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Sub Acromial Pain

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What Is Sub Acromial Pain Syndrome?

The shoulder is a ball and socket joint. The joint is made up from the arm bone (humerus), a shallow socket from the shoulder blade (scapula) and your collar bone (clavicle). There is a space above this joint called the sub acromial space.

Important muscles of the shoulder are the rotator cuff muscles. Many structures run through this space including the rotator cuff tendons, ligaments, and a fluid-filled sac (bursa).

Sub acromial pain syndrome (SAPS) is when one or more of these structures become irritated which can result in pain, reduced range of movement and weakness at the shoulder.  The most common issue is when the tendons of the rotator cuff muscles become irritated. This may be for a variety of reasons such as overuse, age-related changes to the tendon, muscle weakness, obesity, smoking or other factors.

Sub acromial pain syndrome is an umbrella term for shoulder pain not necessarily specific to trauma. It may also be referred to as shoulder impingement, bursitis, calcific tendinitis, rotator cuff degeneration, a rotator cuff tear or a tendinopathy.

diagram of shoulder showing Sub Acromial Pain area

What Are The Symptoms Of Sub Acromial Pain Syndrome?

Symptoms vary but the most common are:

  • A dull ache around the front or side of the shoulder that may move down towards the elbow
  • Increased pain when lying on the painful side often resulting in disturbed sleep
  • Weakness or pain when lifting or reaching the arm
  • A sharp/catching pain when moving the arm away from the body particularly when lifting the arm above shoulder height. For example when putting on a coat or brushing your hair. 

How Common Is Subacromial Pain Syndrome?

 Shoulder pain is the third most common complaint in physiotherapy with sub acromial pain being the most common cause. It mostly affects people between the ages of 35 and 75. It is estimated that in 1 year 7% – 30% of the population will experience shoulder pain.

What Causes Subacromial Pain Syndrome

 The cause of sub acromial pain can be from multiple factors. These can be:

Internal factors involve gradual changes occurring within the shoulder such as

  • Age related changes – As we age our tendons can naturally develop small tears which leads to reduced muscle control at the shoulder and increased contact between the humerus and acromion process.
  • Muscular weakness – The rotator cuff muscles are the main muscle group that controls the movement between the humerus and the scapula when moving your arm from your body. If there is weakness that means there is less control over this movement which may results in compression of the structures at the sub acromial space.
  • Physical factors – This refers to the natural shape of your acromion bone. If it is hook or curve shaped it may lead to reduced joint space and therefore pain when the arm moves causing the joint space to narrow further. This may be a cause in a very small percentage of people with Sub Acromial Pain.

 

External factors involve changes to the shoulder tendons due to outside forces being placed on the shoulder such as

  • Sudden increase in use of shoulder – Increased demand on the tendon remains the most common reasons for SAPS for example decorating a room in a short period of time.
  • Changes in posture may reduce the sub acromial space present
  • Constant increase in the use of your arm may lead to small tears in the tendons for example heavy lifting as part of your job or hobbies. This results in weakness and reduced control at the shoulder thereby increasing contact between the humerus and acromion process.

Other risk factors for developing SAPS include:

  • Diabetes
  • Rheumatoid arthritis
  • Smoking
  • Obesity
  • Unhealthy lifestyle
  • Sustained use of the shoulder in an overhead position
  • Depression/Anxiety
  • Poor sleep

What Can Help With Sub Acromial Pain Syndrome?

 In the past when you hurt your shoulder most people wore a sling to rest it and allow it to heal. With the knowledge we have now we no longer advise patients to do this as keeping the shoulder moving is often the best treatment. Generally, slings are now only worn to allow a broken bone to heal.

If you have recently injured your shoulder it might be helpful to reduce the amount you carry or reach for on a daily basis to allow the pain to settle.

It is important to keep your arm moving to avoid stiffness and weakness developing. There are ways you can change your daily activities to allow your shoulder to move without making your pain worse.

Exercise

Specific shoulder and scapular (shoulder blade) exercises are key in helping to improve your arm movement and reduce pain. It is important to note it can take 6 – 8 weeks of doing specific shoulder exercises to notice a difference in your shoulder pain. It can take a number of months before you feel better. Local NHS Lanarkshire physiotherapists have recorded exercise videos that will get your rehabilitation started and will guide you to manage your shoulder pain. The exercises are divided into early, middle and late stages. Your physiotherapist will help guide you. You should start doing the early exercises first and should find them easy before you progress to the middle exercises. Again you should begin to find the middle exercises easy before you progress to the late exercises.

Pain Activity Ladder

By following the pain activity ladder you can identify activities that you would consider severely painful, moderately painful and mildly irritating and act to change your habits.

The pain scale, most often used in healthcare, measures pain from 0-10 (zero being no pain and 10 representing the worst pain you could imagine).

If you can identify the level of pain you are experiencing, you will find out if you are in the green, amber or red zone. The best way to move down to the green zone is by pacing and spacing your activity.

When you are completing your rehabilitation exercises it is often best to work within the green (and sometimes amber zones depending on what you deem is an acceptable level of pain) both during the exercises and within 48 hours of completing your exercises. If you find yourself in the red zone you are likely pushing yourself too hard and may flare up the pain.

Pacing and Spacing

Pacing and spacing methods can help you manage your pain better.

Pacing is the term used for breaking down an activity or task. This can be done by taking regular breaks. Prioritising daily activities can also help. This can prevent “over stimulating” your pain system.

When completing challenging tasks or activities, it may be useful to set a “baseline”. This is the amount you can manage on a good or bad day without increasing your symptoms. Therefore, you can plan rests and set achievable goals.

Lifestyle Adaptions

Making some lifestyle changes could also be helpful. We have included some examples of ways you can do this below:

  • If your pain gets worse at work and your job involves repetitive movement it may be a good idea to talk to your manager about short-term changes to duties until you feel better.
  • When putting on your jumper or coat place the painful arm in the sleeve first and then the non-painful arm.
  • If you enjoy a couple of cups of tea a day, why not move your cup to a lower cupboard instead of reaching to the higher cupboards?
  • If you enjoy the gym, you could avoid over-head weightlifting whilst you complete your specific shoulder exercise and maybe focus on other aspects of your general fitness.
  • It is important to also eat a healthy diet. Make sure you get a good night’s sleep for your general wellbeing, especially when you are in pain.

If you live in North Lanarkshire more advice on solutions to help you with activities of daily living can be found here:

When To Speak To A Health Professional

If you display any of the symptoms listed below you will need to speak with your GP urgently.

Signs and Symptoms

  • Trauma, pain and weakness, or sudden inability to raise the arm
  • Any shoulder mass or swelling
  • If you feel generally unwell, have a fever, swelling, redness or heat at the shoulder joint
  • Any trauma leading to loss of function and/or changes to the shape of the shoulder
  • Inflammation in several joints e.g. early morning stiffness lasting more than 30 minutes and pain in more than two joints
  • If you are experiencing systemic symptoms such as fever, night sweats, weight loss or new respiratory symptoms (for example a new, persistent cough)
  • If you are experiencing unexplained muscle wasting and difficulty with movement or sensation

Surgery

A very small amount of people with this condition (Approximately 5%) who do not improve with physiotherapy input may be considered for surgery. Often patients who have surgery will achieve the same results as patients who only had physiotherapy. Surgery comes with risks and in the case of sub acromial pain, the risks may outweigh the benefits.

Making positive changes to how you live and exercises are proven to be better than surgery for the majority of people.

Help And Support

If after following the above advice, your symptoms have not improved within 6 to 12 weeks, a referral to a physiotherapist may be beneficial.

You can access physiotherapy by any of the following:

Additional information

Acute Injury Management

POLICE is an acronym (Protection, Optimal Loading, Ice, Compression and Elevation) that is used as a management strategy for many injuries and conditions for the first 24 to 72 hours.

  • Protection and relative rest are advised immediately after injury for the first 24 to 72 hours.
  • Optimal Loading refers to having a balanced rehabilitation program which encourages early and gradual activity to improve recovery. How you progress will vary from person to person depending on the injury. It is about finding the injured areas happy place and increasing slowly and gradually.
  • Ice may be used for reducing pain and swelling. There are safety points to follow when you use ice:
    • Don't ice over a numb area or open wound. If the skin is numb you won't notice if you're developing an ice burn and ice on an open wound can increase the risk of infection.
    • Be wary of ice burns – don't apply ice directly to the skin, wrap an ice pack in a clean, damp tea towel before applying. Avoid prolonged exposure to ice, 10-20 minutes is usually adequate.
    • Apply crushed ice/frozen peas wrapped in a damp towel for 10-20 minutes, 2-3 times per day for the first 5-7 days post injury/ flare up of pain.
    • Stop applying ice if there are any negative effects such as increase in pain or swelling or skin soreness.
  • Compression and Elevation are helpful for reducing inflammation. This can be done by keeping your joint raised on a pillow and compressed by wrapping a bandage around it.
    Do not make the bandage too tight and do not wear tubi-grip or any compression bandage in bed at night.
  • Heat: After 2-3 days, you may find that heat is more relaxing.

You could use a heat pad or a hot water bottle with an insulated cover on it. Make sure this is not too hot and is not directly touching your skin.

You should do this for 10 to 15 minutes, 3 to 4 times a day.

What do I do if my symptoms flare up?

Flare ups of pain are common. Some people have recurrent flare ups of pain so it is important to know how best to manage these flare ups. In most cases a pain flare-up will settle within 6 weeks.

Top Tips

  • You will likely find it helpful to rest a bit more but it is still important to keep active. This will help to avoid becoming stiff and your muscles becoming weak.
  • If you aim to get a balance between rest and activity it should help your pain to settle down. You may be sore at first, however, start slowly and gradually increase the amount you do.
  • Reduce movements or tasks that aggravate your symptoms. This can help especially in the early days.
  • Adopting positions or movements that reduce your pain can be useful.

Pain Relief

Analgesia

  • Analgesia also known as pain relief can be an important part in helping you manage your symptoms and allow you to stay active.
  • Taking suitable pain relief regularly allows you to move more normally and continue your usual activities without causing any damage. It is unlikely that medication alone will resolve your pain totally. For this reason we are using the term pain relief (A 30-50% reduction in pain would be deemed to be a good success).

Paracetamol

  • Paracetamol is a good general pain management medication. It is used to help manage lots of different types of pain.
  • Sometimes people believe they need something ‘stronger’ than paracetamol when in fact, taking a regular dose rather than a one-off dose is more effective.
  • Spreading the doses of the paracetamol evenly out over a day will help you control your pain. Visit NHS Inform for more detailed information on paracetamol.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

  • NSAIDs are medications that can reduce swelling around joints and nerve endings to give pain relief. They are particularly useful
    in treating inflammatory type pain. Two commonly prescribed NSAIDs are ibuprofen and naproxen.
  • Although NSAIDs can be very useful they are not suitable for everyone. Visit NHS inform for further information related to NSAIDs.

There are other forms of pain relievers available. If you feel your current pain relievers are not helping your pain or you are
experiencing any side effects from your medication, please seek advice from your GP or pharmacist.

For general information on medication visit NHS Inform.

Staying in work and returning to work

We know that staying in work or returning to work as soon as possible is good for your mental and physical health.

If you have problems with activities at work, it may be helpful to ask for a workstation/workplace assessment or talk with your manager or Occupational Health Department. This can help with alterations or provision of equipment or altering your working day or tasks.

There are organisations which can support you at work or help you return to work. You can visit Knowledge Scotland for further information.

Weight Management

Weight Reduction – People who are overweight tend to have more prolonged pain and poorer tissue healing due to increased levels of inflammation in the body. Reducing your weight can generally help improve the healing process.

A good indicator of whether you need to lose weight is your body mass index (BMI), which you can calculate with the NHS BMI calculator.

If your BMI states you are overweight or obese it is likely that losing weight will reduce your symptoms. Carrying extra fat also increases your risk of heart disease, stroke, type 2 diabetes, and some cancers. Reducing your portion sizes and eating a balanced diet can be helpful in reducing weight. NHS informs provides a free online 12-week weight management programme to get you started right away.

If you need a little more help and feel that you would benefit from working with others in group sessions NHS Lanarkshire’s Weigh to Go programme, groups in North and South Lanarkshire, will help you become more active, eat well and lead a healthier lifestyle.

Smoking

Smoking can affect how your body recovers from musculoskeletal problems. If you smoke then the good news is that by stopping smoking it can improve your health in many different ways. Giving up smoking is not something you have to do on your own. You’re twice as likely to stop smoking successfully if you get the right support from the NHS. There is a free NHS stop smoking service available in Lanarkshire to help you succeed.

Chronic Pain

Some people will have pain which persists beyond the expected time frame for their condition. For further information on this and how best to manage it please visit our Chronic Pain webpage.

Pain Association Scotland is a national charity that delivers professionally led self-management pain education in the community.

Active Health Programme

South Lanarkshire

Active Health is a programme for residents of South Lanarkshire living with long term conditions. Residents are referred via Acute, Physio & specialist nurses to a 10-week programme and then signposted onto a wide variety of mainstream physical activity, sport & outdoor opportunities.

South Lanarkshire Leisure and Culture have many active community opportunities as well as specialised referral programmes. Full details of the 20 leisure centres can be found on the SLL website. Contact details across South Lanarkshire or call 01698 476262 to find out the number of your local leisure centre.

Please contact your health professional to discuss this referral or contact SLLC on 01698 476262.

Contact details

North Lanarkshire

North Lanarkshire Leisure’s Active Health Programme in partnership with NHS Lanarkshire provides a range of supported programmes to help individuals realise the benefits of becoming more physically active whilst also assisting those who are recovering from minor or even more serious illness.

The Active Health Programme has both a General Programme where individuals can access the mainstream health and fitness programmes running within NL Leisure Venues including swimming, jogging, golf and more!

A Specialised Health Class Programme which requires a referral from a health professional, this option is available to individuals who require additional specialised support in taking part in physical activity and classes include Strength and Balance, Cardio I, Cardio II, Back Care and Macmillan Move More classes.

A health and social care professional can make a referral by using the Active Health referral form found at the bottom of the page in the link below.

Contact Details - Health & Wellbeing Information

Mental Wellbeing

It is very important to look after your own mental wellbeing. This can have an influence on your recovery or management of your Musculoskeletal problem. Visit our mental wellbeing page for more information.

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