Subacromial Impingement

Subacromial or “external” impingement is a common shoulder condition believed to contribute to the progression of rotator cuff disease. Ever since Dr Charles Neer’s 1972 proposal, the undersurface of the anterior acromion has historically, been seen as the culprit in rotator cuff disease and the “anterior acromioplasty” or “subacromial decompression” as the gold standard treatment choice.


In New York State (USA) alone between 1996 and 2006 there was a 254.4% increase in the number of acromioplasties performed (Vitale et al, 2010 JBJS). However, this external irritation model has come under question more recently leading to speculation about the need for routine decompression surgery. Recent evidence suggests an internal derangement or “intrinsic tendinosis” of the cuff tendons with high concentrations of pain producing chemicals and no real evidence of inflammation similar to other tendinopathies seen in the elbow, achilles and patella, Lewis J (2011).

A new model has been put forward for the continuum of rotator cuff tendinopathy by Lewis J (2010) which considers multiple contributory factors leading to tendon reactivity, disrepair and degeneration.

For example, an acutely “overloaded” tendon, possibly due to an unaccustomed or dynamic activity involving speed or a return to sport in a non graduated way could become “reactive”, causing it to swell and increase in volume thereby compressing it and potentially irritating the bursal tissue above it (bursitis) leading to a situation of subacromial impingement with over head or unguarded activities?

What does this mean for you?

Well I am happy to say that things have changed since 1972 and so they should have, don’t you think?

Don’t get me wrong, there is still a place for surgery in the treatment of subacromial impingement. However, in the light of new and emerging evidence for the conservative management of tendinopathies and the fact that current evidence fails to show any significant difference in effectiveness between surgical and conservative treatments, surgery should take a back seat until a comprehensive conservative shoulder physiotherapy program has been completed. Even Dr Neer supported this notion recommending at least 18 months of conservative management prior to any surgical consideration.

What is critical is the effectiveness of the shoulder physiotherapy exercise program? One such conservative program aimed at helping solve your impingement problem is SuperFastShoulders.


Read more:

Common Signs & Symptoms of Subacromial Impingement

Understanding The Causes of Subacromial Impingement Syndrome

Why You Should Seek Treatment For Subacromial Impingement Syndrome


Reference Articles:

Lewis, JS (2010) Rotator cuff tendinopathy: a model for the contiuuum of pathology and related management. Br J Sports Med 44, 918-23

Lewis, JS (2011) Subacromial impingement syndrome: A musculoskeletal condition or clinical illusion? Physical Therapy Review 16, 388-398

Neer CS (1972) Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 54: 41–50.

Neer CS (1983) Impingement lesions. Clin Orthop: 70–77.

Vitale, MA; Arons, RR; Hurwitz, S; Ahmad, CS; Levine, WN (2010) The Rising Incidence of Acromioplasty. J Bone Joint Surg Am 92(9):1842-1850