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L i s te n to T h e A B M P Po d c a s t a t a b m m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 89 external rotation of the shoulder where the subscapularis is stretched. Sometimes there is a popping or snapping sensation associated with range of motion evaluations in the shoulder, as well. There are various special orthopedic tests frequently used to identify impingement problems, such as the Neer impingement sign, empty can test, or Hawkins-Kennedy test, but they don't always have a high degree of accuracy. They may also lead clinicians into more recipe- oriented thinking about the evaluation process by prioritizing this test without evaluating the other critical pattern and movement assessments. Rather than focus on these special orthopedic tests, I find it far more valuable to explore the results and patterns from the active, passive, and resisted motions in the shoulder. TREATMENT The primary goal of SAPS treatment is to eliminate pain and restore appropriate function. What defines appropriate function varies for each client. For example, it isn't always necessary to achieve a particular numerical range of motion measurement. It may be enough just to get the person to decrease pain for the essential things they need to do as part of their daily activities. SAPS treatment generally begins with conservative measures, such as limiting aggravating movements along with moderate exercise. Any rehabilitative exercise is usually performed within a range that does not significantly aggravate the pain. Massage plays a great role at this stage, as it can help reduce irritation and increase overall mobility in the shoulder region. We shouldn't think of massage as necessarily making more space in the subacromial region. Instead, massage helps restore overall shoulder movement, decreases apprehension in shoulder movements, and gradually contributes to increasing available range of motion. A wide variety of techniques can be used to help enhance a greater sense of movement and pain reduction. Previously, we emphasized techniques such as deep transverse friction to the distal supraspinatus tendon to address scar tissue during the healing process. Friction techniques may still be beneficial, but we now find great benefit in techniques that are not as focused on a particular tissue. A wide array of methods used to treat the shoulder girdle can help decrease apprehension and restore a sensation of safe, increased movement as the condition subsides. The greater sense of pain-free movement can encourage the person to perform gradually increasing activity levels that will provide graded exposure and conditioning for the soft tissues so they can improve more rapidly. Surgery may still be considered if conservative treatments are not initially effective. Common surgical approaches include increasing the subacromial space by shaving off the underside of the acromion process in a procedure called acromioplasty. However, recent research suggests treatment outcomes from surgical procedures may be similar to those from conservative treatments, and this has led to a decreased perception of the necessity for surgery. 6 In many cases, surgery is still effective, and what becomes clear is there is no catchall solution that works for everybody, in every situation. As we have seen, there are numerous causes of SAPS. It is a common occurrence and a condition your clients are likely to present with. The more knowledgeable you are about pathologies in this region, the more helpful you can be for them. In addition, you may be working as part of a health-care team with other professionals. When you understand the nature of the problem and how others may be approaching it, you are a more valuable contributor. Notes 1. Christina Garving et al., "Impingement Syndrome of the Shoulder," Deutsches Arzteblatt International 114, no. 45 (November 2017): 765–76, 2. Teemu V. Karjalainen et al., "Subacromial Decompression Surgery for Rotator Cuff Disease," Cochrane Database of Systematic Reviews 1, no. 1 (January 2019), https://doi. org/10.1002/14651858.CD005619.pub3. 3. Charles S. Neer, "Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder: A Preliminary Report," Journal of Bone & Joint Surgery 54, no. 1 (January 1972): 41–50, 4. Gregory Cunningham and Alexandre Lädermann, "Redefining Anterior Shoulder Impingement: A Literature Review," International Orthopaedics 42, no. 2 (June 2017): 359–66, 5. Teun Teunis et al., "A Systematic Review and Pooled Analysis of the Prevalence of Rotator Cuff Disease with Increasing Age," Journal of Shoulder and Elbow Surgery 23, no. 12 (December 2014): 1913–21, https:// 6. R. Diercks et al., "Guideline for Diagnosis and Treatment of Subacromial Pain Syndrome," Acta Orthopaedica 85, no. 4 (March 2014): 1–9, Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at CLINICAL EXPLOR ATIONS

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