What causes subacromial pain?

There are three main causes of pain in the subacromial space:

• Rotator cuff tendinitis is inflammation of the rotator cuff tendons that are located in the subacromial space and can be compressed as the space narrows.

• Bursitis is where the bursa (a fluid filled sac) becomes swollen and inflamed.

• Impingement is where the space between the acromion and rotator cuff is narrowed; often this is caused by a bone spur or an arthritic acromioclavicular joint (ACJ). This causes the acromion to impinge (rub) on the tendon when the arm is elevated.

These causes are all related and therefore the terms ‘rotator cuff tendinitis’, ‘subacromial bursitis’ and ‘subacromial impingement’ are used interchangeably. The diagnosis and treatment is the same for each.

How is a subacromial pain diagnosed?

Usually Mr Moverley can diagnose subacromial pain with a combination of clinical examination and a careful assessment of the history of your symptoms. 

Further diagnostic tests are used for confirmation and to plan treatment:

• X-rays can be obtained on the day of your consultation and may demonstrate a bone spur on the under surface of the acromion or arthritis of the ACJ. Frequently x-rays are normal in younger patients.

• Ultrasound is useful as it can show inflammation in the bursa and dynamic impingement underneath the acromion. Often ultrasound is combined with a steroid injection to provide initial treatment at the same time.

• MRI is most likely to be requested if there is suspicion that you might have a rotator cuff tear.

Treatment options

Mr Moverley will tailor your treatment specifically to the cause of your symptoms, whilst taking into account your expectations and medical history.

Non-operative Management

Non-operative treatment should always be exhausted before considering any form of surgery.  The vast majority of patients will respond well to non-operative treatment. Possible non-operative options include:

• A focussed physiotherapy program to stretch the soft tissues around the shoulder and help regain range of motion will often be all the treatment that is required. Subacromial pain is frequently caused by tightness in the soft tissues at the back of your shoulder, Mr Moverley will assess you for this during you consultation.

• Rest, activity modification, and simple pain relief can provide good benefit, particularly early after the onset of symptoms. 

• Steroid injections are often used to provide short-term relief, which can then allow you to participate in physiotherapy. Repeated injections should not be given as a long-term solution as they may cause further damage to the tendons of your shoulder. 

• There is national guidance related to the management of this condition which can be accessed here.

Surgical Management

Surgery is an option if despite one or two injections and a structured physiotherapy program you are still experiencing pain that is causing you problems. Whether surgery is beneficial is a currently a controversial subject due to some recent changes to the evidence base. Mr Moverley will discuss this in detail with you prior to any agreement to proceed to an operation. 

Shoulder arthroscopy

The operation for subacromial pain is called an arthroscopic subacromial decompression. This is a ‘key-hole’ procedure where inflamed tissue is removed from the subacromial bursa and the size of the space is increased by shaving away a small amount of the acromion.