Subacromial Pain Syndrome


125 Subacromial Pain Syndrome


Egbert J. D. Veen MD and Ron L. Diercks MD


Department of Orthopedics, University of Groningen, University Medical Center Groningen, The Netherlands


Clinical scenario



  • A 48‐year‐old male presents to an orthopedic surgeon with shoulder complaints.
  • He works in a hardware store and has had progressive pain in his right shoulder for five months. The pain is located anterolateral and radiates to the upper arm. There is no history of trauma, overhead activities are painful, and sleeping is disturbed.
  • At examination there is a painful arc between 70 and 120°. The Neer sign and Hawkins–Kennedy test are positive.
  • The orthopedic surgeon doubts whether he uses an magnetic resonance imaging (MRI) or ultrasound (US) to investigate the persistent complaints.
  • A subacromial injection with local anesthetic and steroids gave relieve.

Top three questions



  1. Does the Hawkins–Kennedy test predict subacromial pain syndrome (SAPS) better in patients with shoulder pain compared to other physical tests?
  2. How sensitive is an MRI scan in comparison to US for diagnosing SAPS in patients with shoulder pain?
  3. Does surgery lead to a better functional outcome compared to conservative treatment (physiotherapy, infiltrations) in patients with SAPS?

Question 1: Does the Hawkins–Kennedy test predict subacromial pain syndrome (SAPS) better in patients with shoulder pain compared to other physical tests?


Rationale


SAPS causes pain, impairment in daily activities and work, and a clear and unambiguous anatomical substrate is lacking.1 It is a frequently encountered condition in daily practice of orthopedic surgeons; between 7 and 34% of adults have shoulder pain at times and the incidence of shoulder pain in is estimated to be 19 per 1000 person‐years, and is highest in women over 45 years and lowest in young adults. In the general practice the incidence is 0.8–2.3%, with a lifetime prevalence of up to 66.7%.2 A thorough physical examination is an essential diagnostic tool and can help to rule out other shoulder pathologies. Though often associated with rotator cuff tears, the discussion of SAPS in this chapter will not include cuff tears. Please see Chapters 123 and 124 for a full discussion of rotator cuff pathology.


Clinical comment


Many shoulder tests are available to test a variety of diagnoses of the shoulder. One commonly used test is the Hawkins–Kennedy test.3 The patients is examined while sitting with their shoulder flexed to 90° and their elbow flexed to 90°. The examiner grasps and supports proximal to the wrist and elbow to ensure maximal relaxation. The examiner and the patient then quickly rotate the arm internally. The test is considered positive when the pain is located below the acromioclavicular joint with internal rotation. It would be helpful to have a specific test for SAPS as it is a clinical diagnosis.


Available literature and quality of the evidence


A Cochrane review by Hanchard et al. from 2013 investigated all physical tests for subacromial pain syndrome.4 They reviewed various tests for shoulder pain but five were selected specific for impingement with a total of 356 patients. Only two studies could answer the question with both level II evidence.5,6


Findings


The review included five studies for specific impingement tests. They showed a sensitivity of 0.92 (0. 72–0.99) with specificity from 0.26 (0.13–0.43) to 0.44 (0.32–0.58) but this raised to 0.96 (0.79–1.00) when the Hawkins–Kennedy test or the Neer sign (pain produced by maximal passive abduction in the scapula plane, with internal rotation whilst stabilizing the scapula by the examiner)7 was positive with specificity 0.41 (0.29–0.54). This is also confirmed in another review which stated that one physical sign cannot sufficiently differentiate between the various shoulder disorders and so a combination of tests should be used.8


Resolution of clinical scenario



  • Clinical examination is the hallmark for diagnosing SAPS.
  • The Hawkins–Kennedy has a very high sensitivity for testing SAPS.
  • The test should be combined with other tests to differentiate between different conditions.

Question 2: How sensitive is an MRI scan in comparison to US for diagnosing SAPS in patients with shoulder pain?


Rationale

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Subacromial Pain Syndrome

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