Subacromial impingement is by far the most popular form of rotator cuff impingement, and acromion shape on both coronal and sagittal plane has been implicated. Whether acromial morphology is a congenital or an acquired characteristic is unclear, but some studies has documented a progression from a flat to a curved or hooked acromion over the years, possibly because of traction forces on the coracoacromial arch. Subacromial impingement, however, is not free of criticism, specially because most partial-thickness rotator cuff tears do not occur on bursal surface fibers, where mechanical abrasion from the acromion does occur. Aditionally, it has been suggested that bursal surface cuff tears could be responsible for subacromial spurs and not the opposite. And finally, there is growing evidence that routine acromioplasty may not be required for successful rotator cuff repair, which would be an unexpected finding if subacromial impingement had a major role in generating tendon lesions. In summary, the bulk of evidence suggest that subacromial impingement is a valid theory and may play a dominant role in selected cases of rotator cuff disease, though it is probably not as common as previously believed.

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