Impingement Subacromial e Bursite Folheto

O que você está sentindo

Provavelmente, você sente uma dor profunda na parte superior do ombro. Essa dor frequentemente irradia pela parte externa do braço. Ela é causada por impingement subacromial, no qual os tecidos ficam comprimidos em um espaço estreito acima da articulação. Você também pode ter bursite, que é o inchaço do saco preenchido por líquido que amortecesse essa área.

A dor geralmente piora quando você levanta o braço acima da cabeça. Tarefas simples, como alcançar uma xícara em uma prateleira alta ou abotoar a camisa, podem se tornar difíceis. Você pode ter dificuldade em alcançar as costas para fechar um sutiã ou vestir um casaco. Esses movimentos comprimem os tecidos irritados, causando desconforto agudo ou uma dor sura.

Seus sintomas frequentemente se agravam à noite. Muitos pacientes têm dificuldade para dormir do lado afetado. A pressão de deitar sobre o ombro pode intensificar a dor, dificultando o sono contínuo. Você também pode notar rigidez ao acordar pela manhã.

Essa condição geralmente se desenvolve lentamente. Você pode ter tido dor por pelo menos seis meses antes de considerar a cirurgia. Se repouso e tratamentos anti-inflamatórios não ajudaram, a dor pode persistir apesar dos seus esforços. Você pode se sentir frustrado por atividades cotidianas estarem se tornando um desafio.

Entendemos como isso afeta sua vida diária. Nosso objetivo é aliviar essa pressão e restaurar seu conforto. Ao abordar a compressão mecânica no seu ombro, nosso objetivo é ajudá-lo a se mover livremente novamente, sem dor.

O que está realmente acontecendo

Seu ombro possui uma pequena folga entre o topo do osso do braço e o teto ósseo acima dele. Dentro desse espaço, um tendão e uma bolsa preenchida por líquido deslizam suavemente quando você levanta o braço. Isso é chamado de espaço subacromial. Quando essa área se torna estreita ou inflamada, o tendão fica comprimido. Isso é chamado de impingement subacromial. O atrito causa dor e inchaço na bursa, que é a bolsa de amortecimento.

A forma do seu teto ósseo desempenha um grande papel. Algumas pessoas têm uma forma óssea curva ou em gancho que naturalmente estreita esse espaço. Isso aumenta a pressão sobre o tendão toda vez que você move o braço. O ligamento coracoacromial, uma faixa de tecido na parte superior, também pode se contrair e pressionar o tendão para baixo. Essa compressão mecânica é o que causa sua dor aguda quando você alcança acima da cabeça ou deita-se desse lado.

Muitas vezes, vemos esse problema piorar se o tendão já estiver irritado ou danificado. A inflamação crônica torna os tecidos mais rígidos e menos flexíveis. Isso reduz sua amplitude de movimento, especialmente ao levantar o braço para o lado ou girá-lo para dentro. Você pode sentir fraqueza ou experimentar dor durante movimentos fortes. No entanto, nem todos com essas alterações precisam de cirurgia. Muitos pacientes encontram alívio através de cuidados não cirúrgicos primeiro.

Se a cirurgia for necessária, o objetivo é criar mais espaço nesse local apertado. Isso pode envolver o alisamento do teto ósseo ou a remoção de parte do ligamento. Esse procedimento é chamado de descompressão subacromial. Ele visa impedir a compressão para que o tendão possa cicatrizar e se mover livremente novamente. Para alguns pacientes, isso proporciona um alívio significativo da dor e restaura a função. Para outros, o dano subjacente ao tendão pode exigir uma abordagem diferente, como reparar o próprio rompimento. Seu cirurgião ajudará você a entender qual opção se adapta à sua anatomia e sintomas específicos.

O que podemos fazer a respeito

Esta página reflete a abordagem do Dr. Kieran Hirpara, cirurgião de membro superior do Mater Private Hospital Rockhampton, para este assunto em nossa clínica. Guiamos você por um caminho claro, desde os cuidados autogestionados até a cirurgia, apenas se necessário. Os pacientes chegam à nossa clínica por encaminhamento do médico de família ou fisioterapeuta. Uma avaliação clínica — incluindo anamnese, exame físico e exames de imagem quando necessário — estabelece o diagnóstico. Para problemas degenerativos ou de longa data, geralmente tentamos primeiro o tratamento não operatório. Consideramos a cirurgia quando esse tratamento não proporcionou melhora suficiente. Para problemas estruturais ou agudos, a cirurgia pode ser recomendada imediatamente.

O manejo conservador é a base inicial do tratamento da síndrome do impacto subacromial. Iniciamos com alterações nas atividades para evitar movimentos dolorosos. A fisioterapia visa fortalecer os músculos do ombro e melhorar sua amplitude de movimento. Você deve dedicar pelo menos 6 semanas a esta abordagem para que os resultados se manifestem. Se a dor persistir, podemos sugerir uma injeção de cortisona na bursa (o saco preenchido por fluido sob o osso do ombro). Isso reduz a inflamação e a dor. O efeito é temporário, mas pode ajudar você a se envolver de forma mais eficaz na fisioterapia. Alguns pacientes também se beneficiam de injeções de ácido hialurônico ou PRP (plasma rico em plaquetas), embora as evidências sobre essas opções variem. Monitoramos seu progresso de perto para garantir que você está no caminho certo.

A cirurgia é reservada para casos em que as medidas conservadoras falham. A descompressão subacromial artroscópica é um tratamento válido que reduz a dor e melhora a qualidade de vida dos pacientes selecionados de acordo com as diretrizes nacionais. Consideramos essa opção se você tiver tido dor por pelo menos 6 meses, apresentar um teste de Hawkins persistentemente positivo (um sinal específico do exame físico) e tiver evidências radiológicas de impacto mecânico. Este procedimento remove osteófitos ou tecido inflamado para criar mais espaço para seus tendões. É uma alternativa à cirurgia aberta em casos avançados. Também utilizamos bloqueios da bursa subacromial para alívio eficaz da dor pós-operatória, o que reduz a necessidade de analgésicos potentes. Se você tiver uma ruptura do manguito rotador, o reparo cirúrgico geralmente produz resultados significativamente melhores do que a descompressão isolada. Apresentamos essas opções como uma decisão compartilhada, garantindo que você compreenda os benefícios e as limitações de cada etapa.

O que esperar

Para muitas pessoas, a dor no ombro causada por impingement e bursite melhora com o tratamento não cirúrgico. O tratamento específico com exercícios é eficaz e reduz a necessidade de cirurgia. Esses resultados são mantidos após 10 anos. Se a sua dor persistir, o manejo conservador continua sendo o pilar inicial principal, com a cirurgia reservada para casos que não melhoram.

A cirurgia é geralmente considerada se você tiver tido dor por pelo menos 6 meses, apresentar sinais de impingement mecânico no exame e não ter respondido a outras medidas. Quando esses critérios específicos são atendidos, os resultados são geralmente positivos. Você pode esperar melhora na função do ombro e na qualidade de vida. Esse benefício mantém-se verdadeiro mesmo se você estiver lidando com depressão subjacente ou sintomas depressivos.

Se você se submeter à descompressão subacromial artroscópica, sua recuperação segue um curso previsível. Mais de 90% dos pacientes conseguem voltar a dirigir em 4 semanas e ao trabalho em 6 semanas, conforme relatado em séries publicadas; no entanto, nossa orientação padrão continua sendo não dirigir por seis semanas após qualquer cirurgia no ombro, até ser liberado na consulta de acompanhamento. Se o seu procedimento envolver a remoção de depósitos calcificados, você pode precisar de mais tempo para retornar a atividades sem restrições e sem dor. A recuperação da função subjetiva do ombro leva quase 3 meses em média se as calcificações crônicas forem removidas sem acromioplastia.

É importante saber que essa cirurgia nem sempre é necessária ou benéfica para todos os problemas no ombro. Não há evidências sólidas que apoiem a descompressão subacromial para a tendinopatia do manguito rotador isolada. Além disso, se você precisar de reparo do manguito rotador, a descompressão subacromial formal não resulta em melhores desfechos clínicos até 2 anos após o reparo. Em alguns casos, os desfechos são significativamente melhores quando o reparo do manguito rotador é realizado sem descompressão.

Seu cirurgião ajudará você a decidir se a cirurgia é adequada para você com base em uma seleção cuidadosa dos pacientes. Se você não precisar de cirurgia, a terapia com exercícios oferece um caminho válido para o alívio. Se você decidir prosseguir, o objetivo é reduzir a dor e restaurar a função. Suas perspectivas dependem de quão bem o seu caso se enquadra nos critérios para esse procedimento específico.

Quando procurar um especialista

Procure uma avaliação especializada se a dor no ombro não melhorar com repouso e outras medidas não cirúrgicas após seis meses. Você também deve buscar ajuda se apresentar fraqueza, instabilidade ou se os sintomas interferirem no seu sono ou trabalho. A cirurgia é geralmente considerada quando há evidências claras de impacto mecânico. Seu cirurgião realizará um exame físico para verificar sinais específicos, como um teste de Hawkins positivo, para confirmar a causa. Isso ajuda a garantir que você seja selecionado adequadamente para o tratamento. A avaliação precoce pode esclarecer se mais cuidados conservadores ou um procedimento como a descompressão subacromial é o mais adequado para você.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

Management of subacromial impingement syndrome includes physical therapy, injections, and surgery for some patients [2].
There remains a need for high-quality studies of the pathology, etiology, and management of subacromial impingement syndrome [2].
Current randomized, controlled trial evidence shows no difference in outcomes of shoulder function or pain between surgical and conservative treatment for subacromial impingement syndrome [3].
Ultrasound guidance is not superior in the subacromial bursa and glenohumeral joint injections in pain or function [4].
Subacromial pain syndrome (SAPS) should preferably be treated non-operatively [6].
Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms of SAPS [6].
Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months in patients with shoulder impingement syndrome [10].
Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy at 5 years for patients with shoulder impingement syndrome [11].
Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy on return to work in patients with shoulder impingement syndrome [16].
Arthroscopic subacromial decompression yields good long-term results in the treatment of subacromial impingement for small full-thickness tears [13].
Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes [14].
For patients with a long-term disease course, operative treatments may be considered [15].
Standard arthroscopic subacromial decompression (ASD) surgery is preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression [15].
Preserving the subacromial bursa during rotator cuff surgery may lead to better rotator cuff healing when secondary pain is manageable [22].
Arthroscopic subacromial decompression is a valid treatment, reducing pain and improving quality of life for patients selected for surgery according to the Danish national guidelines [26].

Anatomy & Pathophysiology

Ultrasound guidance is not superior to landmark-based techniques for subacromial bursa injections regarding pain or function outcomes [4].
Ultrasound guidance is not superior to landmark-based techniques for glenohumeral joint injections regarding pain or function outcomes [4].
Ultrasound guidance is superior to landmark-based techniques for bicipital groove injections [4].
A comprehensive classification of individualized impingements around the anterior aspect of the shoulder has been proposed to address conflicting etiologic theories and improve understanding of diagnosis and treatment [5].
Imaging abnormalities of the acromioclavicular joint are common in asymptomatic shoulders [7].
Imaging abnormalities of the subacromial space are common in asymptomatic shoulders [7].
There is no relationship between acromiohumeral distance (AHD) and pain in adults with subacromial pain syndrome [18].
There is no between-group difference in AHD in neutral shoulder position between symptomatic and asymptomatic groups [18].
There is no between-group difference in AHD at 45° shoulder abduction between symptomatic and asymptomatic groups [18].
There is no between-group difference in AHD at 60° shoulder abduction between symptomatic and asymptomatic groups [18].
Subacromial notching rates are low following reverse shoulder arthroplasty using a 135° inlay humeral component and a lateralized glenoid [19].
Subacromial notching is not associated with functional outcomes at short-term follow-up [19].
Subacromial notching is not associated with range of motion at short-term follow-up [19].
Subacromial balloon spacer (SBS) implantation in cadaveric models of irreparable rotator cuff tears results in significant improvements in humeral head position at 0° shoulder abduction [31].
Subacromial balloon spacer (SBS) implantation in cadaveric models of irreparable rotator cuff tears results in significant improvements in humeral head position at 30° shoulder abduction [31].
Subacromial balloon spacer (SBS) implantation in cadaveric models of irreparable rotator cuff tears results in significant improvements in humeral head position at 60° shoulder abduction [31].
Subacromial balloon spacers resist superior humeral head migration in cadaveric studies [45].
Subacromial balloon spacers reduce subacromial pressure in cadaveric studies [45].
Conservation of sufficient subacromial space may have a significant impact on the passive and active function of reverse shoulder arthroplasty [33].
Conservation of sufficient coracohumeral space may have a significant impact on the passive and active function of reverse shoulder arthroplasty [33].
Conservation of scapular posture may have a significant impact on the passive and active function of reverse shoulder arthroplasty [33].
Understanding moment arms is essential to optimize active force generation in reverse shoulder arthroplasty [33].
Understanding muscle tensioning is essential to optimize reverse shoulder arthroplasty performance [33].
Superior capsular reconstruction (SCR) improves glenohumeral superior translation compared with rotator cuff tear at time zero [37].
Superior capsular reconstruction (SCR) improves subacromial contact pressure compared with rotator cuff tear at time zero [37].
The improvement in glenohumeral superior translation and subacromial contact pressure with SCR is independent of graft type [37].
Addressing aberrant movement patterns and facilitating balanced activation of all shoulder muscles may be an appropriate treatment direction for subacromial pain syndrome [34].
Scapular-focused interventions result in a between-group difference in shoulder abduction range of motion in the short term only [39].
Patients who are candidates for subacromial decompression have more pronounced range of motion deficits compared to non-candidates [40].
Patients who are candidates for subacromial decompression do not differ in self-reported shoulder function compared to non-candidates [40].
Patients who are candidates for subacromial decompression do not differ in strength compared to non-candidates [40].
Patients who are candidates for subacromial decompression do not differ in pain compared to non-candidates [40].
A decrease in abduction range of motion is associated with being considered a candidate for subacromial decompression [40].
A decrease in internal rotation range of motion is associated with being considered a candidate for subacromial decompression [40].
Increased pain during maximal abduction strength effort is associated with being considered a candidate for subacromial decompression [40].
The Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire may not be adequate to assess individuals with subacromial pain syndrome when pain occurs above 120 degrees of arm elevation [42].
Lifestyle factors including sleep behaviors and shoulder usage patterns are potential associations with subacromial impingement syndrome [48].
Improving sleep behaviors and optimizing shoulder usage patterns are effective measures to prevent subacromial impingement syndrome [48].

Classification

Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses [1].
The article proposes a comprehensive classification of all individualized impingements occurring around the anterior aspect of the shoulder, including newly described entities [5].

Clinical Presentation

Imaging abnormalities of the acromioclavicular joint and subacromial space are common in asymptomatic shoulders [7].
Synovitis in the subacromial space was milder and not associated with any clinical parameters [8].
Women aged between 30 and 60 years with subacromial pain syndrome and a calcific deposit of >1.5 cm in length have the highest chance of suffering from symptomatic calcific tendinopathy of the rotator cuff [20].
Night pain is a common complaint of patients presenting with impingement of the shoulder but cannot be used in isolation as a diagnostic predictor for the presence of a rotator cuff tear [32].
Examination of the cervical spine in patients with subacromial shoulder pain is variable in randomized controlled trials [24].

Investigations

Due to low certainty of evidence and significant variation among study populations, further research is needed to clarify prevalence estimates of shoulder abnormalities [7].
Ultrasound guidance is not superior to non-guided injection for pain or function outcomes in the subacromial bursa and glenohumeral joint [4].
Ultrasound guidance is superior to non-guided injection in the bicipital groove [4].
Synovitis in the subacromial space was found to be mild and not associated with any clinical parameters in patients with rotator cuff tears [8].
Diagnostic and therapeutic practices regarding internal impingement of the shoulder differ between surgeons, with French surgeons relying more on CT-arthrography and intra-articular injections while international surgeons favor MRI and physical therapy [41].
The acromiohumeral distance is significantly smaller on MRI compared to AP radiographs in shoulders with an intact rotator cuff [47].
The acromiohumeral distance on MRI should not be used as a decision criterion to assess glenohumeral centering or subacromial space width in shoulders with an intact rotator cuff [47].
Machine learning-based ultrasomics may be helpful in the preliminary screening of shoulder pain for subacromial impingement syndrome stages [49].
The subacromial space width is smaller in nearly all rotator cuff pathologies, becomes even smaller as condition severity increases, and is smaller in the case of a complete cuff tear [50].

Treatment

Ultrasound guidance is not superior to non-guided techniques in the subacromial bursa and glenohumeral joint injections regarding pain or function [4].
Subacromial pain syndrome should preferably be treated non-operatively, with subacromial injection with corticosteroids indicated for persistent or recurrent symptoms [6].
Most management regimes for subacromial impingement employ a minimum period of 12 weeks of conservative management incorporating physiotherapy and at least 2 subacromial steroid injections [9].
Arthroscopic subacromial decompression yields good long-term results in patients with small full-thickness tears [13].
Adding a large dose of shoulder strengthening to current nonoperative care for subacromial impingement did not result in superior shoulder-specific patient-reported outcomes [14].
For patients with a long-term disease course, operative treatments may be considered, with standard arthroscopic subacromial decompression (ASD) surgery preferred over arthroscopic bursectomy and open surgical technique [15].
Arthroscopic subacromial decompression is a valid treatment that reduces pain and improves quality of life for patients selected for surgery according to Danish national guidelines [26].
Five randomized trials found that formal subacromial decompression does not result in improved clinical outcomes up to 2 years after rotator cuff repair [27].
There is no evidence from available randomized controlled trials for differences in outcome in pain and shoulder function between conservatively and surgically treated patients with subacromial impingement syndrome [28].
The evidence on the effectiveness of surgical or conservative treatment of shoulder impingement is limited based on a review of seven randomized controlled trials [35].
There is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease [38].

Complications

Subacromial osteolysis has a relatively high and variable incidence following hook plate fixation for acromioclavicular dislocation [17].
The primary factor influencing the reported incidence of subacromial osteolysis is the radiological assessment method [17].
Rates of subacromial notching are low following reverse shoulder arthroplasty with a 135° inlay humeral component and a lateralized glenoid [19].
When subacromial notching occurs, it is not associated with functional outcomes or range of motion at short-term follow-up [19].

Recovery

Variation exists in the management regimes offered to patients with subacromial impingement, but most employ a minimum period of 12 weeks of conservative management incorporating physiotherapy and at least 2 subacromial steroid injections [9].
Arthroscopic subacromial decompression (ASD) in the treatment of subacromial impingement yields good long-term results [13].
For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression [15].
Subacromial osteolysis has a relatively high and variable incidence, and the primary factor influencing the reported incidence is the radiological assessment method [17].
There was no between group difference in acromiohumeral distance (AHD) in neutral shoulder position, shoulder abduction at 45° or 60° [18].
When subacromial notching occurs following reverse shoulder arthroplasty with a 135° inlay humeral component and a lateralized glenoid, it is not associated with functional outcomes or range of motion at short-term follow-up [19].
More than half of patients diagnosed with subacromial pain syndrome in specialist care settings do not adhere to recommendations regarding duration of exercise-therapy, but this is not related to symptom improvement [23].
Major improvements in pain/function were seen at mid- to long-term after isolated arthroscopic subacromial decompression and combined decompression/rotator cuff repair [25].
Adding a large dose of shoulder strengthening exercises to nonoperative care for 16 weeks did not significantly improve long-term outcomes in terms of shoulder disability, health-related quality of life, sick leave, or surgery rates at 1 year [29].
There was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years for partial-thickness rotator cuff tears treated with acromioplasty without repair [30].

Key Evidence

[L3] Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. [1] (10.1177/23259671251332942)
[L5] Management of subacromial impingement syndrome includes physical therapy, injections, and surgery for some patients, but there remains a need for high-quality studies of the pathology, etiology, and management of the condition. [2] (10.5435/00124635-201111000-00006)
[L1] Current randomized, controlled trial evidence shows no difference in outcomes of shoulder function or pain between surgical and conservative treatment for subacromial impingement syndrome. [3] (10.2106/jbjs.9202.ebo579)
[L1] Ultrasound guidance is not superior in the subacromial bursa and glenohumeral joint injections in pain or function. [4] (10.1016/j.arthro.2021.12.013)
[L4] The article proposes a comprehensive classification of all individualized impingements occurring around the anterior aspect of the shoulder, including newly described entities, to address conflicting theories and improve understanding of their etiologic factors, diagnosis, and treatment. [5] (10.1007/s00264-017-3515-1)
[Paper] SAPS should preferably be treated non-operatively, with subacromial injection with corticosteroids indicated for persistent or recurrent symptoms. [6] (10.3109/17453674.2014.920991)
[L2] Due to the low certainty of evidence and significant variation among study populations, further research is needed to clarify these prevalence estimates and to guide evidence-based management of shoulder abnormalities. [7] (10.1186/s13018-024-05378-4)
[L4] Synovitis in the subacromial space was milder and not associated with any clinical parameters. [8] (10.1177/23259671231207818)
[L4] Variation exists in the management regimes offered to patients with subacromial impingement, but most employ a minimum period of 12 weeks of conservative management incorporating physiotherapy and at least 2 subacromial steroid injections. [9] (10.1177/1758573215571010)
[L1] In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months. [10] (10.1136/bmj.k2860)
[L1] Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy at 5 years for patients with shoulder impingement syndrome. [11] (10.1136/bjsports-2020-102216)
[L3] ASD in the treatment of subacromial impingement yields good long-term results. [13] (10.1016/j.jse.2007.06.020)
[L1] Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes. [14] (10.1177/03635465211016008)
[L1] For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. [15] (10.1097/md.0000000000000510)
[L1] Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy on return to work in patients with shoulder impingement syndrome. [16] (10.1186/s12891-021-04768-7)
[L1] Subacromial osteolysis has a relatively high and variable incidence, and the primary factor influencing the reported incidence is the radiological assessment method. [17] (10.1016/j.jse.2024.03.018)
[L1] There was no between group difference in acromiohumeral distance (AHD) in neutral shoulder position, shoulder abduction at 45° or 60°. [18] (10.1038/s41598-020-76704-z)
[L3] When subacromial notching occurs, it is not associated with functional outcomes or range of motion at short-term follow-up. [19] (10.1016/j.jseint.2024.01.009)
[L3] This study demonstrates that women aged between 30 and 60 years with subacromial pain syndrome and a calcific deposit of >1.5 cm in length have the highest chance of suffering from symptomatic calcific tendinopathy of the rotator cuff. [20] (10.1016/j.jse.2015.02.024)
[L5] Preserving the subacromial bursa during rotator cuff surgery may lead to better rotator cuff healing when secondary pain is manageable. [22] (10.1530/eor-2024-0183)
[L3] More than half of patients diagnosed with subacromial pain syndrome in specialist care settings do not adhere to recommendations regarding duration of exercise-therapy, but this is not related to symptom improvement. [23] (10.1016/j.msksp.2021.102322)
[L1] Examination of the cervical spine in patients with subacromial shoulder pain is variable in randomized controlled trials. [24] (10.1177/1758573218798023)
[L3] Major improvements in pain/function were seen at mid- to long-term after isolated arthroscopic subacromial decompression and combined decompression/rotator cuff repair. [25] (10.1016/j.jor.2018.03.004)
[L4] Arthroscopic subacromial decompression is a valid treatment, reducing pain and improving quality of life for patients selected for surgery according to the Danish national guidelines. [26] (10.1016/j.jse.2017.03.028)
[L1] Five randomized trials found that formal subacromial decompression does not result in improved clinical outcomes up to 2 years after rotator cuff repair. [27] (10.1016/j.arthro.2012.06.003)
[L1] According to the best-evidence synthesis, there is no evidence from the available RCTs for differences in outcome in pain and shoulder function between conservatively and surgically treated patients with SIS. [28] (10.1016/j.jse.2009.01.010)
[L1] Adding a large dose of shoulder strengthening exercises to nonoperative care for 16 weeks did not significantly improve long-term outcomes in terms of shoulder disability, health-related quality of life, sick leave, or surgery rates at 1 year. [29] (10.1177/23259671251374314)
[L4] There was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years. [30] (10.1177/03635465020300021801)
[L4] SBS implantation in cadaveric models of irreparable rotator cuff tears results in significant improvements in humeral head position at 0, 30, and 60 of shoulder abduction. [31] (10.1177/03635465221150652)
[L3] Night pain is a common complaint of patients presenting with impingement of the shoulder but cannot be used in isolation as a diagnostic predictor for the presence of a rotator cuff tear. [32] (10.1111/j.1758-5740.2011.00133.x)
[L5] Conservation of sufficient subacromial and coracohumeral space and scapular posture may have a significant impact on the passive and active function of reverse shoulder arthroplasty, while understanding moment arms and muscle tensioning is essential to optimize active force generation and RSA performance. [33] (10.3390/jcm12041616)
[L1] Addressing aberrant movement patterns and facilitating balanced activation of all shoulder muscles may be a more appropriate treatment direction for the future. [34] (10.1177/1758573216660038)
[L1] Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. [35] (10.3109/09638288.2014.907364)
[L1] Independent of graft type, biomechanical studies suggest that SCR improves glenohumeral superior translation and subacromial contact pressure in comparison with RTC tear at time zero. [37] (10.1016/j.arthro.2023.08.025)
[L1] This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease. [38] (10.5435/00124635-200701000-00002)
[L1] A between-group difference in shoulder abduction ROM in the short term only was found. [39] (10.1080/09593985.2018.1423656)
[L4] A decrease in abduction and internal rotation range of motion, and increased pain during maximal abduction strength effort are associated with being considered a candidate for subacromial decompression, while self-reported shoulder function, pain during the last week, and rotator cuff strength are not. [40] (10.1007/s00167-018-4894-6)
[L4] Diagnostic and therapeutic practices regarding internal impingement of the shoulder differ between surgeons in France and in other countries, with French surgeons relying more on CT-arthrography and intra-articular injections, while international surgeons favor MRI and physical therapy. [41] (10.1016/j.otsr.2019.09.007)
[L4] The DASH may not be adequate to assess those with shoulder pain above 120 degrees of arm elevation. [42] (10.1093/ptj/pzab065)
[L1] In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. [45] (10.1016/j.asmr.2020.06.011)
[L4] The acromiohumeral distance is significantly smaller in the MRI in comparison to AP radiographs in shoulders with an intact rotator cuff and should not be used as a decision criterion on MRI to assess glenohumeral centering or subacromial space width. [47] (10.1007/s00167-020-06090-6)
[L1] This evidence supports the development of strategies aimed at improving sleep behaviors and optimizing shoulder usage patterns as effective measures to prevent SIS. [48] (10.1186/s12891-024-07345-w)
[L4] This noninvasive and low-cost approach may be helpful in the preliminary screening of shoulder pain. [49] (10.1002/jum.15914)
[L4] The subacromial space width is smaller in nearly all rotator cuff pathologies, but becomes even smaller as the severity of the condition increases and is smaller in the case of a complete cuff tear. [50] (10.1016/j.ultras.2003.11.015)

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