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For further information, see CMDT Part 41-02: Musculoskeletal Injuries of the Shoulder

Key Features

Essentials of Diagnosis

  • Shoulder pain with overhead motion

  • Night pain with sleeping on shoulder

  • Numbness and pain radiation below the elbow are usually due to cervical spine disease

General Considerations

  • A collection of diagnoses that cause mechanical inflammation in the subacromial space

  • Causes can be related to

    • Muscle strength imbalances

    • Poor scapula control

    • Rotator cuff tears

    • Subacromial bursitis

    • Bone spurs

  • Because shoulder injuries may present differently depending on the demands placed on the shoulder joint, establishing the patient's hand dominance, occupation, and recreational activities is important

Clinical Findings

  • Classically presents with one or more of the following:

    • Pain with overhead activities

    • Nocturnal pain with sleeping on the shoulder

    • Pain on internal rotation (eg, putting on a jacket or bra)

  • On inspection, there may be appreciable atrophy in the supraspinatus or infraspinatus fossa

  • Mild scapula winging or "dyskinesis" may be present

  • A rolled-forward shoulder posture or head-forward posture is commonly seen

  • On palpation, the patient can have tenderness over the anterolateral shoulder at the edge of the greater tuberosity

  • The patient may lack full active range of motion (Table 41–1) but should have preserved passive range of motion

  • Symptoms can be elicited with the Neer and Hawkins signs (Table 41–1)


  • The following four radiographic views should be ordered to evaluate subacromial impingement syndrome:

    • Anteroposterior (AP) scapula: can rule out glenohumeral joint arthritis

    • acromioclavicular joint: evaluates the acromioclavicular joint for inferior spurs

    • Lateral scapula (scapular Y): evaluates the acromial shape

    • Axillary lateral: visualizes the glenohumeral joint as well and for the presence of os acromiale

  • MRI of the shoulder may demonstrate full- or partial-thickness tears or tendinosis

  • Ultrasonography

    • May demonstrate thickening of the rotator cuff tendons and tendinosis

    • Tears may also be visualized, although MRI is preferred to identify partial tears and small full-thickness tears



  • Education, activity modification, and physical therapy exercises

    • Rotator cuff muscle strengthening can alleviate weakness or pain, unless the tendons are seriously compromised, in which case exercises may cause more symptoms

    • Physical therapy is directed at rotator cuff muscle strengthening, scapula stabilization, and postural exercises

  • There is no strong evidence supporting the effectiveness of ice and NSAIDs as a prolonged therapy

  • In a Cochrane review, corticosteroid injections produced slightly better relief of symptoms in the short term when compared with placebo


  • Procedures include

    • Arthroscopic acromioplasty with coracoacromial ligament release

    • Bursectomy

    • Debridement or repair of rotator cuff tears

  • However, the value of acromioplasty alone for rotator cuff problems is not supported by evidence




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