Assessment of subacromial impingement syndrome in the primary care setting: Development of an evidence based clinical framework

Shoulder pain is the third most common musculoskeletal condition presenting to primary care. The term subacromial impingement syndrome (SIS) describes a number of pathologies of the rotator cuff, from bursitis to tendinopathy. The aim of this review is to present an evidence based approach to assessing the shoulder complex in order to assist the primary care clinician in diagnosing SIS. In addition a clinical framework that outlines an examination structure to guide therapists’ assessment of patients with possible SIS is also presented. Approximately 34 clinical tests exist for testing the structures of the shoulder complex for SIS, but the evidence-base on the validity, reliability and the diagnostic accuracy is either absent or reveals data that suggests that no test alone is perfect for diagnosis. The patient’s age and the presence of night pain are the two most useful features of the clinical history in establishing a pre-test probability, especially for a rotator cuff tear rotator cuff tear. As no one test of contractile tissue or impingement has perfect accuracy, it is recommended to combine a number of tests, and to use patient’s history/details to help distinguish SIS from other shoulder pathologies so that appropriate management can commence. The evidence base regarding the most appropriate assessment methods for each category of secondary impingement is inconclusive.