Concept
Subacromial pain is multifactorial. Rotator-cuff tendinopathy and tears arise from age-related tendon degeneration, loading, vascular and mechanical factors rather than from one simple acromial mechanism.
Symptoms
- lateral upper-arm pain
- pain with overhead activity
- night pain
- weakness in larger tears
- painful arc in some patients
Examination
Assess:
- active and passive range
- cuff strength by tendon
- painful arc
- scapular mechanics
- AC joint
- cervical spine
True weakness that persists after pain is reduced increases suspicion of a significant tear.
Imaging
Plain radiographs can identify:
- glenohumeral/AC arthritis
- proximal migration in chronic massive tear
- calcific deposits
Ultrasound and MRI assess tendon integrity. Imaging findings are common in asymptomatic adults, so correlation with symptoms is essential.
Plain radiographs assess:
- glenohumeral arthritis
- proximal humeral migration
- acromiohumeral interval
- calcification
- os acromiale
- AC pathology
Ultrasound and MRI can define tendon integrity. MRI also shows muscle atrophy and fatty infiltration, which influence reparability and prognosis.
Non-operative treatment
First-line treatment for many patients:
- education and activity modification
- analgesia/anti-inflammatory medication when appropriate
- physiotherapy focused on cuff and scapular function
- selective subacromial injection for symptom control
Surgery
Consider surgery when symptoms and functional impairment persist despite appropriate rehabilitation or when an acute traumatic full-thickness tear in a suitable patient is likely to benefit from repair.
Options include:
- arthroscopic cuff repair
- debridement in selected irreparable tears
- tendon transfer or superior capsular reconstruction in selected younger patients
- reverse shoulder arthroplasty for cuff-deficient arthropathy or selected irreparable tears with major functional loss
Routine acromial decompression is not a substitute for diagnosing and treating the actual pain generator.
Spectrum
Rotator cuff disease includes:
- tendinopathy
- partial-thickness tear
- full-thickness tear
- chronic massive tear
- cuff-tear arthropathy
Subacromial pain may arise from several structures and should not automatically be attributed to one “impingement lesion”.
Clinical assessment
Ask about:
- age and activity
- traumatic onset versus gradual pain
- night pain
- weakness
- loss of function
- previous dislocation
- steroid exposure
- smoking
- dominant arm
- occupational demands
Examine active and passive motion, cuff power, lag signs and signs of chronic muscle dysfunction.
True weakness that persists after pain is minimised raises concern for significant tendon failure or nerve injury.
Tear characteristics
Surgical decision-making depends on:
- tear size
- tendon retraction
- tissue quality
- muscle atrophy/fatty change
- chronicity
- patient age
- functional demand
- glenohumeral arthritis
- ability to restore a balanced force couple
A radiological tear is not automatically an indication for repair.
Non-operative management
Many atraumatic degenerative tears and subacromial pain syndromes can initially be managed with:
- education
- activity modification
- analgesia
- physiotherapy focused on cuff/scapular function
- selected injection where appropriate
Response depends on pathology and goals.
Repair principles
Rotator cuff repair aims to restore tendon to anatomic footprint with minimal tension while preserving biology.
Failure risk rises with:
- large chronic tears
- poor tendon quality
- advanced fatty infiltration
- smoking
- diabetes
- older age
- excessive tension
Massive irreparable tears
Options depend on pain, function, arthritis and patient demand:
- rehabilitation/deltoid optimisation
- debridement or biceps procedure in selected cases
- partial repair
- tendon transfer
- superior capsular or other reconstructive techniques in selected settings
- reverse shoulder arthroplasty when pseudoparalysis and arthropathy or irreparable cuff dysfunction justify it
FRCS synthesis
Do not reduce management to “tear = repair”. Explain whether the tear is symptomatic, repairable and functionally important, and whether the joint remains salvageable.