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Arthroscopic subacromial decompression is an effective treatment for impingement syndrome, with published success rates between 77% and 90%. Failure of subacromial decompression is defined as persistent pain and disability after surgery despite adequate postoperative rehabilitation. Potential causes of failure after subacromial decompression are varied and may include technical error, incorrect diagnosis, inadequate rehabilitation, or unrealistic postoperative expectations. A methodical approach to the patient with persistent symptoms after subacromial decompression will allow for accurate diagnosis and treatment of the underlying problem in the majority of cases.