Subacromial Pain Syndrome
The biomechanical problems in those with rotator cuff tendinopathy and those with subacromial pain syndrome are fundamentally the same and so the physical therapy treatments are generally the same.
A Swedish study found good results from a 12 week exercise program for subacromial pain syndrome with a 5 year follow up. Participants were on the waitlist for surgery. They compared a group given non-specific neck and shoulder movement exercises, with a program targeting the strength of the rotator cuff and scapula stabilisers. All patients had tried conservative treatment previously, including physical therapy for many. Among the intervention group 20% ended up having surgery, compared to 63% in the control group. Other outcome measures were also higher in the intervention group. 
They used a pain monitoring model. Using a scale of 0 to 10, the programme allowed pain to go up to 5 out of 10, but if the pain continued to the next morning, or increased over time, then the intensity of exercise was reduced by reducing the resistance. The programme uses eccentric exercises for the rotator cuff, and eccentric/concentric exercises for the scapular stabilisers. The exercise programme is shown in the video below. Shoulder pulleys can be purchased online for example here. It is done twice a day for 8 weeks, then once a day for 4 weeks. Use a resistance where the patient can barely perform 20 repetitions, then use this resistance for 10-15 repetitions for 3 sets.
A large multicentre study in the UK involving 708 individuals with chronic rotator cuff conditions were randomised into 1:1:1:1 groups: 1) progressive exercise only (≤6 physiotherapy sessions); 2) best-practice advice only (1 physiotherapy session); 3) corticosteroid injection then progressive exercise (≤6 sessions); or 4) corticosteroid injection then best-practice advice (1 session).
There was no difference in symptomatic or functional improvement at 12 months with the home-based progressive exercise program compared to in-person physical therapy. The home-based group received one session with a physical therapist, self-management advice, printed information booklet, videos, and resistance bands, but no further in-person sessions. There was some evidence that corticosteroid injection modestly improved shoulder pain and function at 8 weeks, but no difference at 6 and 12 months. The most cost-effective intervention was the best practice advice plus a corticosteroid injection but there was uncertainty with this conclusion.(First reference is protocol, second reference is study findings).
The physiotherapist and participant together chose one or two exercises from the Best Practice Advice Exercise Ladder. The exercises are progressively harder the higher up the ladder. Patients start at the level of exercise they are capable of undertaking, not necessarily the lowest rung. If two exercises are chosen, they don't need to be in the same rung. The lowest level are simple exercises to reduce fear or movement, encourage normal movement, build mobility, and build confidence. Higher levels involve more resistance exercises.
The exercises should be moderately difficult. They begin with one set of eight repetitions at the selected load and build u p to 12 repetitions, and exercise once daily five days a week, with non-consecutive rest days. If the exercise(s) become too easy, another set can be added with a maximum of three sets. If this then becomes too easy, then the exercise is replaced with the next level of difficulty. The next level again starts with one set of eight repetitions, and builds up in the same manner. On the other hand, if things become too difficult, the load and/or number of sets/repetitions can be reduced.
It doesn't appear like they have shared the videos and information booklet, so this limits the external validity. However they did provide images of the exercises on the ladder, and a general outline of what the booklet contained.
- Main article: Subacromial Bursa Injection
Subacromial decompression was shown to provide no therapeutic benefit over diagnostic arthroscopy in a double blind study in patients who failed conservative treatment with isolated subacromial impingement.
- Holmgren et al.. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. British journal of sports medicine 2014. 48:1456-7. PMID: 25213604. DOI.
- Hallgren et al.. A specific exercise strategy reduced the need for surgery in subacromial pain patients. British journal of sports medicine 2014. 48:1431-6. PMID: 24970843. DOI.
- Björnsson Hallgren et al.. Specific exercises for subacromial pain. Acta orthopaedica 2017. 88:600-605. PMID: 28812398. DOI. Full Text.
- Keene et al.. Development and implementation of the physiotherapy-led exercise interventions for the treatment of rotator cuff disorders for the 'Getting it Right: Addressing Shoulder Pain' (GRASP) trial. Physiotherapy 2020. 107:252-266. PMID: 32026827. DOI.
- Hopewell et al.. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial. Lancet (London, England) 2021. 398:416-428. PMID: 34265255. DOI. Full Text.
- Paavola et al.. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ (Clinical research ed.) 2018. 362:k2860. PMID: 30026230. DOI. Full Text.
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