Management of Painful Arc Syndrome (Subacromial Pain Syndrome)
Painful arc syndrome, now better termed subacromial pain syndrome (SAPS), should be managed primarily with non-operative treatment including exercise therapy, with surgery reserved only for cases that fail conservative management after at least 6 months. 1
Initial Diagnosis and Assessment
The diagnosis of SAPS requires a combination of clinical tests, not a single examination finding. 1 The painful arc typically manifests between 70-120 degrees of shoulder abduction, though in severe cases this may be reduced to 50-70 degrees. 2
Key diagnostic steps:
- Perform multiple clinical tests in combination to establish the diagnosis 1
- Obtain ultrasound imaging after 6 weeks of persistent symptoms to exclude rotator cuff rupture 1
- Avoid routine radiographic imaging unless specific indications exist 1
Conservative Management Algorithm (First-Line Treatment)
Step 1: Acute Pain Management (First 6 Weeks)
Analgesics should be used as needed for acute pain relief. 1
- NSAIDs or acetaminophen for initial pain control 3
- Avoid strict immobilization, which is not recommended 1
Step 2: Corticosteroid Injection (Persistent Symptoms)
Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. 1
This intervention provides symptomatic relief and should be administered when initial analgesics prove insufficient. 1
Step 3: Exercise Therapy (Primary Treatment Modality)
Exercise therapy should be specific, low intensity, and high frequency. 1
The exercise program should include:
- Eccentric training as the foundation 1
- Attention to relaxation and posture 1
- Treatment of myofascial trigger points with muscle stretching 1
- Avoid mobilization techniques, which are not recommended 1
Step 4: Occupational Interventions (After 6 Weeks)
Occupational interventions are useful when complaints persist longer than 6 weeks. 1
This addresses workplace-related factors that may perpetuate symptoms. 1
Step 5: Specialized Rehabilitation (Chronic Cases)
Rehabilitation in a specialized unit can be considered for chronic, treatment-resistant SAPS with pain-perpetuating behavior. 1
This is reserved for patients who have not responded to standard conservative measures. 1
Special Considerations
Calcific Tendinosis
If tendinosis calcarea is identified, treat with extracorporeal shockwave therapy (ESWT) or ultrasound-guided needling (barbotage). 1
These are specific interventions for this particular pathology. 1
Associated Pathology
Be aware that rotator cuff pathology is commonly associated with SAPS:
- Over two-thirds of patients with post-traumatic SAPS have concomitant rotator cuff tears 2
- Ultrasound at 6 weeks helps identify these tears 1
- Asymptomatic rotator cuff tears do not require surgical treatment 1
Surgical Management (Last Resort Only)
There is no convincing evidence that surgical treatment for SAPS is more effective than conservative management. 1
Surgery should only be considered after:
- Minimum 6 months of failed conservative treatment 2, 1
- Documented mechanical impingement on imaging 4
- Persistent symptoms despite comprehensive non-operative care 1
Surgical Options (When Indicated)
Historical surgical approaches included:
- Resection of coracoacromial ligament 5, 6, 4
- Anterior acromioplasty 2, 4
- Acromioclavicular joint excision 6, 4
- Greater tuberosity shaving 4
However, current evidence does not support routine surgical intervention. 1
Critical Pitfalls to Avoid
- Do not proceed directly to surgery without exhausting conservative options 1
- Do not immobilize the shoulder strictly 1
- Do not use mobilization techniques 1
- Do not operate on asymptomatic rotator cuff tears 1
- Do not rely on a single clinical test for diagnosis 1