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88 m a s s a g e & b o d y wo r k j u l y/a u g u s t 2 0 2 1 underside of the subscapularis and lead to muscle tears, producing pain that is often mistaken for external impingement. Clearly there are various factors that lead to soft-tissue compression under the coracoacromial arch. Yet, recent research has shown us that there are some people with decreased space or significant soft- tissue degradation in the subacromial region who have no pain. There are also those with significant pain complaints who don't appear to have any evidence of impingement damage that can be identified on imaging studies. This has led researchers to look for other potential causes of anterior and lateral shoulder pain. Our current understanding of tendon pathology helps shed some light on potential alternative explanations for shoulder pain that may not be caused solely by compression damage. Newer theories suggest there may be a more complex interaction between mechanical and biological factors in tendon pathologies around the shoulder. The number of chronic overuse tendon disorders throughout the body increases as people age. 5 Histological studies indicate changes occur at the cellular level within these tendons. It looks as if some subacromial pain complaints are a combination of mechanical irritation, along with degenerative and metabolic change in the tendons. But the idea that metabolic and degenerative changes within the tendons are responsible for subacromial shoulder pain has only recently become more accepted within the research literature. It remains likely that numerous shoulder pain complaints involve both mechanical and metabolic/degenerative factors. ASSESSMENT The best chance for identifying subacromial pain starts with a detailed and thorough client history. Clients usually report pain in the anterior/lateral shoulder region that may radiate to the lateral humerus as well. Subacromial impingement generally produces more lateral shoulder pain, while anterior impingement produces more pain on the front side of the shoulder. It is common to hear reports of night pain, especially when lying on the affected side or sleeping with the arm overhead, as those positions further compress the subacromial structures. X-rays and MRIs are still used for evaluation, but these methods may not reveal crucial information about functional movements and mechanical stresses. A truly thorough approach needs to include a comprehensive physical examination and analysis of assessment patterns that suggest particular tissue involvement. This pattern analysis helps drive the most appropriate treatment strategies. For example, suppose a client presents with lateral shoulder pain during active abduction that is decreased but still present near the end range of passive abduction and during resisted abduction. The presence of pain during active and resisted abduction movements strongly indicates contractile tissues such as the supraspinatus. In most cases, we wouldn't expect to see muscle- oriented pain during passive movements of that same motion. However, the supraspinatus is susceptible to compression under the coracoacromial arch during abduction, so this is one place in the body where pain during a passive movement could indicate muscle-tendon unit involvement. Recognizing these patterns is more helpful than any isolated orthopedic test or a single image from a high-tech diagnostic study. As mentioned earlier, subacromial pain will tend to be more significant during active, passive, or resisted abduction motions, while subcoracoid impingement is more likely to produce pain during active, passive, or resisted flexion motions. Because subcoracoid impingement frequently involves the subscapularis tendon, it is also common to see pain or discomfort during resisted internal rotation because that engages the subscapularis. There may also be pain felt during either active or passive Recent research indicates mechanical impingement may not be the primary cause of pain in some cases of shoulder pathology.