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Subacromial impingement

Full page slideshow of exercises from here prepared by our colleagues at Urmston Physio

Click Here for a patient information document leaflet on physiotherapy exercises for impingement

Subacromial impingement has become a common diagnosis in shoulders. It is a specific diagnosis, and is not the only cause of anterior shoulder pain. In this condition there is inflammation in the subacromial bursa/space. The picture below shows the inflammation (a normal bursa is pale white in colour)


The modern concepts of subacromial impingement start with Charles Neer (Obituary).  He hypothesized that impingement of the rotator cuff is from the anterior  acromion, the coracoacromial ligament, and the acromioclavicular joint rather than by just the lateral aspect of the acromion. There is also evidence that formation of spurs in the lateral acromion leads to attrition damage to the cuff.

This video illustrates the area of inflammation in a subacromail bursa

Diagnosis and Clinical Tests

Physical examination is often conclusive but Neer's test1 is an useful adjunct. This involves injecting about 10 mls of local anaesthetic in the subacromial bursa and then repeating the examination. This abolishes the pain in impingement. This is also a reliable test for predicting results after subacromial decompression2.

Xrays may demonstrate a curved/hooked acromion, and ultrasound scanning may provide evidence of dynamic impingement.


Non operative treatment with analgesics and physiotherapy is often successful, but some patients will need surgery in the form of a subacromial decompression.

Steroid injections in the subacromial space can be effective in the short term, but there is little evidence to show any long term benefit. Rotator cuff tears should be excluded before steroids are injected. This often requires scans.

For a more detailed discussion on steroid injections look here

Subacromial decompression

Normally undertaken through keyhole techniques, this involves a day case procedure (Usually home the day of surgery) performed under general anaesthetic and often a nerve block as well. Two or three small incisions are made and part of the acromion with any bony spurs are shaved away. The coraco-acromial ligament is also released. This creates more space for the shoulder to move and the rotator cuff tendons to glide freely.

The recovery is fairly quick and most patients are driving witin 10 days. Return to work depends on the type of work, but there are no specific restrictions placed on patients.

Physiotherapy is essential after this operation. This is to enable return of movements and strength while maintaining a normal movement pattern

Usually there is minimal or no scarring, and over 85% of patients report significant improvent in pain and function.


  1. Neer, C. S., II: Impingement lesions. Clin. Orthop., 173: 70-77, 1983.
  2. Mair SD, Viola RW, Gill TJ, Briggs KK, Hawkins RJ. Can the impingement test predict outcome after arthroscopic subacromial decompression? J Shoulder Elbow Surg. 2004 Mar-Apr;13(2):150-3.