrome will have a positive effect on both the subjective and objective evaluation of their condition.

The secondary goal was to compare the effect achieved by a series of 3 PRP injections and that achieved by treating the impingement syndrome with a standard single depot corticosteroid injection.

The PRP injection was given at  6 weeks, 3 months, and 6 months after the administration of the injection.

CONCLUSION of Study: “Based on the results of our study, the hypothesis can be accepted that the concentrate of platelet-rich plasma administered through a series of 3 injections applied in the subacromial space in patients with shoulder impingement syndrome has positive effects on the daily activities of patients as well as on the objective evaluation via the selected scoring systems.”

Research like that above, where more than one injection is given counters research that measures PRP’s ability to help swimmer’s shoulder with only one or two injections.

In the May 2017 issue of the Orthopaedic Journal of Sports Medicine, doctors compare PRP injections to exercise as non-surgical treatments of subacromial shoulder pain. Here are the learning points of this research:

Two injections do not make comprehensive treatment

PRP is best used in conjunction with Prolotherapy

In our clinic, we have found that when we use PRP to strengthen tendons within the shoulder capsule, we can help those tendons heal and strengthen by using dextrose Prolotherapy to strengthen the ligaments that surround the shoulder capsule. This process is again, described in the video above.

Prolotherapy on its own has been shown to be an effective treatment for shoulder repair.

In 2013, Medical University research teams in Turkey presented their findings on “The Effects of Prolotherapy in Patients With Subacromial Impingement Syndrome.” (16) These are the learning points of their research:

In this single-center, randomized placebo-controlled, single-blind, prospective study, 80 patients with chronic subacromial impingement syndrome who met the study criteria received two dextrose injections in the affected shoulder at two weeks intervals.

The patients were randomly assigned into two therapy groups, either dextrose or other control (lidocaine) groups.

The injections were repeated two times with two weeks between injections.

Results:  The study demonstrated significant improvements in function and pain in both injection groups. Shoulder flexion, abduction, internal and external rotations showed significant improvements in both groups in the first 3 months. While the range of shoulder flexion did not improve in the control group during the last three months, this range of motion continued to improve significantly in the Prolotherapy treatment group over the same period.

Again we want to point out here that the patients received benefits from only two injections, please watch the video for a comparison of our more aggressive treatment.

In our research, published in Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, (17) Ross Hauser, MD and Danielle R. Steilen-Matias, MMS, PA-C  contributed to findings suggesting Dextrose Prolotherapy has been able to reduce pain and disability of traumatic and nontraumatic rotator cuff conditions.

In our research published in The Open Rehabilitation Journal (18) our research team found that lesions of the glenoid labrum are a common cause of shoulder instability and a frequent finding in patients with shoulder pain. Management of these patients typically involves an attempt to avoid surgery through conservative treatment. However, there is currently a dearth of conservative options that promote labral healing.

More of our research surrounding problems of the shoulder:

Questions about our treatments?

If you have questions about Subacromial shoulder pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections. Offices are located in Oak Park, Illinois and Fort Myers, Florida.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

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This article was update March 8, 2021

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