Subacromial pressures in vivo and effects of selective
experimental suprascapular nerve block
Clément M. L. Werner, MD,a Stephan Blumenthal, MD,b Armin Curt, MD,c and Christian Gerber, MD,a Zürich,
Switzerland
Subacromial impingement has been related to in-
creased subacromial pressures. High subacromial
pressures may, therefore, have a negative effect on
tendon healing after rotator cuff repair, but avoidance
of high pressures during healing is only possible if
pressures in different positions of the arm are known.
The purpose of this study was to determine the sub-
acromial pressures for different positions of active
shoulder movement and to determine the effects of su-
praspinatus and infraspinatus failure on subacromial
pressures, as it is currently held that rotator cuff weak-
ness might increase subacromial pressures. Subacro-
mial pressures were statistically significantly altered by
arm position (P ⫽ .001). There was an increase in
pressure from 17.5 mm Hg at rest up to more than 60
mm Hg during abduction and flexion. Subacromial
pressure decreased in external rotation and increased
in internal rotation. Generally, patients with strong ex-
ternal rotation (arm at the side) had lower subacromial
pressures. Conversely, paralysis of the supraspinatus
or infraspinatus muscles had no statistically significant
effect on subacromial pressures at rest or during active
movements of the shoulder. High subacromial pres-
sures can be prevented by avoiding active abduction,
flexion, and internal rotation of the arm. External rota-
tion does not need to be limited to reduce subacromial
pressure. (J Shoulder Elbow Surg 2006;15:319-323.)
D ifferent theories about the etiology of subacromial
impingement and the possible subsequent tearing of
the rotator cuff tendons have been set forth.14,17,18
Subacromial impingement has been suspected to be
the result of inflammation and degeneration of the
From the aDepartment of Orthorpaedics, bDivision of Anesthesiol-
ogy, Uniklinik Balgrist, and cSpinal Cord Injury Center, Univer-
sity of Zürich, Balgrist, Zürich, Switzerland.
Reprint requests: Christian Gerber, MD, Professor and Chairman,
Department of Orthopaedics, University of Zürich, Balgrist,
Forchstrasse 340, 8008 Zürich, Switzerland (E-mail:
christian.gerber@balgrist.ch).
Copyright © 2006 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2006/$32.00
doi:10.1016/j.jse.2005.08.017
supraspinatus tendon caused by mechanical com-
pression.4,13,17 The tendon of the supraspinatus mus-
cle is also poorly vascularized at and near its bony
insertion.11,15,21,23 Vascularization of the tendon is
sustained from surrounding structures, such as bone,
synovia, rotator cuff muscles, and the subacromial
bursa.25–27 As the superior cuff tendons are subject to
compressive loading between the humeral head and
coracoacromial arch,1,9,12,17,19,20 the microvascular
perfusion of the tendon may be compromised. This
could lead to further damage to the cuff. It is believed
that, once a rupture of the rotator cuff has occurred,
the weakened cuff no longer prevents the humeral
head from rising, which leads to an increase in sub-
acromial pressure and damage to the rotator
cuff.13,16,32
The pressure in the subacromial bursa corresponds
to the pressure within the rotator cuff.25 Different
investigators have, therefore, measured the subacro-
mial pressure and have projected their results to the
probable alterations of pressure in the superior cuff
tendons. Measurements, however, have been per-
formed either during open operations with the patient
under general anesthesia and passive motion of the
arm9,10,12 or on cadaveric models.22,32 These data
can, therefore, merely represent approximations to
the situation found during active glenohumeral motion
in vivo. The only investigation on subacromial pres-
sure during active motion of the shoulder (with the
patient awake and not relaxed) studied the resting
position of the arm and one additional position (com-
bination of 45° upper arm flexion, 30° flexion in the
scapular plane, and 90° elbow flexion) and provides
incomplete data on subacromial pressure changes
throughout different movements.25
Avoidance of peak pressures in the subacromial
space may be of importance in two clinical situations:
(1) postoperative physical therapy after rotator cuff
reconstruction, where tendon perfusion is crucial for
tendon-to-bone healing, and (2) prevention of addi-
tional potential damage to an already torn cuff,
where operative treatment is not warranted or has
been declined by the patient.
The purpose of this study was to identify the posi-
tions of the arm creating maximal subacromial pres-
sures, which should be avoided after rotator cuff
319
320 Werner et al
surgery or in partial or small rotator cuff tears and to
determine the effects of supraspinatus and infraspina-
tus failure on subacromial pressures. The subacromial
pressures were measured at different degrees of ab-
duction, flexion, and internal and external rotation.
MATERIALS AND METHODS
The dominant shoulders of 11 healthy volunteers with no
history of prior trauma or shoulder problems and no allergy
to ropivacaine were included. The study was approved by
the responsible ethical committee for our university. All
volunteers gave written informed consent for the study.
Before any subacromial infiltration or nerve block, a
20-gauge intravenous cannula was inserted into the cubital
vein in the forearm of every volunteer on the nondominant
side and pulse oxymetry was monitored, allowing rapid
intervention in case of emergency (ie, allergic reaction or
hypotension).
After local anesthesia of the skin with 1% lidocaine, an
arterial catheter of 1.0 mm diameter (Seldicath; Prodimed,
Plastimed Divison, Saint-leu-la-Forêt Cedex, France) was
placed into the subacromial bursa via the Seldinger tech-
nique.24 The catheter was inserted through a posterior
approach. It was fixed with adhesive tape and connected to
a transducer placed at the estimated height of the tip of the
catheter within the bursa. The system was flushed with
isotonic saline solution and calibrated (with the barometric
pressure outside corresponding to the pressure within the
bursa). After leveling off (distribution within the subacromial
space), the pressure in the subacromial bursa could be
monitored continuously (Siemens SC 7000, Siemens-Elema
AB, Electromedical Systems Division, Solna, Sweden). Cor-
rect placement of the catheter and patency of the free end
of the catheter were verified by (1) flushing of the system,
which led to an instant increase in the pressure for a few
seconds, (2) verification of prompt changes in pressure
during motion of the arm, and (3) exclusion of blood clotting
within the tip of the catheter after its removal. If there was
uncertainty about positioning of the catheter, a second one
was introduced in a slightly different position until the
criteria for adequate pressure monitoring were fulfilled.
The pressure was recorded with the arm in different
positions: hanging freely at the side, at different degrees of
active abduction in the scapular plane (30°, 60°, and 90°
and maximal possible abduction with the arm in neutral
rotation), in the 90° flexed position in the sagittal plane
(thumb pointing upward), and during maximal external and
internal rotation with the arm at the side. Positions were
controlled by means of a goniometer. Once the arm was
held in a certain position, leveling off of the pressure had to
be awaited for about 20 seconds because of the time lag of
the system (the arm being actively kept in the corresponding
position). Each measurement was repeated at least 3 times
for each position; between the positions, the volunteers
were allowed to keep their arms in the resting position to
avoid muscular fatigue.
Two experimental blocks of the suprascapular nerve
were then sequentially performed, and the effect on sub-
acromial pressure was recorded after each nerve block
separately. The first block was performed to paralyze the
infraspinatus muscle selectively, and the second was done
J Shoulder Elbow Surg
May/June 2006
to paralyze the supraspinatus muscle. All blocks were per-
formed with a stimulator to identify the nerve (Stimuplex
HNS 11; B. Braun Melsungen AG, Melsungen, Germany)
with a short beveled needle (Stimuplex A 21-gauge stimu-
lation needle, B. Braun Melsungen AG) connected to the
negative pole. Needle placement was considered success-
ful when contractions of the infraspinatus muscle and gle-
nohumeral external rotation were obtained with a current
intensity of 0.5 mV or less and an impulse duration of 0.1
milliseconds. The block was performed with 10 mL ropiva-
caine, 0.5% (50 mg) (AstraZeneca AG, Zug, Switzerland).
The first (distal) block was made at the base of the scapular
spine, where the branch for the infraspinatus muscle enters
the infraspinatus fossa3,30; the needle was inserted perpen-
dicular to the skin, 5 cm medial and 1.5 cm distal to the
lateral border of the spine, and advanced until bony contact
was found.
The second (proximal) block of the suprascapular nerve
for additional paralysis of the supraspinatus was performed
at the level of the suprascapular notch, with the needle’s
entry point chosen on a bisector of the scapular spine and
a vertical line through the middle of the scapula, 2.5 cm in
the superolateral direction,6 again by use of 10 mL ropiva-
caine, 0.5%.
Electromyographic (EMG) recordings were performed
during and 20 minutes after the anesthetic blocks to docu-
ment successful and complete paralysis of the infraspinatus
and supraspinatus natus muscles (Dantec Keypoint; Den-
mark, software 2.0). This procedure allowed confirmation
of the selective paralysis of the branches supplying the
infraspinatus and supraspinatus muscles. Paralysis was
rated as successful if full extinction of the EMG response of
the paralyzed muscle could be identified by both electrical
stimulation and voluntary contraction. If these criteria were
not fully met, testing was discontinued.
EMG recordings were also made of the deltoid muscle to
identify an inadvertent paralysis of the axillary nerve in-
duced by the anesthetic block. The deltoid muscle was
assumed to be unaffected if a full interference EMG activa-
tion pattern could be produced by voluntary contraction.
To ensure full recovery of the volunteers after the tests, a
neurologic examination of the extremity was performed,
along with strength measurements (Isobex Dynamometer,
Cursor SA, Bern, Switzerland) for different movements (ab-
duction strength and external rotation strength at different
levels of abduction). This was performed before the exper-
iments and at least once on the day after them.
Statistical analyses were performed by a statistical con-
sultant using SPSS 10.0 for Macintosh OS (SPSS Inc, Chi-
cago, IL) by use of the Greenhouse-Geisser test analysis of
variance, paired-sample t tests, and Pearson correlation.
Decimal logarithmic transformation of the values was per-
formed before analysis to obtain normal distribution and
constant variance. Because of multiple comparisons being
performed, Bonferroni-Dunn correction was applied. The
significance level was, therefore, set at P ⬍ .00625 (instead
of .05) in order to reduce the ␣ error.
RESULTS
Experimental paralysis of the infraspinatus muscle
could be achieved in all 11 patients. Paralysis of the
J Shoulder Elbow Surg
Volume 15, Number 3
Figure 1 Left shoulder after placement of second subacromial
catheter because of inappropriate positioning of first catheter.
Electrostimulated identification of distal branch of suprascapular
nerve and EMG control.
supraspinatus muscle, however, was electromyo-
graphically incomplete in 2 patients. These 2 patients
were excluded for evaluation of the combined paral-
ysis (both infraspinatus and supraspinatus muscles).
The catheter was placed successfully in all volunteers
(Figure 1), although a second attempt was necessary
in 5 to ensure recording of appropriate data.
Pressures found for the nonparalyzed shoulder in
different positions are summarized in Table 1. A box
plot of the pressure patterns found after experimental
paralyses is given in (Figure 2). Pressures within the
subacromial bursa were found to be altered signifi-
cantly by the position in which the arm was held
(Greenhouse- Geisser test, P ⫽ .001). The amount of
pressure registered varied among individuals.25
However, the reactions caused by the respective po-
sitions of the arm reproducibly led to the same pattern
of pressure changes in all individuals. There was a
significant increase in pressure from 17.5 mm Hg at
rest up to more than 60 mm Hg during abduction and
flexion. Subacromial pressure always decreased dur-
ing external rotation and always increased during
internal rotation.
A strong and significant negative correlation be-
tween the amount of pressure measured in the neutral
and abducted positions and the force measured dur-
ing external rotation with the adducted arm was
found (r ⫽ – 0.78, P ⫽ .005). Patients with a strong
external rotation force (arm at the side) had low
subacromial pressures not only in the resting but also
in the abducted positions of the arm and vice versa.
Other forces measured did not correlate with the
amount of pressure measured with the arm at the side
or other positions tested (flexion and external or inter-
nal rotation).
The changes found in subacromial pressures after
each of the two experimental paralyses did not reach
statistical significance (Greenhouse-Geisser test), es-
Werner et al 321
pecially after application of Bonferroni-Dunn correc-
tion (P ⫽ .278 after first paralysis and P ⫽ .105 after
second paralysis). There was, however, a trend to-
ward a decrease in pressure for the neutral position (P
⫽ .53 and P ⫽ .23, respectively) and flexion at 90°
(P ⫽ .016 and P ⫽ .08, respectively) after the two
paralyses.
DISCUSSION
In 2 of 11 volunteers, the proximal nerve blocks
were not fully successful, leading to their exclusion
from further evaluations. This problem was encoun-
tered by previous investigators.28 Repeated identifi-
cation of the incompletely paralyzed nerve was not
performed in this investigation to avoid nerve dam-
age.
The risk of occlusion of the arterial catheter during
active motion, as reported by other investigators us-
ing a lateral approach,25 was not encountered in this
experiment. This is probably because we used a
strictly posterior approach instead of a lateral ap-
proach to the subacromial bursa for catheter place-
ment, and the catheter thus could not be snapped off
during abduction.
The variability of values obtained from different
individuals was wide and has been observed previ-
ously as well.19 The patterns (increase or decrease)
produced by the different arm positions, however,
were always the same in all individuals in this series.
This corresponds to previous findings for abduc-
tion.7,9,10,12,19,25,32 The peak mean amounts of pres-
sure encountered with abduction from 60° in the
scapular plane or flexion (sagittal plane) at 90° (Ta-
ble I) are comparable to pump pressures used during
shoulder arthroscopies. In analogy to these intraoper-
ative pressures, which meet the demands of providing
good arthroscopic visualization by suppressing
bleeding, the same amount of pressure could also
lead to an impaired blood supply to a tendon sup-
posed to heal.
Interestingly, the actual amount of pressure was
strongly correlated with the external rotation force (ie,
probably the force of the infraspinatus muscle). Patients
with a higher strength for external rotation had signifi-
cantly lower ranges of rise in pressure in the neutral
position and during abduction, whereas patients with
weaker external rotation had significantly higher pres-
sures both in the neutral position and during active
abduction. This could be explained by the action of the
infraspinatus muscle, which is supposed to prevent up-
ward migration of the humeral head.3,29 The stronger
the muscle, the more the head is kept centered and,
therefore, does not lead to compression of the superior
cuff and surrounding structures. This finding, however, is
somewhat difficult to interpret, because full paralysis of
the infraspinatus muscle did not influence pressure pat-
322 Werner et al J Shoulder Elbow Surg
May/June 2006

Table I Subacromial pressures in nonparalyzed shoulders

Subacromial pressure (mm Hg)

Minimum and 25th and 75th

Position Mean maximum SD Median percentiles

0° 17.5 5/43 11.9 18 7.5/22.7

Abduction
30° 41.8 5/140 48.3 22 15/48.6
60° 58.2 5/201 72.2 25.7 9.5/68.3
90° 66.9 8/231 76.3 40.3 20.7/89
Maximum 65.2 10/206 56.4 60.3 13.7/88.3
90° Anterior flexion 61.1 13/171 55.1 37.3 16/91.3
External rotation with arm at side 13.7 1/41 13.5 8 3.5/18.3
Internal rotation with arm at side 35.6 6.7/108 35.9 23.5 9/42

Subacromial pressures were measured after leveling off in defined shoulder positions. Because of high variability in the amount of pressure measured, the
median sometimes differs from the mean. The pattern of changes produced by the different positions, however, was always the same.

opposite was demonstrated in all individuals. This

Figure 2 Box plot analysis of subacromial pressures (in millimeters
of mercury) measured for different shoulder position patterns before
and after selective experimental neurolysis of suprascapular nerve.
The pattern was not statistically significantly altered after paralysis.
int rot, Internal rotation with arm at side; ext rot, external rotation
with arm at side; flex, anterior flexion; max, maximum; abd,
abduction.
terns significantly during these movements. It might be,
though, that in individuals with weaker infraspinatus
muscles, the muscle belly of the supraspinatus muscle is
more developed in relation to individuals with strong
infraspinatus muscles and, therefore, leads to earlier or
more accentuated compression of these structures. Lack
of increase in pressure after paralysis of potential hu-
meral head depressors could also be anticipated by
decreased volume of noncontracting muscles, thus com-
pensating for the increased upward migration of the
humeral head. This theory, however, has not been fur-
ther investigated and remains hypothetical.
The finding that pressure rises during external ro-
tation of the shoulder, which has been reported else-
where,10 could not be confirmed. In our study, the
might be because we measured pressure during ac-
tive motion, in contrast to other investigators, who
performed their measurements with passive motion
and the patient under general anesthesia, thus re-
laxed. Their data might absolutely be valid concern-
ing the end range of purely passive motion, where
passive stabilizers of the glenohumeral joint (capsulo-
ligamentous structures) and translations produced by
them come into play.8,31 Decreased pressure during
active external rotation, which has been determined
in our investigation, is also in agreement with external
rotation occuring during abduction, providing clear-
ance of the greater tuberosity and superior cuff ten-
dons as they pass underneath the coracoacromial
arch.2,5
The pressure recorded in the neutral position with
the arm hanging freely was somewhat higher in this
study than has been reported earlier.25 This might be
an artifact created by the local anesthesia and flush-
ing of the system, which led to filling of the bursa with
liquid. However, pressure found immediately after
flushing of the bursa always decreased rapidly and
leveled off after a few seconds. It remained constant
afterward and was only recorded after having
reached this constant level.
In conclusion, pressures within the subacromial
bursa have been found to rise with active abduction,
flexion, and internal rotation. The positions described
might, therefore, have to be avoided during healing
of a repaired tendon, whereas external rotation of the
arm could remain unrestricted. Preoperative muscular
strengthening exercises for external rotation force
should also be encouraged in cases with an intact
infraspinatus muscle to decrease subacromial pres-
sures. The sling that is often used for postoperative
rehabilitation, which puts the arm into a position of
internal rotation, seems to lead to increased subacro-
mial pressures, and its use might be questioned be-
J Shoulder Elbow Surg
Volume 15, Number 3
cause pressures are significantly lower in the resting
position with the arm hanging freely at the side. As
the same patterns of changes of subacromial pres-
sures have been encountered also after paralysis of
the supraspinatus and infraspinatus muscles, one
could conclude that the same rules of arm positioning
or strengthening exercises could also be applied to
conservatively treated tears of the rotator cuff and that
intensive use of the arm in the respective positions is
likely to impair the lesion further.
We thank Professor B. Seifert from the Institute of Biosta-
tistics, University of Zürich, for help with statistical analyses.
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