The Shoulder Symptom Modification Procedure (SSMP)

Comment from Lennard Funk: The SSMP was described by Jeremy Lewis in 2009 and is a very useful and logical approach to the assessment of patients with rotator cuff and subacromial pathology. It is also a very useful guide to clinical decision making and determining those patients which will respond well to the correct rehabilitative programme. Like many clinicians I found it difficult to understand and use, but thanks to Eleanor Richardson I now understand it better and can use it to the benefit of my patients. Eleanor has kindly summarised Jeremy Lewis' work below under the supervision of Jeremy.
For more information Jeremy Lewis can be contacted directly at

The Shoulder Symptom Modification Procedure (SSMP)

Eleanor Richardson & Jeremy Lewis

An Overview of its use in the Assessment and Management of Rotator Cuff Tendinopathy/Subacromial Impingement
Based on the clinical recommendations from Dr Jeremy Lewis PT (BJSM 2009)


Current Orthopaedic Tests for Rotator Cuff Pathology / Subacromial Pain Syndrome:
  • demonstrate low specificities and inadequate likelihood ratios  
  • cannot isolate individual tendons and other structures to inform an accurate diagnosis
  • are unable to inform clinical decision making and patient management
  • (Lewis and Tennent 2007, Hegedus  et al., 2008; Hughes et al., 2008; Lewis, 2009)
How should these tests be interpreted clinically? As a pain or symptom provoking procedures only and not for structural differentiation.

How can we as therapists interpret clinical meaning from these tests? By using them in conjunction with a full clinical history and other physical movements and comparable signs

How can we then use these objective markers and comparable signs to guide patient management? By then applying the SSMP to inform clinical decision making

What is the SSMP? A group of four mechanical techniques that are applied sequentially while the patient performs the activity or movement that most closely reproduces their symptoms with the aim of identifying one or a series of techniques that reduce symptoms by either decreasing pain / symptoms and/or increasing movement and fucntion

What are the four mechanical techniques trying to effect? (see SSMP)

  1. Techniques to reduce the thoracic kyphosis
  2. Scapular positioning techniques
  3. Humeral head positioning procedures
  4. Pain and symptom neuromodulation procedures
How are the mechanical techniques weighted and recorded in terms of symptom modification?
  • By using the Numerical Symptom Rating Scale (NSRS) to determine whether applying any of the four groups of mechanical techniques result in a significant decrease (minimum of 30%) in the patient’s symptoms
  • NB. Although not evident in the original outcome measure, it is suggested that range of motion could also be used in conjunction with, or in replacement of, NSRS as an objective marker when applying the mechanical techniques
If one or more of the mechanical techniques result in a substantial improvement in the patient’s symptoms, what next?
  • Use this information to inform your choice of treatment modality and/or the type of exercises that you issue your patient with
  • For example, if changing scapular position has a greater effect on the patient’s pain than changing humeral head position, then manual techniques to increase scapular mobility or exercises to change scapular position and / or stabilization could be clinically reasoned and prioritized over gleno-humeral joint mobilizations
What are the advantages of using this model of assessment?
  • A definitive clinical diagnosis of rotator cuff tendinopathy and subacromial pain syndrome (impingement) cannot currently be made
  • The SSMP recognizes these inadequacies and proposes that patient management may be guided by the response to symptom modification
  • Using symptom modification and comparable signs allows the therapist to adopt a truly patient specific and functionally relevant means of assessment 
What if the SSMP does not produce and change in symptoms? Then the therapist should consider other treatment options such as injection therapy, pain relieving techniques, general or specific shoulder rehabilitation exercise regimes, modalities, taping or surgery

Points to consider when planning any treatment intervention:

  1. “Technique is the brainchild of ingenuity”
  2. “Physiotherapy is as much an art as it is a science”  (Maitland, 2005)

 Click to download the SSMP Form:
SSMP- Jeremy Lewis V2.pdf

References and Recommended Reading

  1. Hegedus, E. J., Goode, A., and Campbell, S. (2008) Physical examination of the shoulder: a systematic review with meta-analysis of individual tests. British Journal of Sports Medicine, Vol. 42, pp. 80-92
  2. Hughes, C. P., Taylor, N. F., and Green, R. A. (2008) Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy, Vol. 54, pp. 159-170
  3. Lewis JS. Rotator cuff tendinopathy. Br J Sports Med. 2009 Apr;43(4):236-41.
  4. Lewis, J. S. (2009) Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine, Vol 43, pp. 259-264
  5. Lewis JS. Rotator cuff tendinopathy: a model for the continuum of pathology and related management. Br J Sports Med. 2010 Oct;44(13):918-23. 
  6. Lewis JS, Tennent TD.  How effective are diagnostic tests for the assessment of rotator cuff disease of the shoulder? In: MacAuley D, Best TM, editors. Evidenced Based Sports Medicine. 2nd ed. London: Blackwell Publishing; 2007.


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