Subacromial shoulder pain treatment

Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

If you are reading this article you are likely someone with a job where your hands are constantly over your head, such as a home and commercial painter, landscaper, warehouse worker or you are yourself the parent of a swimmer or an athlete where a lot of throwing is involved. You are also likely to be someone who has had these shoulder problems explained to you as an overuse injury due to overhead motion.

Explanations are helpful. But if you have a job where you have to keep moving your hands over your head you need some type of solution. Well, at least you know why you have a lot of pain in the front of your shoulder towards the outside. You have subacromial shoulder pain. You may also have a lot of instability or looseness in your shoulder or you may feel that your shoulder is trying to lock itself up. Many times this occurs with an “on and off” frequency of looseness and tightness. You may also feel like you are losing muscle strength even to the point of dropping things out of your hand.

The situation is getting progressively worse, not better.

  • Your competitive athlete is not swimming or his/her/your training has been significantly altered in an attempt “just to keep you in the water, or, working out.” For the athlete, this leads to clear frustration and returning visits to clinicians who are trying to help but are not getting anywhere.
  • For the worker, this means a lot of medications to help get you through the day.

Summary discussion points of this article:

  • Subacromial shoulder pain – A shoulder pain in search of a diagnosis.
  • The difficulties in understanding subacromial shoulder pain or subacromial impingement syndrome.
  • Rest, Ice, Anti-inflammatories, and Cortisone have not helped generations of American swimmers, pitchers, or patients with Subacromial shoulder pain.
  • Treatment options for Subacromial shoulder pain did not seem to have helped nearly two generations of swimmers or pitchers.
  • When the problem of subacromial shoulder pain is not inflammation but instability.
  • Almost 40 years later – For many, exercise and physical therapy are not helpful either for subacromial shoulder pain.
  • The success of the surgery may not have been the surgery itself but rather, the placebo effect. The idea was that arthroscopic surgery for shoulder impingement was a valueless procedure.
  • Don’t have a subacromial shoulder pain surgery that does not help.
  • Arthroscopic bursectomy for subacromial shoulder pain.
  • Arthroscopic subacromial decompression for subacromial pain syndrome – does it get you back to work?
  • Non-surgical treatment addresses shoulder instability, wear and tear, and inflammation in the swimmer.
  • A look at physical therapy for subacromial shoulder pain.
  • The best training regimen for subacromial impingement syndrome – is there one?
  • Non-athletes don’t want to exercise their shoulder.
  • A look at Prolotherapy and Platelet Rich Plasma Therapy for subacromial shoulder pain.
  • No standard way to offer PRP treatment for shoulder impingement causes controversy.
  • PRP is best used in conjunction with Prolotherapy.

Subacromial shoulder pain – A shoulder pain in search of a diagnosis -The difficulties in understanding subacromial shoulder pain or subacromial impingement syndrome

Frustration mounts for the patient when treatments are not helping. You did not need us to tell you that. If you are reading this article, it is likely that you have been on a course of conservative treatments for some time and you have reached a new degree of urgency in finding your solution. Sometimes the doctors are frustrated too. It almost always has to do with not getting to the true root cause of your problem. If you do not get to the root of the problem, the problem remains.

The difficulties in understanding subacromial shoulder pain are described by doctors from the Department of Orthopedics, Brigham and Women’s Hospital, and Tufts University School of Medicine writing in The Journal of the American Academy of Orthopaedic Surgeons (1). The researchers write: “Coach, and clinician (must) be aware of the discerning characteristics among these different injuries to ensure a proper diagnosis and treatment plan to aid the swimmer in his or her return to competition.”

Is it really a Swimmer’s Shoulder?

Subacromial shoulder pain treatment -swimmer's shoulder

Swimmer’s shoulder is a broad term often used to diagnose shoulder injury obviously in swimmers. However, research has shed light on several specific shoulder injuries that often are incurred by the competitive swimmer.

  • Hyperlaxity (Excessive movement in the shoulder causing unnatural wear and tear and friction on the soft tissue – this is creating unchecked inflammation and shoulder erosion through tissue degeneration).
  • Scapular dyskinesis (or SICK scapula syndrome) is considered an overuse injury in which there is abnormal movement and resting location of the scapula (the shoulder blades or “wing” bones.” In other words, the scapula is not where it is supposed to be and it is causing unnatural wear and tear and friction on the soft tissue).
  • Subacromial impingement syndrome – the rotator cuff tendons and shoulder bursae are trapped under the acromion process, the bone of the “high point,” of the shoulder and this is causing unnatural wear and tear and friction on the soft tissue. Doctors may also look at os acromiale, (Doctors in France describe os acromiale as a failure of fusion of the acromial process, it is in a hypermobile state. It is usually asymptomatic and discovered by chance. When it is painful a differential diagnosis must be made in relation to the subacromial impingement syndrome. (2)
  • Shoulder labral damage,
  • Suprascapular nerve entrapment. The suprascapular nerve is responsible for the innervation (the supplying energy and messages) to the supraspinatus and infraspinatus muscles that attach to the scapula.
  • Glenohumeral rotational imbalances. A disruption of the natural range of motion of the shoulder.

The researchers of this study conclude: “An understanding of the mechanics of the swim stroke, in combination with the complex static and dynamic properties of the shoulder, is essential to the comprehension and identification of the painful swimmer’s shoulder. It is important for the athlete, coach, and clinician to be aware of the discerning characteristics among these different injuries to ensure a proper diagnosis and treatment plan to aid the swimmer in his or her return to competition.”

  • In other words, the clinician needs to investigate deeply the problems of the swimmer’s shoulder to enact the best and quickest treatments.

The damage seen on diagnostic ultrasound imaging could not be fully correlated with the pain the swimmer described

A 2023 research paper helps bring this data up to date. In this study published in the Journal of sports science & medicine (3) the researchers suggested that: “An understanding of the relationship between supraspinatus tendon and pain; and between supraspinatus tendon and strength would assist health care practitioners for developing training regime. ” They hypothesized that “structural abnormality of supraspinatus tendons positively associated with shoulder pain and negatively associated with shoulder muscle strength among elite swimmers.” Simply,  supraspinatus tendon damage would lead to less strength and more pain.

Here are some of the interesting points of this research, in our opinion.

  • 44 elite swimmers underwent examination using diagnostic ultrasound imaging and shoulder internal and external rotation strength was evaluated.
  • 82 shoulders had supraspinatus tendinopathy or tendon tear (93.18%).

Note:

  • However, “there was no statistically significant association between structural abnormality of supraspinatus tendon and shoulder pain.”

In other words, the damage seen on diagnostic ultrasound imaging could not be fully correlated with the pain the swimmer described. What was seen on imaging could not be declared the cause of the patient’s pain. The researchers concluded: “Structural change of supraspinatus tendon was not associated with shoulder pain.”

What are we seeing in this image?

This illustration demonstrates shoulder impingements caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement, the structures within the glenohumeral joint themselves have impinged. These conditions can be caused by excessive shoulder instability.

This illustration demonstrates shoulder impingements as caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement the structures within the glenohumeral joint themselves are impinged. These conditions can be caused by excessive shoulder instability.

Rest, Ice, Anti-inflammatories, and Cortisone have not helped generations of American swimmers, pitchers, or patients with Subacromial shoulder pain

Swimmer’s shoulder has been a problem for a long time. In 1980 Famed orthopedic surgeon Frank Jobe, the same surgeon who invented the Tommy John Surgeryjoined with Dr. Allen Richardson and Dr. H. Royer Collins from the National Athletic Health Institute, Inglewood, California to write in the American Journal of Sports Medicine (4) of the problem of swimmer’s shoulder in America’s best competitive swimmers:

  • Shoulder pain is the most common orthopedic problem in competitive swimming. In a group of 137 of this country’s best swimmers, 58 had had symptoms of “swimmer’s shoulder.”
  • Population characteristics of this group indicated that symptoms increased with the caliber of the athlete, were slightly more common in men, and were related to sprint rather than distance swimming. The use of hand-paddle training exacerbated symptoms, which were more common during the early and middle seasons.
  • Treatment included stretching, rest, ice therapy, oral anti-inflammatory agents, judicious use of injectable steroids, and surgery as a last resort.

Treatment options for Subacromial shoulder pain did not seem to have helped nearly two generations of swimmers or pitchers.

In looking at the 1980 paper above, we can see that this line of treatment was not helpful for two generations of elite swimmers. In 2015, writing in the American Journal of Sports Medicine, (5) doctors from the Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California wrote of applying The 1980 Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score to define functional and performance measures of the upper extremity in overhead athletes. To date, no study has investigated the baseline functional scores for swimmers actively competing in the sport. What the doctors were doing was to use The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score to come up with baseline measurements. They were surprised by what they found:

  • Baseline scores for swimmers, which were lower than expected, were lower than baseline scores seen in studies of other overhead sports athletes.
  • The data corroborate previous studies identifying swimmers as having a high level of shoulder trouble.
  • Further research is indicated for improving shoulder symptoms and performance in competitive swimmers.

It should be pointed out that a 2022 paper published in the International journal of sports physical therapy (6) noted that the Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score was an effective tool for young baseball players. “The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score can differentiate between younger baseball athletes throwing with and without pain. The predictive threshold score can be used in a clinical setting to aid with determining if a youth or high school-aged athlete is suffering from pain while participating in overhead throwing, and to guide rehabilitation management.”

This agreed with a 2013 paper (7) which wrote: Only 7 of 44 healthy asymptomatic pitchers (16%) had a Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score score below 90. Therefore, we believe that the Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score is an accurate assessment for overhead athletes and normal values should be greater than 90. Anything below this value could be a potential cause for concern for team physicians.

When the problem of subacromial shoulder pain is not inflammation but instability

Our clinic has published numerous studies on the problems of shoulder joint instability and inflammation. Some of this research is summarized below. The simple idea is that instability causes inflammation. If you do not correct the instability you can not correct the inflammation. Anti-inflammatory medications can only make the situation worse in the long run. To treat the problems of the swimmer’s shoulder, in our opinion, the swimmer must treat the problems of instability. This, of course, can be addressed in two ways, surgical and non-surgical treatment. Let’s start exploring.

Almost 40 years later – For many, exercise and physical therapy are not helpful for subacromial shoulder pain.

physical therapy are not helpful for subacromial shoulder pain
Physical therapy may not be helpful for subacromial shoulder pain

Supportive therapies to the standard care outlined in the near 40 years of research we are discussing are physical therapy and core strength conditioning. Here we may offer an answer to your question, why isn’t physical therapy helping me? Let’s say it again: When the problem is not inflammation, but instability.

Here is a 2018 study from the Department of Orthopedic Surgery, Copenhagen University Hospital. (8) It may explain the ineffectiveness of your physical therapy.

Here are the learning points:

  • What the study found is that under conservative care, patient-reported function and pain improved after six months but strength and range of motion did not improve.
  • The researchers found this interesting as strengthening exercises are part of most current interventions (conservative care recommendations for subacromial shoulder pain.)
  • The small gains per physio session or 1,000 min of exercise time reduce the clinical relevance of physical therapy and exercise.

The surgical option called into question, criticism from surgeons

The surgical option called into question, criticism from surgeons

We are going to follow a line of research from 201p0 to August 2022 that says shoulder impingement arthroscopic surgery should not be perfromed.

In 2010 Klaus Bak of the Parken’s Private Hospital, Copenhagen, Denmark wrote in the Clinical Journal of Sports Medicine: (9)

  • Balanced strength training of the rotator cuff, improvement of core stability, and correction of scapular dysfunction is central in treatment and prevention.
  • Technical and training mistakes are still a major cause of shoulder pain
  • Imaging modalities (MRI) rarely help clarify the diagnosis, their main role being the exclusion of other pathology.
  • If nonoperative treatment fails, an arthroscopy with debridement, repair, or reduction of capsular hyperlaxity is indicated.
    • The return rate and performance after surgery are low, except in cases where minor glenohumeral instability is predominant.
  • Overall, the evidence for clinical presentation and management of a swimmer’s shoulder pain is sparse.

When discussing surgical options for Swimmer’s shoulder, it is best to bring in surgical opinions. In our clinic, we offer non-surgical regenerative treatments. In many patients we see, surgery can be avoided. Below we will also discuss the scenario when the shoulder is “too far gone,” and surgery will be needed.

The success of the surgery may not have been the surgery itself but rather, the placebo effect. The idea that arthroscopic surgery for shoulder impingement was a valueless procedure

The idea that arthroscopic surgery for shoulder impingement was a valueless procedure was put worth in November 2017, when one of the leading medical journals in the world, The Lancet, (10) reported the findings of 51 surgeons operating at 32 hospitals around the United Kingdom.

In this study, 313 patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were considered eligible for arthroscopic surgery. These same patients had previously completed a non-operative management program that included exercise therapy and at least one steroid injection.

The 313 patients were then divided into three groups:

  1. Arthroscopic subacromial decompression surgery group (106 patients),
  2. investigational arthroscopy surgery only (103 patients),
  3. or no treatment (104 patients)

Here are the results of the researchers:

  • Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. (Not enough evidence to warrant surgery).
  • Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. (The more invasive and complicated surgery offered no further benefit).
  • The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. (The success of the surgery may not have been the surgery itself but rather, the placebo effect).
  • The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process. (Doctors should tell the patient that if they get the more invasive surgery, the less invasive surgery, or no treatment, their outcomes will be about the same).

And finally, in the study recap:

“During the past three decades, clinicians and patients with subacromial shoulder pain have accepted minimally invasive arthroscopic subacromial decompression surgery in the belief that it provides reliable relief of symptoms at low risk of adverse events and complications. However, the findings from our study suggest that surgery might not provide a clinically significant benefit over no treatment.”

In an accompanying article in The Lancet, Netherland University researchers Berend W Schreurs and Stephanie L. van der Pas wrote:(11)

“The findings send a strong message that the burden of proof now rests on those who wish to defend the standpoint that shoulder arthroscopy is more effective than non-surgical interventions. Hopefully, these findings from a well-respected shoulder research group will change daily practice. The costs of surgery are high, and although the low occurrence of complications might suggest that the surgery is benign, there is no indication for surgery without possible gain.”

In other words, don’t have a surgery that does not help.

This study was back in 2018 when, in a landmark study, Finnish researchers showed that arthroscopic surgeries of the shoulder are useless for patients with “shoulder impingement.”

This is the simple conclusion of this groundbreaking study that appeared in the British Medical Journal, July 19, 2018 (12)

“The results of this randomized, placebo surgery controlled trial show that arthroscopic subacromial decompression provides no clinically relevant benefit over diagnostic arthroscopy in patients with shoulder impingement syndrome. The findings do not support the current practice of performing subacromial decompression in patients with shoulder impingement syndrome.”

There are times when tearing of the rotator cuff tendons are so catastrophic, because preventive treatment was delayed or anti-inflammatory treatments went on too long, that the swimmer must make a decision on whether to go through with more invasive surgery, to address the rotator cuff or to address the options surrounding a bursectomy, the surgical removal of the shoulder bursa (bursae).

  1. They are going to continue swimming
  2. How long can they allow themselves to recover in terms of months perhaps years?
  3. Is surgery likely to be of help?
  4. Will the surgery leave you with impaired strength and make itself useless to you for the goal of returning to swimming?

A September 2022 Update: An athlete may elect symptomatic management rather than surgery so that he or she may continue competing until the pain begins to interfere with daily life. Then choose between these surgeries.

Doctors at the Department of Orthopaedic Surgery, University of Kentucky School of Medicine wrote this StatPearls, (13) part of the National Center for Biotechnology Information internet library, September 2022 update:

  • “Surgery is appropriate for structural pathologies (damage). An athlete may elect symptomatic management rather than surgery so that he or she may continue competing until the pain begins to interfere with daily life.
  • For swimmers with persistent multidirectional instability, a capsular plication (this is a radiofrequency (RF) procedure that hopes to tighten soft tissue in the shoulder through a contraction)  or inferior capsular shift procedure (this is an open surgical procedure where the bottom part of the shoulder’s soft tissue is pulled up and the top part is pulled down and secured.)
  • Athletes should be aware, however, that training volumes may need to be reduced permanently to avoid pain.
  • A subacromial exploration and removal of the hypertrophied, inflamed, and scarred tissue (thereby maintaining the structural integrity of the shoulder) is an option for athletes who obtain only limited relief from physical therapy. For swimmers with a labral tear in whom nonsurgical treatment has failed, the next treatment option is labral debridement or repair.”

An August 2022 editorial: Arthroscopic Treatment Should No Longer Be Offered to People With Subacromial Impingement

An editorial from doctors at Monash University in Finland was published in the medical journal Arthroscopy (14). The title of this editorial is: “Arthroscopic Treatment Should No Longer Be Offered to People With Subacromial Impingement.” Here is the opinion from the Monash University doctors:

“Arthroscopic treatment should no longer be offered to people with subacromial impingement. In many people, subacromial impingement (or subacromial pain syndrome) is self-limiting and may not require any specific treatment. This is evident by the fact that almost 50% of people with new-onset shoulder pain consult their primary care doctor only once. The best-available evidence from randomized controlled trials indicates that glucocorticoid injection provides rapid, modest, short-term pain relief. Exercise therapy has also been found to provide no added benefit over glucocorticoid injection. Subacromial decompression (bursectomy and acromioplasty) for subacromial pain syndrome provides no important benefit on pain, function, or health-related quality of life. Acromioplasty does not improve the outcomes of rotator cuff repair.”

Arthroscopic bursectomy

An arthroscopic bursectomy is usually offered as part of the overall “clean-up” or repair of the damaged shoulder joint. The bursectomy may be done during rotator cuff repair or in the context of this article, within a subacromial decompression procedure. Sometimes Arthroscopic bursectomy is performed as a stand-alone or primary procedure in the treatments of shoulder bursitis that is no longer responding to anti-inflammatory or corticosteroid management. During the surgery, if it is determined that even with the complete removal of the inflamed bursa that the shoulder is still a threat of continued impingement, then a subacromial decompression may be performed.

Some people do have good success with Arthroscopic bursectomy, but not everyone. A December 2020 study in the Journal of shoulder and elbow surgery (15) suggested that  “varying results after surgery in patients with subacromial pain syndrome have raised the question on whether there is a subgroup of patients that can benefit from surgery.” Note: As mentioned above certain surgeries remain controversial in that they can make the patient’s situation worse). In this study, the researchers found: “arthroscopic bursectomy is less effective in patients with subacromial pain syndrome with a degenerative shoulder. This finding suggests that an improved treatment effect of arthroscopic subacromial bursectomy can be expected in patients with chronic subacromial pain syndrome if intra-articular pathologies such as glenohumeral osteoarthritis are sufficiently excluded.” In other words in an unstable, degenerative shoulder, subacromial bursectomy will not be effective for many.

Arthroscopic subacromial decompression for subacromial pain syndrome – does it get you back to work?

Doctors in Finland published an October 2021 paper (16) in which they looked at the results of arthroscopic subacromial decompression. They noted that arthroscopic subacromial decompression is one of the most commonly performed shoulder surgeries in the world. It is performed to treat patients with suspected shoulder impingement syndrome, i.e., subacromial pain syndrome. What they also noted was that only a few studies “have specifically assessed return-to-work rates after subacromial decompression surgery.”

The researchers took one hundred eighty-four patients for this randomized trial.

  • 57 people had undergone arthroscopic subacromial decompression
  • 59 people had diagnostic arthroscopy, a placebo surgical intervention
  • 68 people had exercise therapy

Then the patients of the study were assessed for how many of them actually returned to work.

The results:

  • There was no difference in the outcomes of return to work between the study groups.
  • By 24 months, 50 of 57 patients (88%) had returned to work in the arthroscopic subacromial decompression group, while the respective figures were 52 of 59 (88%) in the diagnostic arthroscopy group and 61 of 68 (90%) in the exercise therapy group.
  • No clinically relevant predictors of return to work were found. The proportion of patients at work was 80% (147/184) at 24 months and 73% (124/184) at 60 months, with no difference between the treatment groups.

Conclusions: “Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy on return to work in patients with shoulder impingement syndrome. We did not find clinically relevant predictors of return to work either.”

At what point does conservative care fail and surgery should be performed?

Let’s have April 2023 research published in the International journal of sports physical therapy (17), help us answer the question: At what point does conservative care fail and surgery should be performed? Here is what the researchers of this study noted:

“Subacromial decompression (SAD) surgery remains a common treatment for individuals suffering from subacromial pain syndrome (SAPS), despite numerous studies indicating that Subacromial decompression (SAD) surgery provides no benefit over conservative care. Surgical protocols typically recommend surgery only after exhausting conservative measures; however, there is no consensus in the published literature detailing what constitutes conservative care “best practice” before undergoing surgery.”

In other words, there is no consensus as to when to go to surgery or not. Further:

“Conservative care that individuals with subacromial pain syndrome (SAPS) receive to prevent advancement to Subacromial decompression (SAD) surgery appears inadequate based on the literature.”

In other words, the tradition conservative care does not appear to prevent the need for surgery. That is according to research. Further:

“Interventions, such as physical therapy, Subacromial injections (anesthetics and / or corticosteroids), and NSAIDs, are either underreported or not offered to individuals with subacromial pain syndrome prior to advancing to surgery. Many questions regarding optimal conservative management for subacromial pain syndrome persists.”

In other words, it is unclear if these therapies work because there is not enough outcomes studies or doctors are skipping them and recommending a sooner surgery.

Non-surgical treatment addressing shoulder instability, wear and tear, and inflammation in the swimmer

At our clinic, we have provided more than 28 years of service to patients seeking non-surgical options to get them back to their sport. In this section, we will show our research and research of other clinicians in offering non-surgical solutions to “Swimmer’s Shoulder.”

Part of the reason for arthroscopic surgical failure is that it does not properly address the problems of hypermobility and shoulder instability. Possibly, because you are removing tissue in the shoulder during surgical procedures, the problem of instability becomes worse.

The problem of how to deal with this instability was reflected in a study from the Hospital for Special Surgery, published in 2018 in the journal Current Reviews in Musculoskeletal Medicine. (18)

“Swimmers may develop increased shoulder laxity over time due to repetitive use. Such excessive laxity can decrease passive shoulder stability and lead to rotator cuff muscle overload, fatigue, and subsequent injury in order to properly control the translation of the humeral head (the movement of the shoulder).

  • Generalized laxity can be present in up to 62% of swimmers, while a moderate degree of multi-directional instability can be present in the majority.
  • Laxity in swimmers can be due to a combination of underlying inherent anatomical factors as well as repetitive overhead activity.
  • The role of excessive laxity and muscle imbalance is crucial in the swimmer’s shoulder and should be well understood since they are the primary target of the training and rehabilitation program.”

A look at physical therapy for subacromial shoulder pain treatment

physical therapy for subacromial shoulder pain treatment

Like the world of regenerative medicine, physical therapists seek to prevent further destruction of the swimmer’s shoulder with a rehabilitation plan.

A review published in the North American Journal of Sports Physical Therapy, (19) gives a good outline of the challenges facing physical therapists in helping the patient with a swimmer’s shoulder.

“Physical therapists involved in the treatment of competitive swimmers should focus on prevention and early treatment, addressing the impairments associated with this condition, and analyzing training methods and stroke mechanics.”

“Swimmers shoulder is a condition that may be prevented with adequate preseason screening that can identify impairments and training errors that may lead to symptoms. If a swimmer does become symptomatic during the season, the physical therapist should identify the most likely impairments or training errors and rule out any significant tissue pathology that would warrant a referral to an orthopedic surgeon. A comprehensive rehabilitation program usually includes strengthening of the rotator cuff and scapular stabilizers, stretching anterior chest musculature that may be shortened, and implementing activity modification so the athlete can still participate in the sport.”

Exercise ineffective in some subacromial pain syndrome patients who suffer from a greater sensuosity to pain and they have a lower tolerance for pain

A July 2022 study published in the European journal of pain (20) examined the effects of exercise on clinical pain and pain mechanisms in patients with subacromial pain syndrome.

This study examined:

  • If 8-weeks of exercise could modulate clinical pain or temporal summation of pain (this is a condition where the same arm movement causes an increase in pain intensity, if you lifted your arm above your head, it hurts worse the more you do it), conditioned pain modulation (the patient was given a treatment to lessen the pain), and exercise-induced hypoalgesia (exercise decrease pain intensity) and
  • If any of these parameters could predict the effect of 8-weeks of exercise in patients with un this study of 37 patients, ilateral subacromial pain syndrome.

In this study of 37 patients , the researchers findings suggested reduction in pain and improved sleep quality after 8-weeks of exercise. Furthermore, the results suggests that low pain intensity and high temporal summation of pain scores (indicative for pain sensitization) may predict a lack of pain improvement after exercise.

  • The reason for physical therapy and exercise not being successful in some subacromial pain syndrome is that the patient suffers from a greater sensitivity to pain and lower tolerance for pain.

The best training regimen for subacromial impingement syndrome - is there one?

The best training regimen for subacromial impingement syndrome – is there one?

A January 2022 study from researchers in Denmark published in the journal BMC Musculoskeletal Disorders (21) looked to answer the question regarding the best training regimen for subacromial impingement syndrome. While they found effective training programs, they did not find the best. Here is what they wrote:

“There is no consensus on the best training regimen for subacromial impingement syndrome. Several have been suggested but never tested. The purpose of the study is to compare a comprehensive supervised training regimen based on the latest evidence including heavy slow resistance training with a validated home-based regimen (you are on your own training). We hypothesized that the supervised training regimen would be superior to the home-based training regimen.

In this study, 126 consecutive patients with subacromial impingement syndrome were recruited and divided into two groups with each group getting 12 weeks of either supervised training regimen, or home-based training regimen. What the researchers found was that both the supervised by therapist group and the at home do-it-yourself group had very similar results for pain and function after six months. The wrote: “We found no significant difference between a comprehensive supervised training regimen including heavy training principles, and a home-based training program in patients with subacromial impingement syndrome.”

For many people, there are no long sessions of physical therapy. Many, perhaps like yourself, were given one or two or three sessions of supervised physical therapy that focused on demonstrations of exercises that you would be able to perform on your own. Most of the exercises involved stretching and then strengthening exercises. You were probably also given instruction not to do those activities that would aggravate your shoulder pain.

Improving exercise outcomes in middle-aged men with subacromial impingement

An August 2022 study (22) looked at purposeful blood flow restriction in strengthening exercises in two patients with subacromial impingement and high irritability.

In brief, the case history doctors noted that evidence shows individuals exercise can help patients presenting with subacromial impingement syndrome. This includes strengthening exercises directed at the shoulder musculature. The doctors write: “Patients with subacromial impingement syndrome can present with pain during and after completion of heavy resistance training limiting the applicability of this recommended treatment approach. Blood flow restriction (in simplest terms, the use of a compression cuff to restrict blood flow temporarily to the injured shoulder ) training is indicated for patients who have pain while completing heavy resistance training and may represent an important treatment modification for patients with subacromial impingement syndrome unable to fully participate in a strengthening exercise program.”

In this study: “Two middle aged, non-operative patients with signs and symptoms consistent with subacromial impingement syndrome and high levels of irritability were included. Treatment over one month consisted of three commonly used exercises in the treatment of subacromial impingement syndrome in conjunction with a standard BFR protocol: 75 reps broken up into sets of 30,15,15,15 with the BFR cuff placed over proximal humerus (to of the shoulder). At the end of the course of treatment, clinically meaningful improvements were observed in patient reported outcomes (in pain reduction and functionality).

Non-athletes don’t want to exercise their shoulder

Older patients and those patients who no longer compete at a high level or have given up sport have mixed feelings about how much exercise can help their Subacromial shoulder pain. Many do not comply to exercise programs given to them to do at home. A January 2021 study (23) notes:

  • “Exercise is recommended for patients with subacromial pain.
  • It has been suggested that good exercise adherence improves clinical outcomes.
  • Despite this, little attention has been paid to the need for behavioral frameworks to enhance adherence to home exercise programs for patients with subacromial pain.”

In other words, patients are not adhering to the exercise program they were given. Why? In some patients we see, there is a fatigue in constantly doing treatments or therapies that the patient sees as not helping.  In this study, an exercise program was introduced to the study participants “who had received conservative treatment during the past 6 months.” What did these researchers find? Recruitment (simply getting patients to participate in an exercise study) and adherence to the self-managed exercise program were both below the anticipated level.

A look at Prolotherapy and Platelet Rich Plasma Therapy for Shoulder Instability and Pain

At our clinic, we frequently work with physical therapists who are treating athletes. For physical therapy to achieve maximum benefit in the patient with Subacromial shoulder pain, the shoulder capsule itself has to be capable of providing muscle resistance. If the tendons of the rotator cuff and the ligaments that hold the bone structure of the shoulder are compromised, as seen by excessive shoulder instability and hypermobility, including partial dislocation, the shoulder may not be able to provide the resistance needed for maximum gain.

When it comes to seeking non-surgical options in the treatment of difficult to treat or chronic shoulder pain, patients frequently find themselves researching our injection treatments of Comprehensive Prolotherapy incorporating various treatments to include Platelet Rich Plasma Therapy and Dextrose Prolotherapy.

These injection techniques stimulate the repair of injured tissue and have been cited in the research as curative for chronic pain.

Platelet Rich Plasma Therapy is an injection treatment that re-introduces your own concentrated blood platelets into areas of chronic joint and spine deterioration, more commonly referred to as PRP. There are many orthopedic surgeons now offering this treatment.

For the competitive swimmer or worker who does a physically demanding job requiring overhead movements, we utilize a more aggressive approach as demonstrated in the video.

In this video, a general demonstration of Prolotherapy and PRP treatment is given.
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:

  • PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
  • In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
  • The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
  • This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
  • The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
  • With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
  • PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
  • PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.

One steroid versus one Prolotherapy treatment subacromial steroid injections

A October 2023 paper in the American journal of physical medicine & rehabilitation (24) compared the treatment effectiveness of subacromial steroid injections and dextrose prolotherapy for chronic subacromial bursitis patients. The study concluded “Both hypertonic dextrose prolotherapy and steroid injections can provide short-term improvements of pain and disability among chronic subacromial bursitis patients. Moreover, steroid injections showed better effectiveness than hypertonic dextrose prolotherapy in ameliorating pain and improving function.”

In this study, the steroid injection did better at 12 weeks after treatment than Prolotherapy. As written many times, Prolotherapy, for most people, is best given as a repeat course. At the 4 – 6 week interval. It is interesting to note that Prolotherapy’s effect could suggest a rebuilding of supporting tissue whereas the steroid worked to reduce inflammation.

There were chronic subacromial bursitis 54 patients enrolled in this double-blind randomized controlled trial. Shoulder Pain and Disability Index and visual analog scale were the primary outcomes. (Pain and function before and after assessed through questionnaire).

  • Results: Pain reduction.
    • The 26 patients in the steroid group exhibited significant visual analog scale score (pain reduction) improvements comparing with baseline at weeks 2, 6, and 12 weeks. The dextrose prolotherapy group 28 patients exhibited visual analog scale score improvements at weeks 6 and 12.
  • Results: Improved function.
    • The steroid group displayed significant Shoulder Pain and Disability Index score improvements (pain and function improvements) compared with baseline at weeks 2, 6, and 12
    • The dextrose prolotherapy group exhibited significant score decreases (improvements) at weeks 2 and 6. Compared with the dextrose prolotherapy group, the steroid group demonstrated significantly greater decreases in visual analog scale scores at weeks 2 and 6; the steroid group showed significantly greater decreases in Shoulder Pain and Disability Index scores at weeks 2, 6, and 12.

No standard way to offer PRP treatment for shoulder impingement causes controversy

The medical literature is filled with studies suggesting that PRP treatment is effective for a myriad of shoulder problems. PRP works because it addresses damaged tendons and repairs them in a non-surgical way by rebuilding tissue on a cellular level. We are going to stress throughout this segment of our article, our more than 25 years of experience in offering regenerative medicine techniques, such as PRP and will call into question doctors and clinicians who offer this treatment after attending a weekend workshop and then announce to their patients that this treatment does not seem to be effective. We will also bring attention to “failed PRP” treatments that consist of a “single injection.”

In a new study from 2018, Doctors at The Orthopedic-Traumatology Department of Prostějov Hospital in the Czech Republic published these observations. (25)

This study aimed to explore the effects of new therapeutic procedures in patients with shoulder impingement syndrome. The primary goal of the study was to confirm the hypothesis that the application of the platelet-rich plasma (PRP) in patients with shoulder impingement syndrome will have a positive effect on both the subjective and objective evaluation of their condition.

The secondary goal was to compare the effect achieved by a series of 3 PRP injections and that achieved by treating the impingement syndrome with a standard single depot corticosteroid injection.

The PRP injection was given at  6 weeks, 3 months, and 6 months after the administration of the injection.

CONCLUSION of Study: “Based on the results of our study, the hypothesis can be accepted that the concentrate of platelet-rich plasma administered through a series of 3 injections applied in the subacromial space in patients with shoulder impingement syndrome has positive effects on the daily activities of patients as well as on the objective evaluation via the selected scoring systems.”

Research like that above, where more than one injection is given counters research that measures PRP’s ability to help swimmer’s shoulder with only one or two injections.

In the May 2017 issue of the Orthopaedic Journal of Sports Medicine(26) doctors compare PRP injections to exercise as non-surgical treatments of subacromial shoulder pain. Here are the learning points of this research:

  • The doctors went into the study with an expectation that Platelet-rich plasma (PRP) would be an effective method in treating subacromial impingement.
  • This was a single-blinded randomized clinical trial with 1-, 3-, and 6-month follow-up.
  • Sixty-two patients were randomly placed into 2 groups, receiving either PRP or exercise therapy.
    • The outcome parameters were pain, shoulder range of motion (ROM), muscle force, functionality, and magnetic resonance imaging findings.
  • Results: Both treatment options significantly reduced pain and increased shoulder ROM compared with baseline measurements.
  • Both treatments also significantly improved functionality.
  • Both PRP injection and exercise therapy were effective in reducing pain and disability in patients with subacromial shoulder pain, with exercise therapy proving more effective.

Two injections do not make comprehensive treatment

  • The study above indicated that two treatments of PRP worked very well, but over the same course of time exercise worked a little better. What if the subjects of this study received a more aggressive PRP program, what if the more aggressive PRP was combined with physical therapy? Would not the swimmer get back to the pool that much faster? What if we now add the third component? The dextrose Prolotherapy.

PRP is best used in conjunction with Prolotherapy

In our clinic, we have found that when we use PRP to strengthen tendons within the shoulder capsule, we can help those tendons heal and strengthen by using dextrose Prolotherapy to strengthen the ligaments that surround the shoulder capsule. This process is again, described in the video above.

Prolotherapy on its own has been shown to be an effective treatment for shoulder repair.

In 2013, Medical University research teams in Turkey presented their findings on “The Effects of Prolotherapy in Patients With Subacromial Impingement Syndrome.” (27) These are the learning points of their research:

  • Recent treatments for subacromial impingement syndrome are palliative (in other words treating the symptom and not the cause). Dextrose injection, Prolotherapy, has emerged as a treatment option for chronic situations such as shoulder tendonitis and shoulder bursitis.
  • The aim of the study is to investigate the effects of dextrose injection in patients with chronic shoulder pain caused by subacromial impingement syndrome.

In this single-center, randomized placebo-controlled, single-blind, prospective study, 80 patients with chronic subacromial impingement syndrome who met the study criteria received two dextrose injections in the affected shoulder at two weeks intervals.

The patients were randomly assigned into two therapy groups, either dextrose or other control (lidocaine) groups.

The injections were repeated two times with two weeks between injections.

  • Clinical assessments included measurement of:
    • range of motion (ROM),
    • pain assessment
    • shoulder functions and daily living activities
    • Magnetic resonance imaging (MRI) evaluation was conducted before the first injection and compared with MRI’s taken again on the third month following the second injection.

Results:  The study demonstrated significant improvements in function and pain in both injection groups. Shoulder flexion, abduction, internal and external rotations showed significant improvements in both groups in the first 3 months. While the range of shoulder flexion did not improve in the control group during the last three months, this range of motion continued to improve significantly in the Prolotherapy treatment group over the same period.

Again we want to point out here that the patients received benefits from only two injections, please watch the video for a comparison of our more aggressive treatment.

Caring Medical Research

Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago.

In our research, published in Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, (28) Ross Hauser, MD and Danielle R. Steilen-Matias, MMS, PA-C  contributed to findings suggesting Dextrose Prolotherapy has been able to reduce pain and disability of traumatic and nontraumatic rotator cuff conditions.

  • Research revealed that treatment of moderate to severe rotator cuff tendinopathy due to injury with injections of hypertonic dextrose on painful entheses (the ligament and tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline.
  • In a retrospective case-control study, dextrose Prolotherapy improved pain, disability, isometric strength, and shoulder active range of motion in patients with refractory chronic non-traumatic rotator cuff disease.

In our research published in The Open Rehabilitation Journal (29) our research team found that lesions of the glenoid labrum are a common cause of shoulder instability and a frequent finding in patients with shoulder pain. Management of these patients typically involves an attempt to avoid surgery through conservative treatment. However, there is currently a dearth of conservative options that promote labral healing.

  • Regenerative injection therapies, including Prolotherapy, have shown promise in the treatment of several musculoskeletal disorders, but have not previously been applied to a glenoid labral tear.
  • Here we review several important aspects of these lesions and present an initial case series of 33 patients with a labral tear that was treated in our clinic with intra-articular injections of hypertonic dextrose.
  • Patient-reported assessments were collected by questionnaire at a mean follow-up time of 16 months.
  • Treated patients reported highly significant improvements with respect to pain, stiffness, range of motion, crunching, exercise, and need for medication.
  • All 31 patients who reported pain at baseline experienced pain relief, and all 31 who reported exercise impairment at baseline reported improved exercise capability. Patients reported complete relief of 69% of recorded symptoms. One patient reported worsening some symptoms. Prolotherapy for glenoid labral tear appears to be a safe procedure that merits further investigation.

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This article was updated October 8, 2023

 

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