Subacromial Pain Syndrome (SAPS): Best Physiotherapy Exercises for Shoulder Pain Relief

Subacromial Pain Syndrome (SAPS) refers to non-traumatic, typically unilateral shoulder pain around the acromion, worsening with arm elevation. It causes discomfort in the subacromial space—the area beneath the acromion of the shoulder blade. This syndrome often arises from irritation or inflammation of the structures in this region, including the rotator cuff tendons and the bursa.

Causes of Subacromial Pain Syndrome 

Subacromial Pain Syndrome (SAPS) can result from a variety of factors that lead to irritation or impingement of the structures within the subacromial space. The common causes include:

• repeated arm movements, especially overhead motions (e.g., in sports like swimming, tennis or jobs involving lifting)
• rotator cuff tendon degeneration
• subacromial impingement
• scapular dyskinesis
• acromion shape variations - such as a curved or hooked acromion
• shoulder instability
• weakness in the rotator cuff muscles or surrounding shoulder stabilizers (e.g., serratus anterior, trapezius)
• rounded shoulders or a forward head posture
• trauma or injury
• calcific tendonitis
• thoracic kyphosis

 

Clinical presentation of Subacromial Pain Syndrome 

Diagnosis

As a physiotherapist, diagnosing Subacromial Pain Syndrome (SAPS) involves a combination of taking a thorough history, conducting a physical examination and performing specific clinical tests. Here’s a step-by-step approach:

Patient History

• Ask about the onset, duration, location and nature of the pain (e.g., sharp, dull, aching).
• Ask about aggravating factors like pain during overhead activities or night pain etc.
• Ask about pain relieving factors.
• Any history of repetitive overhead activities, sports, or work-related tasks.

Observation

• Look for muscle atrophy around the shoulder, especially in the supraspinatus or infraspinatus.
• Observe the patient's posture, noting any forward head posture or rounded shoulders.
• Watch for scapular dyskinesis (abnormal scapular movement) during shoulder elevation.

Palpation

• Palpate the subacromial space, anterior shoulder and rotator cuff tendons to check for localized tenderness.
• Swelling in the subacromial bursa may be present, especially if there is significant inflammation.

Range of Motion (ROM) Testing

• Active ROM: 

Ask the patient to raise their arm in different directions (flexion, abduction, external rotation) and note any pain or limitations, particularly in the "painful arc" between 60° and 120° abduction.

• Passive ROM: 

Passively move the patient’s shoulder through its range of motion to assess for pain, especially during abduction and flexion.

Strength Testing

• Perform resisted strength testing of the shoulder muscles, particularly the supraspinatus and infraspinatus. Weakness or pain during resisted shoulder abduction or external rotation may indicate rotator cuff involvement.

Special Tests

Several impingement and rotator cuff-specific tests can be used to diagnose SAPS:

• Neer’s Impingement Test - suggests subacromial impingement
• Hawkins-Kennedy Test - pain during internal rotation indicates impingement of the subacromial space
• Painful Arc Test: - pain occurring between 60° and 120° of arm abduction
• Empty Can Test: suggest a supraspinatus tendon problem
• Infraspinatus Test - indicate infraspinatus involvement
• Speed’s Test - indicate biceps tendon or subacromial involvement

 

Scapular Movement Assessment

• Assess the scapulohumeral rhythm during shoulder elevation. Scapular dyskinesis (winging or altered movement) can contribute to subacromial impingement and SAPS.

Functional Tests

• Apley’s Scratch Test: Ask the patient to reach behind their back with one arm overhead and the other behind the back. Limitations or pain during this maneuver can indicate shoulder dysfunction related to SAPS.

Imaging Studies

• Ultrasound: Useful for assessing rotator cuff tendons for inflammation, tears or calcifications.
• MRI: May be necessary if a rotator cuff tear is suspected or if conservative treatment fails.
• X-ray: Can show acromion shape or other bone abnormalities contributing to SAPS.

 

Differential Diagnosis

• Rotator Cuff Tear
• Adhesive Capsulitis (Frozen Shoulder)
• Glenohumeral Osteoarthritis
• Biceps Tendonitis
• Calcific Tendonitis
• Glenohumeral Instability
• Acromioclavicular Joint Pathology
• Cervical Radiculopathy
• Labral Tear (e.g., SLAP lesion)
• Subscapularis Tendonitis

 

Physiotherapy Management of Subacromial Pain Syndrome

Pain Management

Initial focus is on reducing pain and inflammation to allow for better mobility and function. It is done through avoiding activities that aggravate symptoms, particularly overhead movements. Electrotherapy modalities used are:

• Ice Therapy (Cryotherapy)
• TENS (Transcutaneous Electrical Nerve Stimulation) or
• Therapeutic Ultrasound 

Myofascial Trigger Point Release (MTPR) Technique is also performed.

Myofascial Trigger Point Release (MTPR) targets painful myofascial trigger points (MTPs) within tight muscle bands, offering effective pain relief and improved muscle flexibility. MTPR has been shown to significantly reduce chronic shoulder pain, such as in Subacromial Pain Syndrome (SAPS), by decreasing muscle stiffness and enhancing patients' overall quality of life. During therapy, a skilled physiotherapist applies pressure to the MTP until muscle tension and pain subside. Research highlights a significant reduction in upper trapezius stiffness, although no notable changes were observed in the middle or lower trapezius muscles.

Improving Range of Motion (ROM)

Once pain is under control, the focus shifts to restoring full range of motion in the shoulder.

• Passive and Active-Assisted ROM Exercises
• Pendulum Exercises
• Shoulder Pulley Exercises

 

Stretching Exercises

Incorporating targeted stretching exercises can help reduce shoulder stiffness, improve mobility and ease discomfort caused by SAPS.

• Posterior Capsule Stretches - improve internal rotation
• Sleeper Stretch: Aimed at improving internal rotation.
• Cross-body Stretch

 

Strengthening Exercises

• Rotator Cuff Strengthening
• Isometric Exercises - e.g., external rotation, internal rotation and abduction
• Theraband or Resistance Exercises
• Scapular Stabilization Exercises - muscles targeted are serratus anterior, trapezius, rhomboids, teres major, levator scapulae and the latissimus dorsi

Benefits of Scapular Stabilization Exercises

• reduced pain
• improved proprioception 
• better shoulder kinematics
• increased muscle strength
• postural alignment

 

Postural Correction

Poor posture, such as forward head posture or rounded shoulders, can contribute to SAPS by altering the subacromial space. Postural correction is key in the management of SAPS.

• Postural Exercises: 

Strengthening exercises aimed at correcting forward shoulder posture, such as rows or shoulder blade squeezes, can help align the scapula and reduce shoulder strain.

• Chin tucks: 

Help correct forward head posture and take stress off the shoulders.

• Thoracic mobility exercises: 

Exercises to improve thoracic extension and mobility can improve scapular positioning and shoulder function.

• Postural Education: 

Teach patients ergonomic adjustments and postural awareness to avoid shoulder strain, especially during work or daily activities (e.g., desk setup, standing posture).

 

Neuromuscular Re-Education

This phase focuses on retraining proper movement patterns to prevent recurrence.

• Scapulohumeral Rhythm Training: Exercises that help patients regain normal coordination between the shoulder blade and upper arm during movement, ensuring smooth and pain-free motion.
• Y-T-I exercises: Strengthen the shoulder stabilizers while promoting proper scapular movement.
• Closed kinetic chain exercises: Include exercises such as wall push-ups or push-ups on a ball to improve shoulder stability.
• Proprioception Training: Exercises that enhance joint awareness and control can help improve shoulder function and prevent further injury.
• Weight shifts on hands: Encourage patients to shift their weight from one hand to the other in a closed-chain position, helping with proprioception and scapular stability.

 

Manual Therapy

Physiotherapists can perform manual joint mobilizations to increase shoulder mobility, focusing on the glenohumeral and scapulothoracic joints. Techniques used are:

• glenohumeral joint mobilization (inferior and posterior glide)
• thoracic mobilization

Dry Needling

A recent study revealed that combining deep dry needling with routine physical therapy provides more effective and longer-lasting relief for pain and disability in shoulder impingement syndrome compared to Hong's dry needling technique. This combination offers better results in managing shoulder pain and improving mobility.

Kinesio Taping 

According to a research, KT showed reduced pain intensity (VAS score). Pain-free ROM for abduction, flexion, and scapular plane elevation improved by 10-19 degrees. KT can also be combined with a home exercise program.

• KT reduces muscle pain and load by applying 15-25% stretch to the affected area.
• KT stimulates weakened muscles when applied from the origin to insertion.
• It enhances pain relief and increases range of motion (ROM) for musculoskeletal injuries.

A gradual return to activity is essential in avoiding re-aggravation of shoulder conditions. Functional exercises that mimic daily or sport-specific tasks, like overhead reaching or lifting, help the shoulder handle required loads. Strength-endurance training using resistance bands or light weights focuses on building muscle endurance, especially for repetitive or overhead activities. 

Patient education is crucial for long-term success, with a tailored home exercise program (HEP) and ergonomic advice to prevent shoulder strain. Short-term goals focus on pain reduction and improved range of motion, while long-term goals aim for full restoration of shoulder function without limitations.