The document discusses shoulder pain, specifically subacromial pain/non-specific shoulder pain. It notes that shoulder pain is prevalent, can impact daily activities, and for 40% of patients the pain is ongoing or recurrent after 12 months. Imaging and physical exams are not always reliable in diagnosing the source of pain. Exercise appears to be the most promising intervention for shoulder pain, though what type or amount of exercise is unclear. A proposed intervention focuses on teaching patients self-management skills and a home exercise program with 1-5 sessions from a physiotherapist and proactive follow-up.

1. Shoulder pain -
Subacromial pain/non-
specific shoulder pain
Assessment and
Management
Daniel H. Major
Physiotherapist (MSc)
PhD Candidate

2. Introduction
• Shoulder pain is prevalent – point prevalence 7% to 26% (Luime 2004)
• Common in clinical practice, with an incidence of 10 per 1000 in primary care (Ostor
2005, Van der Windt 1995)
• Shoulder pain can impact on daily activities, including working ability and engagement
with leisure and sporting activities (Luime 2004)
• Approximately 40 % of the patients are reporting on-going or recurrent symptoms 12
months after onset, which indicates that for a significant proportion this is not a self-
limiting or short-lasting problem (Van der Windt 1996, Kooijman 2013, Winters 1999)
• A cost-of-illness study from Sweden (Virta 2012)
• Mean healthcare cost per shoulder patient was €326 (SD 389) during six months
• Physiotherapy treatments accounted for 60%
• The costs for sick leave contributed to 84% of the total costs and the mean annual total cost
was €4139 per patient
• Estimated costs for secondary care increased the total costs by one-third
• Approximately 20% of the patients were responsible for 91% of the total costs and for 44%
of the healthcare costs
• Shoulder pain is an umbrella term for disorders with different aetiology and course;
subacromial pain is a clinical diagnosis, which is thought to be based on symptoms
provoked by tensile loading or compression of the rotator cuff tendons (Lewis 2009, Seitz
2011)

3. Many synonyms
• Subacromial pain (syndrome)
• Rotator cuff tendinopathy
• Rotator cuff related pain
• Subacromial impingement syndrome
• Non-specific shoulder pain
• Bursitis
• Supraspinatus, infraspinatus, subscapularis
tendinitis, tendinopathy

4. Ask your patient: What do you think is going on in your shoulder?
(Inspired by Adriaan Louw)

5. PHYSICAL EXAMINATION TESTS
• E.g. Hawkins-Kennedy, Neer sign, Empty can etc
• «…no consistent evidence that any examination
procedure used in shoulder assessments have
acceptable levels of reliability»

6. PHYSICAL EXAMINATION TESTS
• «Special tests» for shoulder pain
• Sensitive
• proportion of people with shoulder pain/pathology correctly identified
• Not specific
• proportion of people without shoulder pain/ pathology correctly
identified
• This means…
• Confirms what the patient tells you; that their painful
shoulder is painful! Also hurts those without shoulder
pain!!
• –Unrealistic to think that these tests selectively tension specific
structures
Lewis J (2008). Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of
assessment?

8. IMAGING
Frost et al (1999)
• Using MRI could not distinguish between people
diagnosed with subacromial impingement and age-
matched controls according to structural pathology
Templehofet al (1999); Worland et al (2003);
Yamamoto et al (2010)
• Approx. 40% of the general population have
asymptomatic rotator cuff tears

9. IMAGING
Girish et al (2011)
• N = 51; age = 40 to 70 years; asymptomatic
participants
Using diagnostic ultrasound
• Bursal thickening –78%
• ACJ OA –65%
• SS tendinosis-39%
• Subscapularis tendinosis–25%
– “Asymptomatic shoulder abnormalities were
found in 96% of the subjects”
X

10. DIAGNOSIS
• Biomedical diagnosis, relating to specific tissues at fault, e.g. , bursal
thickening, calcification, presence of tendinopathy, partial or full thickness tear
of the rotator cuff not associated with clinical outcomes

11. Physical Examination of the ‘Scapula’
•Points to consider:
• Scapula dyskinesis is present in those with and
without painful shoulder pain (Catlinet al. 1995;
Lucasiewiczet al. 1999)
• Scapulae of dominant shoulder shows greater
retraction and upward rotation at all points during
elevation of the arm (Morais and Pascoal 2013)
Highlights the presence of relative movement
differences in the scapulae of asymptomatic or
healthy people
Stop blaming the scapula!!
May be part of the puzzle…

12. Physical Examination of the ‘Scapula’
‘Currently, there is insufficient evidence to support a
clinical belief that the scapula adopts a common and
consistent posture in SIS.
–It also raises the possibility that deviation from a
‘normal’ scapular position may not be contributory
to SIS but part of normal variations.’

13. Prognostic factors
• Shift towards thinking more about prognosis than diagnosis (Greene et al
2017, Vos Andersen et al 2017)
• Baseline pain
• Baseline disability
• Duration of symptoms
• Expectations of recovery
• Pain self-efficacy

14. ASSESSMENT
What I do…. Inspired by
Littlewood
Stage one:
1. ‘Exclude’ cervical spine
•Repeated movement assessment
Spurling test?
2. Exclude shoulder pain with restriction (frozen shoulder)
• <45 degrees lateral rotation (k = 0.82 (0.65-0.99) (Hanchard et al 2005)
3. Pain with resisted testing (rotator cuff tendinopathy/subacromial pain)
•Typically abduction / lateral rotation (k = 0.81)
(Palmer 2000)
4. Instability?

15. Mitchell 2008

16. MANAGEMENT
Review findings
• “Exercise” appears to be one of the most promising
intervention
• Additonal benefits and cost-effective
• Can be self-managed
• •Multimodal physiotherapy or surgery, confer no additional
benefit over exercise alone
• Manual therapy, acupuncture, US, Laser, PSWD
• No added benefit over active exercise alone
• Not superior to active control
• ESWT not superior to placebo
• CCS injections = possible small short-term effect
Littlewood et al 2012, Page et al 2016

17. Updated systematic review
• Exercise remains most promising intervention
and benefit of adding further interventions is
unclear

18. Exercise interventions

19. Beard et al., 2017

20. Important components
•Inclusion of some level of resisted exercise does
seem to matter - optimal level is unclear
Also unclear:
• optimal number of exercise repetitions, although higher
repetitions might confer superior outcomes
•Three sets of exercise is preferable to two or one set
but the optimal frequency, e.g. daily, three times
weekly, is unknown
•Most exercise programmes should demonstrate
clinically significant outcomes by twelve weeks but the
potential for achieving significant outcomes is less
clear prior to this time point
(Littlewood et al 2015)

21. General vs. «specific» exercise?

22. Produce or avoid pain?
Conclusion:
• Painful exercises offer a small but sign. benefit over pain-free exercises in
the short term (moderate quality of evidence)
• In the medium and long term there is no clear superiority of one treatment
over another
• Pain during therapeutic exercise for chronic musculoskeletal pain need not
be a barrier to successful outcomes
• Further research is warranted to fully evaluate the effectiveness of loading
and resistance programmes into pain for chronic musculoskeletal disorders

23. MORE PROMISING THAN WHAT?

24. Thomas Kuhn

26. Beard et al., 2017
ARE WE OVERMANAGING A
SELF-MANAGEABLE CONDITION?

27. THE AD-SHOULDER INTERVENTION
1-5 consultations

28. THE AD-SHOULDER INTERVENTION
1-5 consultations
Delivered by experienced physiotherapists

29. THE AD-SHOULDER INTERVENTION
1-5 consultations
Delivered by experienced physiotherapists
Focuses on 5 core self-management skills (Lorig et al., 2003)

30. THE AD-SHOULDER INTERVENTION
1-5 consultations
Delivered by an experienced physiotherapist
Focuses on 5 core self-management skills (Lorig et al., 2003)
Home-exercises 3 times per week (maximum 3 exercises)

31. THE AD-SHOULDER INTERVENTION
1-5 consultations
Delivered by an experienced physiotherapist
Focuses on 5 core self-management skills (Lorig et al., 2003)
Home-exercises 3 times per week (maximum 3 exercises)
Pro active follow-up (sms, e-mail, telephone)

32. 5 CORE SELF-MANAGEMENT SKILLS
CORE SELF-
MANAGEMENT
SKILLS
4. Forming of a
patient/health
care provider
partnership
3. Resource
utilization
2. Decision
making
5. Taking action
1. Problem
solving
Lorig et al., 2003

33. 5 CORE SELF-MANAGEMENT SKILLS
CORE SELF-
MANAGEMENT
SKILLS
4. Forming of a
patient/health
care provider
partnership
3. Resource
utilization
2. Decision
making
5. Taking action
1. Problem
solving
Lorig et al., 2003

34. 5 CORE SELF-MANAGEMENT SKILLS
CORE SELF-
MANAGEMENT
SKILLS
4. Forming of a
patient/health
care provider
partnership
3. Resource
utilization
2. Decision
making
5. Taking action
1. Problem
solving
Lorig et al., 2003

35. 5 CORE SELF-MANAGEMENT SKILLS
CORE SELF-
MANAGEMENT
SKILLS
4. Forming of a
patient/health
care provider
partnership
3. Resource
utilization
2. Decision
making
5. Taking action
1. Problem
solving
Lorig et al., 2003

36. 5 CORE SELF-MANAGEMENT SKILLS
CORE SELF-
MANAGEMENT
SKILLS
4. Forming of a
patient/health
care provider
partnership
3. Resource
utilization
2. Decision
making
5. Taking action
1. Problem
solving
Lorig et al., 2003

37. 5 CORE SELF-MANAGEMENT SKILLS
CORE SELF-
MANAGEMENT
SKILLS
4. Forming of a
patient/health
care provider
partnership
3. Resource
utilization
2. Decision
making
5. Taking action
1. Problem
solving
Lorig et al., 2003

38. THE AD-SHOULDER INTERVENTION
Session 1
Assessment (focus on patient history)
Develop a strong therapeutic alliance
Make an action plan based on collaborative
problem solving
Cognitive reassurance
Resource utilization
Session 2
Improve decision making skills
Educate/talk about the multidimensional
nature of pain (individualised based on
the assessment findings)
Make an action plan
Session 3-5
Progress exercises
Make new action plan
Deal with uncertainty
Provide emotional support, motivation,
encouragement
Long term action plan
Pro active follow-up
Deal with uncertainty
Collaborative problem solving
Improve decision making skills
Make new action plans
Provide emotional support, motivation,
encouragement

39. THE EXERCISE PROGRAM
FLIES
SHOULDER
PRESS
ABDUCTION
ROTATION
PULLOVER
ROWING
ABDUCTION
Credit: ExorLive

40. Other Scandinavian models/interventions

41. Other Scandinavian models/interventions
All patients received an corticosteroid injection prior to
treatment
Reduce pain, increase strength, normalize posture
6 exercises:
2 eccentric rotator cuff exercises
3 concentric scapula stabilizing exercises
1 posterior shoulder stretching exercise
7 individual treatments for 12 weeks,
Daily home exercises for 12 weeks
The patients were not allowed to exceed 5 on this 0-10
scale when they performed the exercises; however, they
were recommended to feel some pain
during loading.
Primary treatment goal: Correction of scapula malposition,
Particular attention was directed toward the correction of
upper body posture and the restoration of scapulothoracic
and glenohumeral muscular control and stability
supplemented by patient education for a better
understanding of shoulder function and treatment principles
Treatment sessions of forty minutes were given twice weekly
for twelve weeks
Exercises that the patient had learned to master correctly
were given as home exercises, but only one or two at a time
The principal focus was on relearning of normal movement patterns, which
could then be transferred to daily activities. The initial aim was to unload the
stress on the rotator cuff and subacromial structures. During this phase, a
mirror for awareness of posture, manual techniques for loosening tense
muscles, an elastic rubber band, and a sling fixed to the ceiling were used.
The patients received immediate feedback and correction (supervision) by
the physiotherapist. Once dysfunctional neuromuscular patterns were
normalised, endurance exercises were performed with gradually increasing
resistance. Principles of closed and open kinetic chain and plyometric
exercises were incorporated in the next phase of training.
Patients had an adjusted programme at home, which consisted of correction
of alignment during daily living and simple low loaded exercises with a thin
elastic cord to provide assistance and resistance to the movement.
Simple advice was given.

42. Other Scandinavian models/interventions
All patients received an corticosteroid injection prior to
treatment
Reduce pain, increase strength, normalize posture
6 exercises:
2 eccentric rotator cuff exercises
3 concentric scapula stabilizing exercises
1 posterior shoulder stretching exercise
7 individual treatments for 12 weeks,
Daily home exercises for 12 weeks
The patients were not allowed to exceed 5 on this 0-10
scale when they performed the exercises; however, they
were recommended to feel some pain
during loading.
Primary treatment goal: Correction of scapula malposition,
Particular attention was directed toward the correction of
upper body posture and the restoration of scapulothoracic
and glenohumeral muscular control and stability
supplemented by patient education for a better
understanding of shoulder function and treatment principles
Treatment sessions of forty minutes were given twice weekly
for twelve weeks
Exercises that the patient had learned to master correctly
were given as home exercises, but only one or two at a time
The principal focus was on relearning of normal movement patterns, which
could then be transferred to daily activities. The initial aim was to unload the
stress on the rotator cuff and subacromial structures. During this phase, a
mirror for awareness of posture, manual techniques for loosening tense
muscles, an elastic rubber band, and a sling fixed to the ceiling were used.
The patients received immediate feedback and correction (supervision) by
the physiotherapist. Once dysfunctional neuromuscular patterns were
normalised, endurance exercises were performed with gradually increasing
resistance. Principles of closed and open kinetic chain and plyometric
exercises were incorporated in the next phase of training.
Patients had an adjusted programme at home, which consisted of correction
of alignment during daily living and simple low loaded exercises with a thin
elastic cord to provide assistance and resistance to the movement.
Simple advice was given.
WHERE IS THE FOCUS WITHIN
A BIOPSYCHOSOCIAL MODEL?
WHAT IS THE THEORETICIAL
RATIONALE?

43. Klintberg et al 2015

44. Klintberg et al 2015
1.WHERE IS THE FOCUS
WITHIN A BIOPSYCHOSOCIAL
MODEL?
2. WHAT IS THE THEORETICIAL
RATIONALE?
3. DO THEY FOCUS ON
PROGNOSIS?

45. Important future shoulder research
PANDA-S

46. Norwegian guidelines
http://www.helsebiblioteket.no/fagprosedyrer/ferdige/fy
sioterapi-for-subakromiale-smerter

47. Literature
Beard, D. J., Rees, J. L., Cook, J. A., Rombach, I., Cooper, C., Merritt, N., . . . Woods, D. (2017). Arthroscopic subacromial decompression for subacromial shoulder pain
(CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. doi:10.1016/S0140-6736(17)32457-1
Bennell, K., Wee, E., Coburn, S., Green, S., Harris, A., Staples, M., . . . Buchbinder, R. (2010). Efficacy of standardised manual therapy and home exercise programme for
chronic rotator cuff disease: randomised placebo controlled trial. Bmj, 340, c2756. doi:10.1136/bmj.c2756
Bury, J., West, M., Chamorro-Moriana, G., & Littlewood, C. (2016). Effectiveness of scapula-focused approaches in patients with rotator cuff related shoulder pain: a
systematic review and meta-analysis. Man Ther, 25. doi:10.1016/j.math.2016.05.337
Chester, R., Jerosch-Herold, C., Lewis, J., & Shepstone, L. (2016). Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a
multicentre longitudinal cohort study. Br J Sports Med. doi:10.1136/bjsports-2016-096084
Chester, R., Shepstone, L., Daniell, H., Sweeting, D., Lewis, J., & Jerosch-Herold, C. (2013). Predicting response to physiotherapy treatment for musculoskeletal shoulder
pain: a systematic review. BMC Musculoskelet Disord, 14, 203. doi:10.1186/1471-2474-14-203
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48. Literature…
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49. Literature…
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