肩袖损伤

肩袖损伤是指肩部周围肌肉或肌腱撕裂造成的损伤，是导致肩关节疼痛和活动受限的一种常见疾病，对患者的日常生活造成了较大影响。根据临床表现和症候特征，肩袖损伤主要分为风寒湿痹证、气滞血瘀证、肝肾亏虚证和血不荣筋证四大中医证型。本文归纳整理了近些年来中医药治疗肩袖损伤的临床诊疗进展，以期为今后肩袖损伤的治疗和临床研究提供参考。

肩袖损伤是骨伤科常见引起肩痛的疾病之一，严重影响日常工作生活。痛安汤是国医大师韦贵康教授根据多年临床经验所拟，其功效是活血散瘀，行气止痛。本文将论述肩袖损伤的发病机制，分析痛安汤加减在治疗肩袖损伤的应用，为肩袖损伤的中医药干预提供策略。

肩袖损伤是引起肩关节不适的常见原因。术后适当的康复训练对于手术的成功至关重要，但关节镜下肩袖修复术后的康复方案存在重大争议。当前的康复主要是早期康复与延迟康复，本文参考国内外相关文献，归纳总结了近年来肩袖损伤术后早期与延迟康复的研究进展，并予以综述。

肩袖损伤是临床上导致肩关节疼痛和活动受限的常见疾病，随着人口老龄化及诊断技术的成熟，发病率呈逐年上升趋势。治疗分为手术治疗和保守治疗。其中中医药治疗在非手术治疗中扮演着重要作用。具有安全性高、操作便捷、副作用小、易于接受的特点。中医药在肩袖损伤的治疗领域采用了多种手段，然而这些手段所产生的疗效存在差异，并且目前尚未形成统一的治疗标准。文章围绕对肩袖损伤的中医治疗进行了综述。

目的：对关节镜下治疗肩袖部分撕裂的临床疗效进行分析和总结。方法：选取我院于2020年11月~2022年11月期间收治的21例肩袖部分撕裂患者作为本次研究对象，均给予关节镜下肩袖清创与冈上肌肌腱肱骨大结节止点重建术治疗，撞击征阳性者还进行肩峰成形术治疗。结果：随访12个月，术前与术后的肩关节功能评分相比，存在统计学差异(P < 0.05)。结论：对于肩袖部分撕裂患者，采用关节镜下冈上肌肌腱肱骨大结节止点重建术治疗，能够有效改善患者的肩关节功能，临床疗效确切。

肩袖损伤是导致肩痛的主要原因，糖尿病与肩袖肌腱的改变有着密切的联系，糖尿病是肩袖损伤的危险因素之一，同时影响肩袖损伤的发生及术后愈合。随着糖尿病患病率的逐年上升，它们对肩袖损伤的影响研究变得更为重要。然而，糖尿病影响肩袖损伤的机制尚不清楚。有几个因素被提出，包括炎症反应、营养供应及血液供应等。本文就糖尿病与肩袖损伤的关系，影响肩袖的病理生理变化及其发病机制，以及对肩袖修补术后愈合和术后并发症的影响等方面进行综述，为提供个性化的预防措施及康复指导提供相关依据。

目的：通过对肩袖损伤患者采用平面治疗头、可伸缩治疗头冲击波两种不同类型冲击波进行干预，然后用治疗前后指标来对比，从而得到最佳的治疗方式。方法：选取患有肩袖损伤的运动员21名，随机分成3组，7人/组，每周治疗一次，共治疗四次；主要选取超声诊断、压痛点的VAS评分、关节活动度、肩袖相关肌肉的肌力测试四个指标进行效果评估。结果：在炎症愈合程度方面，可伸缩治疗头组相对平面治疗头组有较好的治疗效果；在促进疼痛缓解方面，两种治疗头皆对患者肩袖疼痛起到缓解和治疗作用，皆有显著性差异；在改善关节活动度方面，平面治疗头冲击波对肩关节屈伸和内外旋活动度的有较明显的改善作用，而可伸缩治疗头冲击波在外展、水平内收、和内旋这三个运动方向中，治疗后相对治疗前有显著性差异；在改善关节肌力方面，两组冲击波对于提高肌力并没有明显效果。结论：两种冲击波方案均对缓解疼痛，增加关节活动度有一定效果，针对不同的需求可以选择不同的治疗方案。

肩袖损伤是骨科临床常见疾病，其发病机制复杂，涉及外伤、退变、过度使用等多种因素。近年来，随着代谢性疾病与骨骼肌肉系统疾病关联研究的深入，高脂血症作为重要的代谢异常指标，与肩袖损伤的相关性逐渐受到关注。本文通过梳理国内外相关研究，从病理生理机制、临床研究证据、诊断与治疗启示等方面，系统阐述高脂血症在肩袖损伤发生、发展及预后中的作用，旨在为肩袖损伤的病因探索、风险评估及临床干预提供新的思路，同时为后续相关研究指明方向。

肩关节是参与上肢关节活动中重要的一个关节，肩袖在维持盂肱关节稳定性的同时，可以辅助肩关节进行广泛的活动。国内外专家学者对肩袖损伤的诊疗已研究多年，自从富血小板血浆进入临床应用起，因为其富含纤维蛋白和高浓度生长因子在创伤方面具有很好的治疗作用，所以在肩袖损伤的多种治疗方式中，富血小板血浆的使用脱颖而出并越来越受欢迎。目前，临床上对于PRP在肩袖损伤治疗中的应用暂无统一的规范及流程，本文通过肩袖损伤的发病机制、体格检查、影像检查、分型、治疗，PRP的制备、作用机制、PRP的临床应用等相关研究进展进行综述，为今后研究PRP治疗肩袖损伤的临床医师及科研工作者提供参考。

肩袖，是肩胛下肌、冈上肌、冈下肌和小圆肌组合而成的肌肉和肌腱复合物，具有调节肩关节稳定性和灵敏性的功能。目前，已知的肩关节疼痛病因主要是肩峰撞击以及肩袖损伤，而两者合并发生往往导致肩峰下滑囊和肩袖肌腱严重破损，对上肢活动带来重大影响，因此，精确诊断肩关节疼痛病因具有重要意义。医学影像学诊断在肩峰撞击合并肩袖损伤的评估中扮演着极其重要的角色，近年来如X线、超声和MRI等成像方法，可以用于精准的诊断和鉴别，以明确病因并针对治疗。本文综述了肩峰撞击症合并肩袖损伤影像学诊断方法最新研究进展，着重探讨各种影像学检查方法的优缺点以及它们在诊断肩峰撞击合并肩袖损伤中的作用。

目的：比较早期康复护理干预在关节镜下肩袖损伤术后肩关节功能恢复中的影响分析。方法：本研究回顾性分析2019年1月至2022年12月本院收治的因肩袖损伤行肩关节镜下肩袖损伤修补术的患者60例为研究对象，采用VAS评分评估干预前、干预后患肢疼痛分级并进行比较，采用SAS评分、SDS评分、AS-ES评分、JOA评分评估患者干预前、干预后关节功能以及患者心理状态。结果：观察组与对照组分别在干预前，干预后进行统计学分析，干预前两组未见统计学差异(P > 0.05)。干预后比较差异具有统计学意义(P 0.05)。干预后3天，干预后2周比较差异具有统计学意义(P < 0.05)。结论：综上所述，对肩关节镜下开展修复手术治疗的肩袖损伤患者开展早期康复护理，可有效促进患者功能恢复，改善肩关节活动度，提高日常生活能力。

肩袖损伤术后疼痛严重影响术后患者生活质量，中医药对于治疗术后疼痛，促进肩关节功能康复具有独特的疗效，本文就关节镜下肩袖损伤术后中医康复治疗的研究进展予以综述。

目的：探讨肩袖不完全撕裂经小切口手术治疗的临床疗效。方法：分析自2014年6月至2016年6月在山东省立医院创伤骨科采用小切口手术治疗肩袖不完全撕裂的患者36例及保守治疗肩袖不完全撕裂的患者11例，其中手术治疗组：男性20例，女性16例，年龄35~64岁，平均48.4岁；保守治疗组：男性6例，女性5例，年龄28~55岁，平均39.5岁。治疗前拍摄肩关节正位、冈上肌出口位X线片及MRI检查，手术治疗组中28例患者术中行肩峰下滑囊切除及肩峰成形术。手术全部采用气管插管全麻，沙滩椅体位，经三角肌小切口入路，选用不同大小锚钉缝合固定撕裂肩袖，术后肩关节外展位支具固定，并严格规范进行肩关节功能锻炼。保守治疗组给予休息制动(外展枕、肩人字石膏等)、理疗、封闭等保守治疗6~8周，后早期进行肩关节功能锻炼。结果：所有患者均获得随访，随访时间8~18月，平均11.2月。手术治疗组(36例)：术前及术后8月使用美国加州大学洛杉矶分校(UCLA)肩关节功能评定方法进行功能评价，术前UCLA评分：13~24 (17.2 ± 3.4)分，术后8月UCLA评分：18~34 (33.6 ± 4.1)，优12例，良20例，可3例，差1例，术后优良率为88.9%，术前与术后8月差异明显，具有统计学意义(P < 0.05)；保守治疗组(11例)：治疗前UCLA评分：16~28 (24.2 ± 4.6)分，治疗后8月UCLA评分：21~35 (32.2 ± 3.4)，优3例，良6例，可2例，差0例，治疗后优良率为81.8%，治疗前与治疗后8月有差异，具有统计学意义(P < 0.05)；其中1例患者因疼痛等原因没有进行规范的术后肩关节功能训练，致后期肩关节功能恢复不甚理想，其余46例患者后期功能恢复尚可，日常活动及工作不受明显影响。本研究手术组所有患者刀口均一期愈合，并且刀口瘢痕小而美观，无刀口感染、腋神经损伤及术后修补肩袖再撕裂等并发症。患者对治疗效果均为满意。结论：经小切口手术治疗肩袖不完全撕裂，不仅具有创伤小、操作视野清晰、手术时间短、固定可靠、住院费用低等优点，而且术后并发症发生率低，相较于保守治疗，手术治疗消除疼痛效果更好，从而能更早的恢复肩关节功能活动，是一种很好的治疗方式。

肩袖损伤常好发于中老年人，以肩关节疼痛、无力、活动受限为主要症状。肌腱断裂大于5毫米者称为巨大肩袖损伤。近年来，关节镜下肩袖修补术在临床上得到广泛应用。镜下治疗肩袖损伤对组织损伤小，术后可进行早期功能锻炼。系统性红斑狼疮是一种自身免疫性疾病，病程迁延不愈，且目前无根治方法。两种疾病合并一起使患者生理和社会功能都受到影响，生活质量下降。很多患者因担心手术使红斑狼疮加重，只单纯的进行保守治疗，最后导致肩关节损伤加重，形成巨大肩袖损伤，无法进行日常生活。随着医学模式的转变，生活质量成为各国医务工作者的研究热点。2013年9月，我院收治一例巨大肩袖损伤合并红斑狼疮的患者,长期服用强的松，因担心手术会使加重病情，一直在当地医院进行保守治疗，效果很差，患者患肢活动障碍，肩关节前屈上举85˚，外旋15˚，无法进行正常活动，生活质量严重下降。经他人介绍，转来我院治疗。护士对患者术前术后的常规护理，术后体位的安置及肩关节外展包制动的指导，在进行骨科常规护理时着重加强皮肤护理，在不影响手术的前提下避免皮肤刺激，观察并发症的同时注意鉴别症状引起原因，对症处理。患者肩关节恢复良好，未因手术创伤使原始疾病加重。

目的：系统梳理近年中医外治法治疗肩袖损伤的临床与机制研究，概括疗效与安全性证据，并提出规范化应用与研究改进方向。方法：基于既往临床试验、回顾性研究与综述，对针刺、电针、小针刀、推拿及中药外用等外治法的应用、疗效与安全性进行分析。结果：多数研究显示，中医外治可显著缓解疼痛、提升肩关节功能，并与康复训练协同促进恢复。常规针刺通过改善微循环与调节炎症通路镇痛；电针联合康复训练在疼痛缓解和功能改善方面可能较单纯康复具有一定优势。超声引导小针刀可松解粘连、减轻疼痛，严重不良事件罕见。推拿与中药外治对功能改善亦有积极作用。结论：中医外治在肩袖损伤的保守治疗与术后康复中具有显著镇痛与功能改善优势，安全性总体可控。未来需大样本、多中心、长期随访的随机对照试验，并统一操作与报告规范。

肩峰下撞击综合征(subacromial impingement syndrome, SIS)是导致肩关节疼痛最常见的原因之一。其临床症状与肩关节周围炎、肩关节骨性关节炎、肩关节不稳等疾病类似，故在临床上较难鉴别，且SIS通常伴有肩袖的损伤，若不能及时发现并治疗，会产生逐渐加重并产生慢性的肩袖损伤。随着临床经验的积累和影像学的发展，临床上对于SIS的诊断与治疗也在不断发展创新。本文将对SIS的诊断与治疗进展做一综述，希望能对临床医生及相关研究人员提供一定参考。

目的：探讨早期与晚期康复训练对肩袖修补术后患者关节活动度及功能的影响。方法：回顾性分析2021年9月至2022年8月新疆维吾尔自治区人民医院住院的43例肩袖撕裂患者。其中男21，女22，年龄45~63，右肩18例，左肩25例。早期康复组为术后第2周开始康复训练；晚期康复组患者术后第6周开始康复。比较两组患者术后6周，3个月，6个月疼痛视觉模拟评分(visual analogue scale, VAS)，constant评分，简明肩关节功能测试(simple shoulder test, SST)，前屈及外旋活动度。术后6个月进行MRI检查判断术后愈合情况。结果：比较两组患者术后6周，3个月VAS评分，constant评分，SST评分，前屈及外旋活动度存在显著差异，P 0.05。结论：肩袖修补术后，早期积极康复训练不影响愈合的同时对患者术后早期关节活动度，关节功能恢复和疼痛的改善有促进作用。尽管患者早期训练对关节早期活动有明显的影响但后期各组之间未见明显的差异。因此鉴于本研究和其他相关研究的结果，临床上我们需考虑患者具体病情，服从情况并且选择适合的康复训练方式，有效提高患者肩关节活动及功能恢复。

肩袖主要控制肩关节的活动并维持稳定性，一旦损伤难以自愈。虽然关节镜术后肩袖结构和生物力学得到了提高，但目前研究的重点已经转向通过生物制剂来提高愈合质量。富血小板血浆(Platelet-Rich Plasma, PRP)作为一种新兴潜在的生物增强剂在促进肌腱骨愈合方面获得了良好的效果，近年来在肩袖损伤领域获得了很多人的关注，尽管多项研究表明PRP注射可以很好地控制疼痛，由于其类型多样、给药方式及次数等不同，且患者肩袖撕裂的类型及大小也存在差异，因此出现了不同的临床结果。本文旨在评估PRP在治疗肩袖损伤中的疗效和用途。

肩撞击综合征是康复医学科较为普遍的一种肩关节疾患，又称疼痛弧综合征，包括肩袖肌腱炎、肩关节滑囊炎等，最早由Neer于1972年提出并推行至今，它与我们所熟知的肩周炎不能混为一谈。因此要研究其相关发病机制、诊断标准以降低临床误诊率、规范其治疗手段。临床中，从事较多体力劳动者及参与过顶项目的运动员是SIS的高发人群。

目的：比较神经肌肉电刺激(NMES)联合运动训练(ET)与单纯运动训练对功能性肩峰下撞击综合征(SIS)患者肩部功能、疼痛、关节活动度和肌力的影响。方法：将符合纳入条件的患者随机分为NMES + ET组(25例)和ET组(25例)。分别在治疗前、治疗8周后应用Constant评分量表评定患者肩功能，视觉模拟评分(VAS)评估疼痛程度，测角器测量肩关节活动度，手持测力仪评定肌力。结果：治疗结束时两组患者的肩部功能、关节活动度和肌力均增加，而疼痛均减轻。与ET组相比，NMES + ET组患者活动时的疼痛缓解更明显，肩外旋活动度和肌力提高更显著。结论：在ET的基础上加用NMES并不能额外提高功能性SIS患者肩部功能，但在提高肩关节外旋活动度、肌力和减轻活动时疼痛方面效果更好，二者联合应用的长期疗效需后续研究进一步探索。

目的：观察对II期肩峰下撞击综合征患者采用超声引导下针刀联合富血小板血浆注射治疗的效果。方法：将59例肩峰下撞击综合征患者按随机数字法分为对照组(29例)，观察组(30例)，对照组采用超声引导下针刀治疗，观察组采用超声引导下针刀联合富血小板血浆治疗，两组患者每周治疗1次，连续治疗3周。通过比较两组患者治疗前后的NRS评分、Constant-Murly评分及肩峰下滑囊厚度。结果：治疗后两组患者NRS评分及肩峰下滑囊厚度均较治疗前下降(P < 0.05)，且观察组低于对照组。Constant-Murly评分升高，观察组评分高于对照组(P < 0.05)。结论：超声引导下针刀联合富血小板血浆注射治疗II期肩峰撞击综合征可改善患者的症状，降低滑囊厚度，具有确切疗效。

肩胛下肌是肩袖中最大、最强的肌肉，在肩袖损伤中位居第2位，是肩关节前方维持盂肱关节生物力学稳定性的重要结构，漏诊或误诊将会给患者带来持续的前方肩关节疼痛。国内外对于肩胛下肌的研究较少，术前误诊、漏诊率较高，尤其是部分撕裂的患者。肩胛下肌腱损伤的发病机理尚不清楚，没有统一的MRI诊断标准，没有统一的分型标准，因此全面了解肩胛下肌的解剖、发病机理、损伤分型、检查方法及修复治疗等研究进展将有助于我们提高对肩胛下肌损伤的诊疗水平。

目的：探讨MRI测量临界肩角(Critical Shoulder Angle, CSA)、肩峰指数(Acromial Index, AI)、肩肱间距(Acromio Humeral Interval, AHI)与肩袖退变性撕裂之间的关系。方法：回顾性搜集2021年1月至2023年1月来院就诊的肩痛患者的MRI图像，共565例，其中肩袖退变性撕裂组353例，对照组212例，且均通过MRI或关节镜证实。在MRI图像上分别测量CSA、AI、AHI数值，用方差分析及Spearman检验对CSA、AI、AHI进行统计学分析，并采用受试者工作特征曲线(Receiver Operator Characteristic Curve, ROC)确定CSA、AI、AHI诊断肩袖退变性撕裂的分界值及其敏感性和特异性。结果：1) CSA、AI撕裂组大于对照组，AHI撕裂组小于对照组，差异均有统计学意义(p < 0.05)；2) CSA、AI具有相关性；3) CSA的曲线下面积、与肩袖撕裂灵敏性及特异性最高；诊断肩袖撕裂的最佳分界点：CSA为34.25˚、AI为0.66、AHI为7.01 mm。结论：MRI对CSA、AI及AHI的测量在肩袖退变性撕裂诊断中均具有价值，其中CSA的诊断效能最高。

目的：探讨氨甲环酸在肩袖损伤围术期的临床有效性。方法：回顾性分析2023年1月至12月新疆医科大学第六附属医院运动医学科收治的60例肩袖损伤患者，按是否使用氨甲环酸分为对照组(30例)和治疗组(30例)。治疗组在关节镜探查后向关节腔注射1 g氨甲环酸生理盐水溶液，对照组给予等量安慰剂。比较两组术前及术后24 h、72 h总失血量(基于血红蛋白动态监测)、血清总蛋白、白蛋白及铁代谢指标，并统计分析血常规参数变化。结果：① 术前资料：术前两组患者的年龄、性别构成、体质量指数、高血压、糖尿病、手术时间以及血红蛋白、血小板、红细胞平均体积、平均血红蛋白浓度、血清总蛋白和白蛋白指标进行比较，差异均无显著性意义(P > 0.05) ② 血红蛋白水平在术后第5天治疗组(108.22 ± 19.32 vs. 101.32 ± 15.90, t = 1.611, P = 0.111)虽未达统计学显著，但呈现升高趋势；治疗组术后第5天白蛋白(36.83 ± 4.89 vs. 33.91 ± 3.69, t = 2.817, P = 0.006)及治疗组在术后第5天营养储备(白蛋白)及红细胞动态(计数、血红蛋白)方面表现优于对照组，可能反映其治疗效果对造血功能及营养状态的积极影响。结论：结果表明，治疗组在肩关节镜下肩袖修补术中应用的止血效果比较明显，因此在肩关节镜下肩袖修补术中作者建议首选氨甲环酸作为止血药物。

肩袖损伤是中老年人常见的肩部疾病，关节镜下肩袖修补术(ARCR)因其微创优势成为主流治疗方式，但术后早期疼痛、僵硬等问题仍影响康复效果。西医通过手术技术改进(如双排缝合、无结技术、保残修补术等)提升生物力学稳定性，结合药物(非甾体抗炎药、皮质类固醇、玻璃酸钠等)和生物治疗(PRP、补片技术、生长因子等)促进早期功能恢复。中医将术后诸症归为“肩痹”范畴，以针灸、推拿、中药(如舒筋活络汤、补肾化瘀方等)辨证施治，调和气血、减轻炎症，显著改善术后早期疼痛与关节功能。中西医结合康复策略兼具西医精准修复与中医整体调理的优势，未来需进一步优化技术标准化与联合治疗方案，为患者提供更全面的术后康复路径。

背景：迄今为止，关于关节镜下肩袖修复术后应佩戴外展支具或肩带吊带还没有得出结论。为此，对随机对照试验进行了系统综述和Meta分析。方法：根据系统综述和Meta分析首选报告项目(PRISMA)的更新指南，系统搜索PubMed、Embase和Cochrane中央对照试验注册中心(Central)中从其建立到2022年3月1日的所有相关文献。结果评定包括恒定评分(Constant score)、西安大略肩袖(WORC)指数、视觉模拟量表(VAS)评分、肩关节活动范围(ROM)和肩袖愈合失败事件。Cochrane偏倚风险工具用于评价随机对照试验(RCT)的质量。结果：两位评价者(陈、刘)独立评价了275篇文章，其中只有5篇符合纳入标准，4篇纳入Meta分析，共302例患者。两项RCT中偏倚的总体风险较高，一项不明确，另两项较低。临床结果如下：常数评分(P = 0.08；MD，3.06；95%可信区间[CI]，−0.42~6.53)，WORC (P = 0.23; MD, 3.32; 95%CI, −2.15~8.79)，视觉模拟量表(VAS)评分(P = 0.09; MD, −1.27; 95%CI, −2.75~0.21)，ROM (P = 0.1; MD, 4.75; 95%CI, −0.98~10.48)，以及肩袖愈合失败事件(P = 0.78；比值比[OR]，0.86)；关节镜下肩袖修复后，外展支具和简单吊带之间没有显著差异。结论：这项系统综述和Meta分析的结果表明，肩袖修复后佩戴外展支具既不能改善肩关节的恒定评分、VAS评分、WORC评分和ROM，也不能降低肩袖再撕裂的风险。因此，从成本效益来看，简单吊带可能是更好的选择。预计使用更大更同质样本的研究将有助于验证我们的结果。

目的：观察富血小板血浆注射对肩袖部分全层撕裂的治疗疗效。方法：选取2023年1月至2024年5月在青岛大学附属医院就诊的肩袖部分全层撕裂患者27名，在超声引导下向撕裂部位及周边注射PRP 5 ml。于治疗前、治疗后4周、8周、12周记录患者的视觉模拟评分(VAS)、肩关节Constant-Murley评分(CMS)；在随访期间观察并记录患者的不良反应。结果：治疗后4周、8周、12周的VAS评分均较治疗前显著降低(P P P P < 0.05)；除注射后疼痛外，未出现其他不良反应。结论：富血小板血浆注射治疗肩袖部分全层撕裂可缓解患者的肩关节疼痛，改善功能障碍，疗效显著，且不良反应小，具有临床应用价值。

肩部钙化性肌腱炎(RCCT)是由于钙化物质在关节周围的肌腱中沉积，刺激肌腱并导致其柔韧性下降及炎症反复发作的非创伤性肩部疾病。其确切的发病机制目前尚未完全明确。RCCT在中医学中属于“痹症”等范畴，中医对肩痹疼痛的研究历史悠久。目前，针对肩袖钙化性肌腱炎的治疗方法尚未形成统一的标准，中西医治疗各有其优势。鉴于本病具有自限性特点，保守治疗和微创治疗成为首选方案，对于那些经过保守治疗无效的RCCT患者，最终可能需要采取手术治疗。本文旨在探讨肩袖钙化性肌腱炎的中西医诊疗策略。

目的：观察超声引导下富血小板血浆注射治疗部分厚度肩袖撕裂的临床有效性和安全性。方法：选取部分厚度肩袖撕裂患者31名作为研究对象，在超声引导下向撕裂部位注射PRP 3 ml，每周注射1次，共注射3次。观察治疗前、治疗后1周、4周、12周VAS评分、CMS评分、Quick-DASH评分数值变化。结果：在治疗后1、4、12周PTRCT患者的VAS评分和Quick-DASH评分均较治疗前下降(P < 0.05)，在治疗后1、4、12周PTRCT患者的CMS评分较治疗前升高(P < 0.05)。结论：超声引导下富血小板血浆注射可以有效缓解PTRCT患者的疼痛，改善肩关节功能，可以成为临床治疗部分厚度肩袖撕裂的一种有效、安全的手段。

目的：对比肩关节镜下单排缝合与双排缝合治疗巨大肩袖撕裂的临床疗效。方法：我们在青岛市市立医院收集了70例巨大肩袖撕裂患者，所有患者均收治于2022年7月~2023年1月期间，根据手术方式不同分为单排组和双排组，每组35例。单排组给予关节镜下单排缝合治疗，双排组给予关节镜下双排缝合治疗。随访两组患者术后6个月肩关节临床功能恢复情况及核磁共振影像肩袖完整情况。结果：两组患者术前ASES、CMS、UCLA、OSS、VAS评分相比较，P > 0.05，无统计学差异。两组患者术后ASES、CMS、UCLA评分均比术前高，且双排组比单排组高，P 0.05，比较不存在统计学差异。两组患者术后MRI肩袖完整情况均优于术前，且双排组优于单排组，P < 0.05，比较存在统计学差异。结论：肩关节镜下治疗巨大肩袖撕裂，在ASES、CMS、UCLA、OSS评分及MRI下肩袖完整情况方面说明双排缝合治疗相比于单排缝合效果更佳，但在VAS评分方面双排缝合治疗相比于单排缝合并无明显优势。

目的：设计一种新型可调节式个性化肩关节上肢牵引架，能够增加术中肩关节间隙，确保牵引架可以满足不同身材的患者的需求，从而提高手术效率。方法：收集2021年1月至2022年1月应用于30例肩关节镜手术患者资料，其中肩袖损伤15例，冻结肩6例，肩峰撞击症6例，肩关节盂唇损伤3例。所有患者使用本文所设计的肩关节镜上肢牵引架完成手术。结果：本组手术患者全部采用侧卧位进行肩关节镜手术。术中肩关节能够获得稳定、大小适宜的牵引力。所有患者未出现牵引过度导致术野暴露不足及患肢神经血管损伤。结论：本新型可调式肩关节镜上肢牵引架可以实现个性化的肩关节牵引，同时获得良好的手术视野，有效提高了手术效率，减少手术时间，避免手术并发症，值得临床推广及应用。

Resumo Objetivo Analisar a eficácia do uso de plasma rico em plaquetas (PRP) no tratamento de pacientes portadores de síndrome de impacto do manguito rotador em comparação ao tratamento com injeção subacromial de corticosteroides. Métodos O estudo é de caráter comparativo, longitudinal, duplo cego e randomizado. A evolução clínica dos pacientes foi quantificada pelas escalas The Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, University of California Los Angeles (UCLA) shoulder rating scale e Constant-Murley shoulder outcome score (CMS) no dia da aplicação, e novamente após 1, 3, e 6 meses. Resultados Não foram encontradas diferenças etsatisticamente significativas (p < 0.05) ao comparar os resultados do DASH outcome measure, UCLA shoulder rating scale, e CMS dos dois grupos na admissão. Após o tratamento, ambos os grupos apresentaram melhora significativa tanto do DASH, quanto do UCLA (p < 0,05). Entretanto, o escore do CMS referente ao tratamento com corticoide mostrou-se pior no 6° mês em comparação com o escore à admissão. Conclusão Esses achados sugerem que o PRP é um tratamento seguro e que pode ser uma ferramenta útil no arsenal terapêutico contra doenças do manguito rotador, uma vez que não foram encontradas diferenças significativas entre os grupos que receberam PRP e injeção subacromial de corticosteroides. Abstract Objective This research aims to study the effectiveness of platelet-rich plasma (PRP) in the treatment of patients with rotator cuff impingement syndrome compared with the treatment with subacromial injection of corticosteroids. Methods This is a double-blind, randomized, comparative clinical trial. The patients were clinically evaluated with the use of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, University of California Los Angeles (UCLA) shoulder rating scale and Constant-Murley shoulder outcome score (CMS) on the day of application, and then again after 1, 3 and 6 months. Results No statistically significant differences were found (p < 0.05) when comparing the results of the DASH outcome measure, UCLA shoulder rating scale and CMS of the two groups at baseline and after 1, 3, and 6 months of treatment with subacromial injection. After the treatment, both groups showed a significant improvement in the DASH and UCLA scores (p < 0.05) when compared with the baseline. However, the CMS at 6 months after treatment with steroids was lower than the baseline. Concusions These findings suggest that PRP is a safe treatment and can be a useful tool in the therapeutic arsenal against of the rotator cuff diseases, for there was no significant difference between the subacromial use of PRP and corticosteroids.

Background Impingement syndrome was shown to be associated with shoulder pain in 44–70% of patients worldwide. It usually occurs due to imbalance and insufficient activation of the rotator cuff (RC) muscles. Aim This study explores the relative effects of handgrip-strengthening exercises on shoulder function, pain, strength, and active range of motion as part of the treatment program for the patients with primary subacromial impingement syndrome. Materials and Methods A total of 58 patients aged 18-50 years with primary subacromial impingement syndrome were randomly enrolled to participate in this single-blind randomized clinical trial. Out of them, only forty patients have eligibly matched the inclusion criteria and randomly assigned to one of two groups to undergo a standardized therapeutic program consisting of two sessions a week for 8 weeks. The control group prescribed ultrasound therapy, ice, and stretching exercises, while the experimental group followed the same program with the addition of handgrip-strengthening exercises (HGSE). Both patients of conventional therapy (control) and handgrip-strengthening exercises (experimental group) were advised to adhere also to stretching and HGSE exercises once a day at home for eight weeks. The outcomes were the shoulder function, pain intensity, muscle strength, and active range of motion of the shoulder joint. Results Patients treated with conventional interventions plus handgrip-strengthening exercises showed the significant improvement over time in shoulder pain and function, strength of rotator cuff muscles, and pain-free range of motion forward flexion, abduction, and external and internal rotation through eight weeks in the experimental group compared to control patient group treated with conventional interventions. In addition, patients of both control and experimental groups showed no significant difference in the adherence to respective home-based stretching and HGSE exercises once a day at home for eight weeks. Conclusions Adding handgrip-strengthening exercises to conventional intervention increases the efficacy of treatment for patients with primary subacromial impingement syndrome in terms of shoulder function, pain, muscle strength, and active range of motion.

Internal impingement—or entrapment of the undersurface of the rotator cuff tendon against the glenoid during overhead activities—is believed to contribute to articular‐sided tears. However, little is known about internal impingement outside athletic populations. Therefore, the objectives of this study were to (1) describe glenoid‐to‐footprint distances and proximity centers during dynamic, in vivo motion in asymptomatic individuals, and (2) determine the extent to which these measures differed between individuals with and without a rotator cuff tear. Shoulder kinematics were assessed in 37 asymptomatic individuals during scapular plane abduction using a high‐speed biplane radiographic system. Glenoid‐to‐footprint distances and proximity center locations were calculated by combining the kinematics with computerized tomography‐derived bone models. Glenoid‐to‐footprint contact was presumed to occur when the minimum distance was less than the estimated labral thickness. The condition of the supraspinatus tendon (intact, torn) was assessed using ultrasound. Minimum distances and proximity centers were compared over humerothoracic elevation angles (90°, 110°, 130°, 150°) and between supraspinatus pathology groups using two‐factor mixed model analysis of variances. Glenoid‐to‐footprint minimum distances decreased consistently across elevation angles (p < 0.01) without a significant difference between groups. Contact was estimated to occur in all participants. Proximity centers were generally located on the anterior half of the rotator cuff footprint and on the posterosuperior glenoid. Statement of Clinical Significance: Internal impingement during overhead motions may be a prevalent mechanism of rotator cuff pathology as contact appears to be common and involves the region of the rotator cuff footprint where degenerative rotator cuff tears are thought to originate.

This study describes measurements between the coracoid, glenoid, and humerus; characterizes coracoid shape, rotator cuff fatty infiltration, and quantitatively evaluates coracoid impingement and its association with anterosuperior rotator cuff tears (ASCT). 193 shoulder magnetic resonance imaging (MRI) scans demonstrating: rotator cuff tear; isolated tear of the supraspinatus; tear of supraspinatus and subscapularis, were included. MRI measurements included coracohumeral interval (CHI), coracoid overlap (CO), coracoid recess (CR), coracoglenoid angle (CGA), and coracoglenoid interval (CGI) on axial slices; acromiohumeral interval (AHI) on coronal slices; and coracohumeral interval (CHI) and coracoacromial ligament (CAL) thickness on sagittal slices. The coracoid shape was classified as flat, curved, or hooked. An Independent T-test was used to compare the MRI measurements and the different rotator cuff tear groups. In 79% of the patients with ASCT tears, the coracoid was curved. Axial CHI, CGA, sagittal CHI, and AHI were decreased in ASCT when compared to no tears and isolated supraspinatus tears (p < 0.05). CO was increased in ASCT compared to no tears and isolated supraspinatus tears (p < 0.05). Patients with an ASCT had a significantly increased subscapularis and supraspinatus Goutallier fatty infiltration score when compared to no tear and isolated supraspinatus tears (p < 0.05). These quantitative measurements may be useful in identifying patients at risk for ASCT. Level of Evidence III.

Rotator cuff injury caused by subacromial impingement presents different morphologies. This study aims to investigate the correlation between various shoulder anatomical indexes on X‐ray with subacromial impingement and morphology of rotator cuff tears to facilitate surgical management.

BACKGROUND Subacromial impingement of the rotator cuff caused by variations in acromial anatomy or altered glenohumeral kinematics leads to inflammation and degeneration of the rotator cuff, ultimately contributing to the development of tendinopathy. However, the underlying cellular and molecular changes in the impinged tendon remain poorly understood. Since the rat is an accepted model for rotator cuff studies, we have developed a rat model to study rotator cuff tendinopathy. METHODS Forty four adult male Sprague-Dawley rats were allocated to one of four study groups: intact control group (Group 1, n=11); bilateral subacromial surgical clip placement to induce supraspinatus impingement for 2 weeks (Group 2, n=11), 4 weeks (Group 3, n=11) and 8 weeks (Group 4, n=11). Bilateral shoulder specimens were harvested for biomechanical testing, histology, and quantitative real-time polymerase chain reaction (qRT-PCR) analysis. RESULTS Radiography confirmed that all microvascular clips remained in stable position in the subacromial space. Gross inspection of supraspinatus tendon specimens in the impingement groups revealed changes in tendon morphology at the enthesis and midsubstance. Biomechanical evaluation demonstrated decreased supraspinatus tendon failure force and tissue stiffness at all time points compared to control tendons. Semi-quantitative scoring of histologic specimens demonstrated significant, persistent tendinopathic changes over 8 weeks. qRT-PCR analysis of impinged tendon specimens demonstrated upregulation of gene expression for Col3 and MMP14 in the impingement groups compared with control groups. In muscle samples, significant upregulation was seen in the expression of genes that are commonly associated with muscle atrophy (MURF1 and UBE2B) and fatty infiltration (FABP4, PPARγ2, and KLF15). CONCLUSION This novel rat subacromial impingement model creates cellular and molecular changes consistent with the development of rotator cuff tendinopathy. The results of this study may serve as a baseline for future investigation. LEVELS OF EVIDENCE Basic Science Study; Biomechanics; Histology and Microbiology; Animal Model.

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Historically, many causes have been proposed for rotator cuff conditions. The most prevalent theory is that the rotator cuff tendons, especially the supraspinatus, make contact with the acromion and coracoacromial ligament, resulting in pain and eventual tearing of the tendon. However, more recent evidence suggests that this concept does not explain the changes in rotator cuff tendons with age. The role of acromioplasty and coracoacromial ligament release in the treatment of rotator cuff disease has become questioned. Evidence now suggests that tendinopathy associated with aging may be a predominant factor in the development of rotator cuff degeneration. We propose that the overwhelming evidence favors factors other than "impingement" as the major cause of rotator cuff disease and that a paradigm shift in the way the development of rotator cuff pathology is conceptualized allows for a more comprehensive approach to the care of the patient with rotator cuff disease.

Purpose: Several radiographic parameters describe humeral head coverage by the acromion. We describe a new radiographic measurement, the acromion–greater tuberosity impingement index (ATI), and its ability to predict rotator cuff pathology. Methods: The ATI was measured with magnetic resonance imaging (MRI) and X-ray analysis in 83 patients with rotator cuff pathology and 76 patients with acute rotator cuff tears. The lateral acromial angle (LAA), acromion type, the acromion index (AI) and the critical shoulder angle (CSA) were measured to assess their correlations with the ATI. Receiver operating characteristic (ROC) curves were used to predict degenerative rotator cuff pathology. The change in the ATI after acromion surgery was evaluated in both groups. Results: According to the ROC curves, the ATI is a good predictor of degenerative rotator cuff pathology on both X-ray (cut-off, 0.865) and MRI (cut-off, 0.965). Patients with degenerative rotator cuff pathology had a significantly higher average ATI compared to the trauma group (p = 0.001 for X-ray and MRI). The degenerative group had a significantly lower LAA (p = 0.001) and a higher ratio of type III acromion (p = 0.035) than the trauma group. The ATI on X-ray was negatively related to the LAA and positively related to the AI, the CSA and acromion type (each p < 0.05). The ATI on MRI was negatively related to the LAA and positively related to the AI and acromion type (each p <0.05). More patients in the degenerative group than the trauma group needed acromioplasty or acromion decompression (p < 0.05). The ATI on MRI was significantly lower after acromion surgery compared to before surgery in both groups (p < 0.05). Conclusion: The ATI is a good predictor of degenerative supraspinatus tendon tears or subacromial impingement syndrome. The ATI on MRI is more accurate and can precisely guide acromion surgery.

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Introduction: Acromion process of the scapula and the subacromial space plays an important role in shoulder impingement syndrome and rotator cuff pathology. The aim is to study the morphological and morphometric parameters of the acromion process of human dry scapula in the South Indian population for its relevance in shoulder impingement syndrome and rotator cuff pathology. Material and Methods: Seventy adult unpaired dry scapulae (35 right and 35 left) of unknown age, gender, and without deformity were studied. The various shapes of acromion process were identified. Parameters such as acromioglenoid (AG) distance, coracoglenoid (CG) distance, coracoacromial (CA) distance, and height of the coracoacromial arch (HtCAA) were measured using a digital vernier caliper. The data were statistically analyzed. Results: The three types of acromion process observed were Type I flat in 57.14%, Type II curved in 40%, and Type III hooked in 2.86%. The mean ± standard deviation of AG distance was 24.9 ± 3.7 mm, CG distance was 22.7 ± 4.2 mm, AC distance was 30.9 ± 5.4 mm, and HtCAA was 19.2 ± 2.7 mm. A significant difference was observed with respect to AG (P = 0.04) and CG (P = 0.0007) between both sides of the scapula. Discussion and Conclusion: Knowledge about the common variant and morphometric dimensions of acromion process can aid to better understanding and planning for the treatment of rotator cuff pathology due to impingement syndrome.

BACKGROUND Current conservative management of subacromial shoulder impingement (SSI) includes generic strengthening exercises, especially for internal (IR) and external (ER) shoulder rotators. However, there is no evidence that the strength or the ratio of strength between these muscle groups is different between those with SSI (cases) and an asymptomatic population (controls). OBJECTIVE To identify if isokinetic rotator cuff strength or the ratio of strength is significantly different between cases and controls. STUDY DESIGN Case Control Study. METHOD Fifty one cases with SSI and 51 asymptomatic controls matched for age, gender, hand dominance and physical activity level completed isokinetic peak torque glenohumeral IR and ER testing. Within the SSI group, 31 dominant limbs were symptomatic and 20 non-dominant limbs were symptomatic. IR and ER were measured separately using continuous reciprocal concentric (con) and eccentric (ecc) contraction cycles at a speed of 60 degrees per second and again at 120 degrees per second. Values of peak torque (PT), relative peak torque (RPT) and ratios were compared using independent t-tests between the SSI and asymptomatic groups. RESULTS Significant strength differences between the two groups were present only when the symptomatic SSI shoulder was the dominant shoulder (con ER PT at 60°/second, ecc ER PT at 120°/second, ecc ER RPT at 120°/second and ecc IR PT at 60°/second and 120°/second). CONCLUSIONS Changes in rotator cuff strength in SSI may be related to limb dominance, which may have implications for strengthening regimes. LEVEL OF EVIDENCE Level 3a.

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Background and purpose — Arthroscopic acromioplasty is still commonly used in the treatment of shoulder impingement syndrome, even though its benefits are questioned; randomized controlled studies have not shown any benefits when compared to non-operative treatment. In this randomized study, we investigated whether operative treatment protects from later rotator cuff rupture and whether it has any effect on the development of rotator cuff muscle volume. Patients and methods — 140 stage-II impingement patients were randomized to a structured exercise group (n = 70) or to an operative group (n = 70). In the operative group, arthroscopic acromioplasty was performed, after which a similar structured exercise program was begun. MRI of the shoulder was done at baseline and at 5 years. Results — There were no statistically significant differences in either the amount of perforating ruptures of the supraspinatus tendon or in the changes in muscle volume at 5 years. The grading of muscle fatty degeneration showed worse results in the operative group, but this difference was not statistically significant. Interpretation — In this study, we found that arthroscopic acromioplasty does not have any long-term benefit based on radiological findings of muscle volumes. Also, the frequency of later rotator cuff rupture was similar irrespective of whether or not surgery was performed. Acromioplasty is not justified as a treatment for dynamic shoulder impingement syndrome.

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Patients with an isolated diagnosis of rotator cuff impingement syndrome were prospectively entered into the study. Each of the 23 subjects was refractory to conservative therapy, had preoperative roentgenograms, and underwent an open acromioplasty. The roentgenograms included anteroposterior, axillary, 30 degrees caudal tilt, and supraspinatus outlet views. The roentgenograms were measured by four independent readers. The separate views were then scored for reliability, and the correlation of the measurements with intraoperative acromial measurements was assessed. Interobserver reliability was highest for the caudal tilt view (0.84) and lowest for the axillary view (0.09). The supraspinatus and caudal tilt views correlated significantly with distinct intraoperative measurements of acromial spur size. We continue to advocate the evaluation of both views for preoperative assessment of the acromial spur in the rotator cuff impingement syndrome.

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Understanding the anatomy, injury patterns, and surgical procedures is essential for image interpretation. While direct evaluation of the rotator cuff cannot be made, radiographs of the shoulder provide the initial evaluation of the osseous abnormalities associated with rotator cuff impingement. MR imaging is considered the study of choice for the evaluation of the shoulder because of the comprehensive assessment of both bone and soft-tissue abnormalities. MR can accurately evaluate the size and shape of tendon tears, tendon tear retraction, and tendon and muscle quality. Computed tomography is an excellent modality for the evaluation of osseous detail and detection of gas and calcium deposition; however, conventional CT is much less sensitive for bone marrow edema detection and soft tissue detail of the rotator cuff. Ultrasound can assess the rotator cuff with results similar to MRI, but cannot evaluate osseous structures.

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BACKGROUND Rotator cuff tears are the leading cause of pain and functional disability of the shoulder. Conservative treatment is an essential part of their management. Despite the limited evidence, rehabilitation is the mainstay of the treatment for rotator cuff tears associated to impingement syndrome. There are current reports on the utility of strengthening with resistance, particularly by eccentric exercise. OBJECTIVE This report aims to present an overview of the efficacy of eccentric exercises in tendinopathies and current evidence of its benefit in rotator cuff tears. METHODS AND RESULTS We describe the information available in tendinopathy and analyzed four studies published on eccentric strengthening for rotator cuff tears. There is theoretical evidence about its usefulness in this pathology, but only a controlled clinical trial has been published with data on improvement in strength but not in pain or functionality. CONCLUSIONS More studies are needed with better methodological designs in order to generate evidence of their utility and recommendation.

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Background The current study aimed to measure the effectiveness of manual therapy in addition to stretching and strengthening exercises in patients with shoulder impingement syndrome to improve functional capacity, pain, and scapular range of motion. Methods This is a single-blinded randomized controlled trial. Thirty-two participants with chronic shoulder impingement syndrome were randomly allocated into two groups. Both groups received stretching and strengthening exercises while the treatment group was given manual therapy additionally. Treatment was started after the patients signed an informed consent form. The data were collected from the University of Lahore Teaching Hospital between March 2022 and December 2022. The study aimed to measure pain using a numeric pain rating scale, functional capacity was assessed by the disability of the arm and shoulder, and goniometry was used for scapular ranges, i.e., scapular protraction and upward rotation. Each treatment session lasted 45 min for the treatment group and 30 min for the control group. The treatment comprised five days a week for four weeks, after which post-intervention measurements were taken. Results Thirty-two participants were enrolled in the study, and 16 were divided into each group. The mean age of the participants in the treatment group was 38.19 ± 7.31 while the comparison group was 35.69 ± 7.98. An independent sample t-test was run on the data with a 95% confidence interval, statistically significant results were obtained, i.e., p-value < 0.05, post-intervention in the treatment group. Both groups have significantly improved functional capacity and scapular protraction ( p  < 0.005), however, pain and scapular upward rotation were not found statistically significant in the control group ( p  > 0.05). Conclusion The addition of manual therapy along with exercise therapy showed clinical and statistical significant results for pain, functional capacity, and scapular range of motion. It demonstrated superior effects than exercise therapy alone for the chronic condition of SIS. Trial Registration The trial was registered in the Iranian Registry of Clinical Trials ( https://www.irct.ir/ ) with the registration number: IRCT20230526058291N1, (Date: 12/08/2023).

Objective: This study aimed to investigate the effect of a virtual reality (VR)-mediated gamified rehabilitation program added to a home exercise program on pain, functionality, and quality of life in shoulder impingement syndrome. Methods: Forty-eight participants with shoulder impingement syndrome were included in this prospective, randomized, single-blind study between January and July 2022. The participants were randomized into two groups: the VR group (n = 24) and the control group (n = 24). All participants were given a home exercise program for 3 weeks, with five sessions per week. The participants in the VR group received 15 sessions (45 minutes each session) of a gamified shoulder exercise program with an immersive VR headset, while those in the control group received 15 sessions (45 minutes each session) of supervised therapeutic exercises. The participants were evaluated and compared before and after treatment using the 36-item Short Form Survey (SF-36), range-of-motion (ROM) measurements, the Visual Analog Scale (VAS), and the Shoulder Pain and Disability Scale (SPADI). Results: At the baseline assessment, the two groups were homogenous regarding demographic and clinical parameters. The post-treatment shoulder extension and adduction ROM was significantly greater in the VR group and the post-treatment pain subscales for SPADI and SF-36 were significantly lower in the VR group. Conclusion: In individuals with shoulder impingement syndrome, a VR-mediated gamified exercise program added to a home exercise program increased shoulder ROM and reduced pain scores. Further clinical studies are needed to prove the long-term efficacy of the addition of VR-mediated gamified exercises to the treatment of this condition in clinical settings.

To estimate the effectiveness of the Mulligan technique for the shoulder complex on the subacromial space, shoulder ROM, pressure pain threshold, and function of the shoulder in the impingement syndrome patient.Thirty patients who suffered from shoulder impingement syndrome were at random allocated into two groups; the experimental group received shoulder complex mobilization with movement plus conventional therapy, and the control group received conventional treatment. All patients were examined by ultrasonography for subacromial space, shoulder range of motion using a digital goniometer, electronic algometry for pressure pain threshold, and the Quick DASH for a difficulty level involved in carrying out several physical activities.In comparison to group B post-treatment, there were statistically significant improvements in the subacromial space (p > 0.004), flexion and abduction ROM, PPT of the biceps and supraspinatus (p > 0.001), and a significant reduction in the quick DASH (p > 0.001).Shoulder complex mobilization with movement plus conventional therapy improved subacromial space, shoulder ROM, pressure pain thresholds, and function more than conventional therapy alone in shoulder impingement syndrome patients.

Shoulder impingement is the most common diagnosis for shoulder pain. Shoulder impingement syndrome has been scrutinized as a misleading "umbrella" term, due to its vague and nonspecific context. It is better subcategorized into subacromial, internal, and subcoracoid impingement. The evaluation and treatment algorithm for each is grossly similar. A thorough history, focused physical examination, and standard radiographs are the first steps. Advanced imaging with MRI or ultrasound may be useful. The mainstay of treatment includes physical therapy, anti-inflammatory medications, and injections. Surgical treatment is reserved for refractory cases, and includes decompression, debridement, and/or repair of injured structures.

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OBJECTIVE To investigate if muscle energy technique (MET) to the thoracic spine decreases the pain and disability associated with shoulder impingement syndrome (SIS). DESIGN Single centre, three-arm, randomised controlled trial, single-blind, placebo control with concealed allocation and a 12-month follow-up. SETTING Private osteopathic practice. INTERVENTIONS Participants were randomly allocated to: MET to the thoracic spine (MET-only), MET plus soft tissue massage (MET&STM) or placebo. PARTICIPANTS 3 groups of 25 (n=75) participants ≥ 40 years with SIS received allocated intervention once a week for 15 minutes, 4 consecutive weeks. OUTCOME MEASURES Primary outcome measure: Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. SECONDARY OUTCOME MEASURES Shoulder Pain and Disability Index (SPADI) questionnaire, visual analogue scale (VAS-mm/100) -current, 7-day average, 4-week average, patient specific functional scale (PSFS) and global rating of change (GROC). Measures recorded at baseline, discharge, 4-weeks follow-up, 6-months and 12-months. Also baseline and discharge thoracic posture and range of motion (ROM) measured using an inclinometer. STATISTICAL ANALYSIS Mixed effects linear regression model for DASH, SPADI, VAS, PSFS, GROC and thoracic posture and ROM. RESULTS MET-only group demonstrated significantly greater improvement in pain and disability (DASH, SPADI, VAS 7-day average) compared to placebo at discharge (mean difference DASH=-8.4; 95% CI -14.0,-2.8; SPADI=-14.7;-23.0,-6.3; VAS=-15.5;-24.5,-6.5), 6 -months (-11.1;-18.6,-3.7; -14.9;-26.3,-3.5; -14.1;-26.0,-2.2) and 12 -months (-13.4;-23.9,-2.9; -19.0;-32.4,-5.7; -17.3;-30.9,-3.8). MET&STM group also demonstrated greater improvement in disability, but not pain compared to placebo at discharge (DASH=-8.2;-14.0,-2.3; SPADI= -13.5;-22.3,-4.8) and 6 months (-9.0;-16.9,-1.2; -12.4;-24.3,-0.5). For the PSFS, MET-only improved compared to placebo at discharge (1.3;0.1,2.5) and 12 months (1.8;0.5,3.2); MET&STM at 12 months (1.7;0.3,3.0). GROC: MET-only improved compared to placebo at discharge (1.5;0.9,2.2) and 4 weeks (1.0;0.1,1.9); MET&STM at discharge (1.2;0.5,1.9) and 6 months (1.2;0.1,1.3). There were no differences between MET-only and MET&STM, and no between-group differences in thoracic posture or ROM. CONCLUSION MET of the thoracic spine with or without STM improved the pain and disability in individuals over 40 with SIS and may be recommended as a treatment approach for SIS.

Context: To determine optimal treatment strategies for shoulder impingement syndrome (SIS). Objective: To compare subacromial nonsteroidal anti-inflammatory injections (SNIs) and subacromial corticosteroid injections (SCIs) on pain relief and functional improvement in individuals with SIS. Second, to perform a cost analysis of the 2 injections. Data Sources: MEDLINE, SPORTDiscus, CINAHL, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials using several keywords. Study Selection: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized, and 10 studies comparing changes in pain or function in humans with SIS receiving SNIs or SCIs were included. Quality and risk of bias were assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 scale and the Cochrane Collaboration tool. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 1. Data Extraction: Baseline and follow-up scores of the visual analog, Constant-Murley, and University of California Los Angeles shoulder scales were extracted to calculate effect sizes (ESs), represented as Cohen d. Metaregression and publication bias analyses were performed. Procedural and medication costs were extracted from Medicare guidelines. Results: A total of 7 high and 3 good quality studies were included, with a mean score of 21.1. Only 1 study had a high risk of bias. The meta-analyses produced pooled ESs of 0.05 (P = 0.83), 0.12 (P = 0.71), and 0.07 (P = 0.79) for each scale, respectively, with CIs crossing 0. Procedural costs were equal between groups, whereas ketorolac was the least costly medication ($0.47). There was no significant difference in side effects between the 2 injections. Conclusion: SNIs are as effective as SCIs for short-term pain relief and improving function in patients with subacromial impingement syndrome. In addition, they are less expensive and cause no major difference in complications, providing a viable, cost-effective alternative for injection therapy in patients with SIS.

The purpose of this study is to assess and compare corticospinal excitability in the upper and lower trapezius and serratus anterior muscles in participants with and without shoulder impingement syndrome (SIS). Fourteen participants with SIS, and 14 without SIS were recruited through convenient sampling in this study. Transcranial magnetic stimulation assessment of the scapular muscles was performed while the participants were holding their arm at 90 degrees scaption. The motor-evoked potential (MEP), active motor threshold (AMT), latency of MEP, cortical silent period (CSP), activated area and center of gravity (COG) of cortical mapping were compared between groups using the Mann-Whitney U tests. The SIS group demonstrated following significances, higher AMTs of the lower trapezius (SIS: 0.60 ± 0.06; Comparison: 0.54 ± 0.07, p = 0.028) and the serratus anterior (SIS: 0.59 ± 0.04; Comparison: 0.54 ± 0.06, p = 0.022), longer CSP of the lower trapezius (SIS: 62.23 ± 22.87 ms; Comparison: 45.22 ± 14.64 ms, p = 0.019), and posteriorly shifted COG in the upper trapezius (SIS: 1.88 ± 1.06; Comparison: 2.76 ± 1.55, p = 0.048) and the serratus anterior (SIS: 2.13 ± 1.02; Comparison: 3.12 ± 1.88, p = 0.043), than the control group. In conclusion, participants with SIS demonstrated different organization of the corticospinal system, including decreased excitability, increased inhibition, and shift in motor representation of the scapular muscles.

Introduction To analyze the change in Visual Analog Scale (VAS), QuickDASH score, and the range of motion at the shoulder joint following a single injection of platelet-rich plasma (PRP) in shoulder impingement syndrome. Methods Twenty patients (21 shoulders) of either sex above the age of 18 years with a clinical diagnosis of shoulder impingement having a positive shoulder impingement test (positive Hawkins-Kennedy impingement test and/or positive Neer's impingement sign), ultrasonographic confirmation of shoulder impingement, and a failure to respond to standard non-operative methods for a minimum period of four weeks were included in this prospective interventional study. PRP was injected at the proposed site. At three months after the injection, the changes in the VAS, QuickDASH score, and the range of motion at the shoulder joint were analyzed. Results There were significant changes in the VAS, QuickDASH score, and range of motion at the shoulder joint following a single injection of PRP. Conclusions Platelet-rich plasma (PRP) injection results in a significant decrease in pain and improvement in the range of motion and an overall excellent functional outcome in shoulder impingement syndrome. However, future studies with a bigger sample size and longer follow-up are needed.

Reduction in isometric strength of the scapulohumeral muscles is a commonly seen impairment in overhead athletes afflicted with shoulder impingement syndrome (SIS). The purpose of this study was to compare the effects of two different treatment programs: progressive resistance exercises plus manual therapy (PRE plus MT) and motor control exercises (MCE), on isometric strength of upper trapezius (UT), middle trapezius (MTr), lower trapezius (LT), serratus anterior (SA), supraspinatus (Supr.), anterior deltoid (A.D), and latissimus dorsi (LD). 80 male university-level overhead athletes clinically diagnosed with SIS were randomly allocated into either of the two groups: PRE plus MT and MCE group. Athletes in the PRE plus MT group underwent graduated exercises with resistance elastic band, stretching exercises, and mobilization of the thoracic and shoulder joints. MCE group was submitted to motor control exercises in varied planar positions. Athletes in both groups underwent management 3 times a week for 8 weeks. Isometric strength of UT, MTr, LT, Supr, A.D, SA, and LD was measured at three-time points: baseline, 4th week, and 8th week. Relative to baseline, both interventions were found to be effective in increasing and optimizing the isometric strength of muscles (p < 0.05) except for supraspinatus in the MCE group (p > 0.05). However, athletes in PRE plus MT group presented a more pronounced increase in isometric strength than those in the MCE group. Between groups analysis found the largest isometric strength improvement in PRE plus MT group for A.D, followed by Supr. and UT muscles (p < 0.05; effect size: 0.39 to 0.40). The study concluded that compared to MCE, PRE plus MT provides greater improvement in the isometric strength of scapulohumeral muscles.

Background Shoulder impingement syndrome (SIS) is the most common form of shoulder pain. Conservative and surgical treatments for SIS are often not effective. One such surgical intervention is subacromial decompression, aimed at widening the subacromial space (SAS). A better understanding of the changes in the SAS may help explain the relative ineffectiveness of current interventions. Objective: To measure the acromiohumeral distance (AHD) and supraspinatus tendon thickness (STT) in people with SIS using a case control study. Methods The AHD and STT of 39 participants with SIS ≥3 months and 39 age, gender and dominant arm matched controls were measured using ultrasound imaging. Between-group differences for AHD and STT were compared using t-tests. A linear regression was used to determine if there was a relationship between AHD and STT measures, with group as a covariate. Results Compared to controls (mean age 55.7 years, SD 10.6), individuals with SIS (mean age 57.1 years, SD 11.1) had a significantly larger AHD (mean difference 2.14 mm, 95% CI 1.21, 3.07, p  < 0.001) and STT (mean difference 1.25 mm, 95% CI 0.60, 1.90, p  < 0.001). The linear regression model indicated an association between AHD and STT (β = 0.59, 95% CI 0.29, 0.89, p  < 0.01, R 2  = 0.35, n  = 78), suggesting that as STT increases in size, so does the AHD. Conclusion Individuals with SIS had a larger AHD and greater STT than controls. These results suggest the SAS is already wider in people with SIS and that the symptoms associated with SIS may be more related to an increased STT than a smaller SAS.

PURPOSE The study aimed to compare the effects of exercise therapy plus manual therapy (ET plus MT) and exercise therapy (ET) alone on muscle activity, muscle onset latency timing and shoulder pain and disability index-Hindi (SPADI-H) score in athletes with shoulder impingement syndrome (SIS). MATERIALS AND METHOD Overhead male athletes diagnosed with SIS were randomly allocated into ET plus MT group(n = 40) and ET group(n = 40). Muscle activity, muscle onset latency timings and SPADI-H score were assessed. Both the groups performed 8 weeks of intervention and were evaluated at baseline, 4th and 8th weeks. RESULT ET plus MT group was more effective in increasing muscle activity, optimising latency timings and decreasing SPADI score when compared to ET group alone(p < 0.05). After treatment muscle activity and SPADI-H improved in both groups (p < 0.05). CONCLUSION ET plus MT was superior for improving muscle activity, muscle onset latency timing and SPADI score compared to ET alone.

OBJECTIVE The aim of this study was to investigate the effects of a combination of dry needling (DN) and muscle energy technique (MET) on pain intensity (PI), pressure pain threshold (PPT) and shoulder active range of motion (ROM) in patients with shoulder impingement syndrome and active trigger points in the infraspinatus muscle. METHODS 39 patients, aged 20-50 participated in this study. All the cases were randomly assigned into three groups: group 1 (n = 13) received DN, group 2 (n = 13) received MET, and group 3 (n = 13) received DN & MET. The patients were treated for three sessions in a one-week period with at least a two-day break between sessions. RESULTS The results showed a significant improvement in visual analog scale (VAS), PPT and shoulder ROM over time (P < 0.001) in all three groups. There were no significant differences BETWEEN VAS (P = 0.406) PPT (P = 0.293), external rotation(EXT.ROT) (0.476), internal rotation (INT.ROT)(P = 0.476) and extension(EXT) (P = 0.574) ROMs in the three groups; however, DN group was significantly more effective on abduction(ABD) (P = 0.003) and flexion(FLEX) (0.012) ROM compared with other two groups. CONCLUSION In line with previous studies, the present study found that the application of DN, MET and combined of these treatment on active trigger points in the infraspinatus muscle of patients with shoulder impingement syndrome helps reduce pain, increase PPT and enhance the shoulder ROM. Both techniques are effective in the treatment of trigger points. Nevertheless, DN is more effective in enhancing the ROM of flexion & abduction.

INTRODUCTION Shoulder impingement syndrome is evaluated radiologically with two-dimensional measurement parameters. None of these measurement parameters accurately reflect the three-dimensional geometry. The purpose of this study was to evaluate the volumetric status of the subacromial space in patients with shoulder impingement syndrome and to investigate its relationship with two-dimensional parameters. HYPOTHESIS The primary hypothesis of this study is that subacromial volume is reduced in patients with impingement syndrome. The second hypothesis is that the sagittal plane morphology of the acromion reflects the subacromial volume better than the coronal plane morphology. PATIENTS AND METHODS This retrospective study consisted of a total of 52 participants: 26 patients with impingement syndrome and 26 controls. Volumetric measurements were performed with using magnetic resonance imaging. The relationship between humerus and acromion was evaluated by acromiohumeral distance. The sagittal plane morphology of the acromion was evaluated with an objective acromial angle, while the coronal plane morphology was evaluated with a lateral acromial angle. The radiological parameters between groups were compared. RESULTS The mean subacromial volume was significantly smaller in the impingement group compared to the control group (p=0.01). The subacromial volume had a negative correlation with the objective acromial angle (R=-0,46; p=0.01) The mean tendon volume was significantly higher in the impingement group (p<0.001). The mean acromiohumeral distance in the impingement group (6.8mm ± 1.0mm), was calculated to be significantly lower than the control group (10.1mm ± 1.5mm) (p<0.001). There was a positive moderate correlation between subacromial volume and acromiohumeral distance (R=0.61; p=0.01). DISCUSSION This is the first study to demonstrate a reduction in subacromial volume in patients with impingement syndrome. The sagittal plane morphology of the acromion, rather than the coronal plane, appears to be more closely related to the subacromial volume. LEVEL OF EVIDENCE III; case-control study.

To find out which structure is crucial for the formation of shoulder impingement syndrome with the purpose of directing surgical procedures of subacromial decompression and discussing whether it is necessary to manage acromioclavicular joint during operation and how to do it properly.

Introduction Shoulder impingement syndrome (SIS) is one of the common problems which lead to shoulder disabilities. This condition has been described as impingement to the rotator cuff by the anterior third of the acromion process and has been classified into three stages. Treatment option varies depending on the grade of the disease. Arthroscopic subacromial decompression (ASAD) has become more popular in recent years and has shown to have a good outcome. The purpose of this study is to evaluate the outcomes following ASAD in terms of the functional, clinical, and radiological parameters in treating SIS in the ageing population in Kuantan, Pahang, Malaysia. Materials and methods This was an observational study looking at the outcomes of patients with stage 2 and stage 3 (partial cuff tear) impingement syndrome who underwent ASAD in Hospital Tengku Ampuan Afzan and International Islamic University Malaysia Medical Centre from May 2018 to June 2019. The functional outcomes were evaluated using American Shoulder and Elbow Surgeons (ASES) score taken at pre-operative, six weeks, three months, and six months post-operation. Clinical outcomes were evaluated using Constant score (CS) taken at six months post-operation. Radiological outcomes were measured by comparing acromiohumeral distance pre- and post-operation on anteroposterior (AP) view radiograph of the affected shoulder. Results A total of 28 patients were selected for the study. On functional outcome, there was a significant effect of time on the ASES scoring system (p-value <0.05) from pre-operative to six months post-operation. On clinical outcome, the CS at six months showed 13 patients have excellent scores, 10 have good, and five have fair scores. There was a statistically significant difference in mean values of all categories (p-value <0.05). In terms of the radiological outcome, this study observed a significant increase in patients’ subacromial space on X-ray from the pre-operative and post-operative treatment stages. In this study, we also observed that there was no significant difference in outcomes between partial and intact rotator cuff (RC) tears at six-month post-operation. Conclusion In this study, ASAD was found to be a beneficial intervention in the treatment of patients with shoulder impingement evidenced by the significant outcomes in terms of functional, clinical, and radiological parameters.

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Objectives This study aims to evaluate the intra- and inter-rater reliability coefficients of the supraspinatus tendon thickness, acromiohumeral distance, and occupation ratio in patients with shoulder impingement syndrome. Patients and methods The study included 83 patients (21 males, 62 females; mean age 51.6±11.0 years; range, 26 to 70 years) with shoulder impingement syndrome. The supraspinatus tendon thickness, acromiohumeral distance, and occupation ratio values were obtained one week apart by two observers. The intraclass correlation coefficient (ICC), minimum detectable change, and standard error of measurement were calculated. Results The first observer had excellent intra-rater reliability in all measurements (ICC >0.90) with minimum detectable change of 0.740-0.047 mm and standard error of measurement of 0.017-0.26 mm. The second observer had excellent intra-rater reliability in supraspinatus tendon thickness and acromiohumeral distance measurements (ICC >0.90) with minimum detectable change of 0.498-0.770 mm and standard error of measurement of 0.18-0.28 mm and good intra-rater reliability in the occupation ratio measurement (ICC; 0.75-0.90) with minimum detectable change of 0.060 mm and standard error of measurement of 0.022 mm. Inter-rater reliability coefficients were 0.916 (95% confidence interval [CI]; 0.873-0.945) for supraspinatus tendon thickness, 0.943 (95% CI; 0.914-0.963) for acromiohumeral distance with minimum detectable change of 0.673 mm and standard error of measurement of 0.243 mm and 0.790 (%95 CI; 0.693-0.853) for occupation ratio with minimum detectable change of 0.077 mm and standard error of measurement of 0.028 mm. Conclusion These findings suggest that ultrasonographic measurements of the supraspinatus tendon thickness, acromiohumeral distance and occupation ratio can be reliable and consistent for clinical evaluation of patients with shoulder impingement syndrome in terms of supporting diagnosis and monitoring the treatment effect.

Objective: To investigate if adding Kinesio tape to therapeutic exercise is an effective treatment to improve clinical outcomes compared to therapeutic exercise alone and no intervention, in patients with shoulder impingement syndrome. Design: Three-arm randomized controlled trial Setting: Outpatient setting Subjects: One hundred and twenty patients (mean (SD): age 37.8 (5.4)) with shoulder impingement syndrome. Intervention: Patients were randomly assigned to eight-weeks therapeutic exercise alone, therapeutic exercise with Kinesio tape, and control group. Main measures: Pain was measured with a numerical rating scale and disability and scapular kinematics were measured with a relative questionnaire and motion analysis software respectively, at baseline and after eight-weeks intervention. Results: There was significant differences in therapeutic exercise with Kinesio tape group vs. therapeutic exercise alone and control group respectively for pain (d = –0.34, P = 0.042; and d = –1.53, P = 0.001), disability (d = –0.46, P = 0.024; and d = –2.18, P = 0.001), scapular upward rotation at sagittal plane (d = 0.33, P = 0.033; and d = 0.68, P = 0.001), scapular plane (d = 0.18, P = 0.045; and d = 0.43, P = 0.001), scapular tilt at sagittal plane (d = 0.55, P = 0.043; and d = 1.39, P = 0.001), and scapular plane (d = 0.29, P = 0.034; and d = 0.58, P = 0.001). Therapeutic exercise alone was superior over control group in all significant outcomes (P < 0.05). Conclusion: Although therapeutic exercises alone showed positive effect on clinical outcomes, adding Kinesio tape to therapeutic exercises had more significant effects with larger effect sizes. Adding Kinesio tape to therapeutic exercise may be of some assistance to clinicians in improving clinical outcomes in patients with shoulder impingement syndrome.

BACKGROUND Shoulder impingement syndrome (SIS) is the most common form of shoulder pain and a persistent musculoskeletal problem. Conservative and invasive treatments, aimed at the shoulder joint, have had limited success. Research suggests shoulder function is related to thoracic posture, but it is unknown whether thoracic posture is associated with SIS. OBJECTIVE The objective of this study was to investigate whether there is a relationship between SIS and thoracic posture. DESIGN This was a case control study. METHODS Thoracic posture of 39 participants with SIS and 39 age, gender, and dominant arm matched controls was measured using the modified Cobb angle from a standing lateral radiograph. Thoracic range of motion (ROM) was also measured using an inclinometer. Between-group differences were compared using t tests. The relationship between thoracic posture and thoracic ROM was determined with linear regression. RESULTS Twenty females and 19 males with SIS (mean age 57.1 years, SD 11.1) and 39 age, gender, and dominant arm matched controls (mean age 55.7 years, SD 10.6) participated. Individuals with SIS had greater thoracic kyphosis (mean difference 6.2o, 95% CI 2.0, 10.4) and less active thoracic extension (7.8o, 95% CI 2.2, 13.4). Greater thoracic kyphosis was associated with less extension ROM (i.e more flexion when attempting full extension: β = 0.71, 95% CI 0.45, 0.97). LIMITATIONS These cross-sectional data can only demonstrate association and not causation. Both radiographic measurements and inclinometer measurements were not blinded. CONCLUSIONS Individuals with SIS had a greater thoracic kyphosis and less extension ROM than age and gender matched healthy controls. These results suggest that clinicians could consider addressing the thoracic spine in patients with SIS.

Background The objective of the study was to compare the effects of neuromobilization (NM) techniques and routine physiotherapy on pain and functional disability in patients having shoulder impingement syndrome (SIS). Present study was aimed to discover evidence based conservative and cost effective remedy on pain and functional disability. Study design Single blinded randomized control clinical trial. Methods A total of 80 patients with SIS were randomly assigned into care and experimental groups (40 in each group). After the baseline assessment routine physiotherapy was executed on both groups, while NM was applied additionally to experimental group. Pain and functional disability score were evaluated by Visual Analogue Scale and University of California at Los Angeles rating score at baseline, 5th and 11th week. Differences in outcome between groups were evaluated with clinical improvement. Results The experimental group compared with care group at 11th week had lower mean pain score 2.15(1.66–2.64) vs 4.90(4.41–5.40); between group difference, 1.82; 95% (CI), − 2.38 to − 1.25; P < 0.001 and Partial ƞ 2  = 0.33, similarly functional disability score 28.58(27.32–29.83) vs 20.10(18.84–21.36); between group difference,5.62; 95%CI, (4.32–6.92); P < 0.001 and Partial ƞ 2  = 0.49 respectively. In experimental group NM was a more effective technique to reduce the pain severity and disability in SIS patients as compare to care group. Conclusion Neuromobilization techniques in addition to routine physiotherapy were significantly effective for the treatment of SIS. Trial registration IRCT20190121042445N1 , Registered 19 February 2019.

BACKGROUND Round shoulder posture (RSP) is one of the potential risks for shoulder impingement syndrome (SIS) due to alignment deviation of the scapula. Evidence on how the characteristics of a shoulder brace affecting the degree of RSP, shoulder kinematics, and associated muscle activity during movements is limited. RESEARCH QUESTION The purposes of this study were (1) to compare the effects of a shoulder brace on clinical RSP measurements, muscle activities and scapular kinematics during arm movements in subjects with shoulder impingement syndrome (SIS) and RSP; and (2) to compare the effects of two configurations (parallel and diagonal) and two tensions (comfortable and forced tension) of the brace straps on muscle activities and scapular kinematics during arm movements in subjects with SIS and RSP. METHODS Twenty-four participants (12 males; 12 females) with SIS and RSP were randomly assigned into 2 groups (comfortable then forced, and forced then comfortable) with 2 strap configurations in each tension condition. The pectoralis minor index (PMI), acromial distance (AD) and shoulder angle (SA) were used to assess the degree of RSP. Three-dimensional electromagnetic motion analysis and electromyography were used to record the scapular kinematics and muscle activity during arm movements. RESULTS All clinical measurements with the brace were significantly improved (p < 0.05). Under forced tension, muscle activities were higher with the diagonal configuration than with the parallel configuration in the lower trapezius (LT) (1.2-2.3% MVIC, p < 0.05) and serratus anterior (SA) (2.3% MVIC, p = 0.015). For upward rotation and posterior tilting of the scapula, the diagonal configuration was larger than the parallel configuration (1.5°, p = 0.038; 0.4°-0.5°, p < 0.05, respectively). SIGNIFICANCE Different characteristics of the straps of the shoulder brace could alter muscle activity and scapular kinematics at different angles during arm movement. Based on the clinical treatment preference, the application of a shoulder brace with a diagonal configuration and forced tension is suggested for SIS and RSP subjects.

OBJECTIVE To investigate the effects of Kinesio Taping® (KT) on scapular kinematics and electromyographic (EMG) activity in subjects with shoulder impingement syndrome (SIS). METHODS Twenty subjects with a diagnosis of SIS performed abduction, scaption, and flexion movements in two load conditions: (1) without load and (2) holding a dumbbell. The same movements were evaluated again with the use of KT over the deltoid muscle with a 20% tension. Scapular kinematics data of the shoulder complex were captured with BTS SMART-DX at a frequency rate of 100 Hz. EMG activity was evaluated for the upper trapezius, lower trapezius, middle deltoid, and serratus anterior muscles with BTS FREE EMG 1000 at a frequency rate of 1000 Hz. The root mean square values normalized by the maximal voluntary contraction and the peak values of upward rotation, internal rotation, and posterior tilt were compared with the KT conditions through repeated-measures ANOVA (α = 0.05) using SPSS software. RESULTS No significant differences between KT conditions were found for scapular kinematics (p > 0.05). For EMG activity, a reduction in the lower trapezius was found (p < 0.05) during abduction with load (p < 0.05) and elevation without load (p < 0.05). CONCLUSIONS According to the results of this study, it was not possible to verify changes in scapular kinematics in subjects with SIS. However, a reduction in EMG activity was observed for the lower trapezius muscle. Therefore, caution should be taken in prescribing KT for SIS subjects, who already have a reduction in EMG activity in this muscle, as KT may have an adverse effect.

Background Anatomic changes in the acromion have been considered a main cause of shoulder impingement syndrome (SIS). To evaluate the relationship between SIS and the acromion process, we devised a new morphological parameter called the acromion process cross-sectional area (APA). We hypothesized that the APA could be an important morphologic diagnostic parameter in SIS. Methods We collected APA data from 95 patients with SIS and 126 control subjects who underwent shoulder magnetic resonance imaging (MRI). Then we measured the maximal cross-sectional area of the bone margin of the acromion process on MRI scans. Results The mean of APAs were 136.50 ± 21.75 mm2 in the male control group and 202.91 ± 31.78 mm2 in the male SIS group; SIS patients had significantly greater APAs (P < 0.001). The average of APAs were 105.38 ± 19.07 mm2 in the female control group and 147.62 ± 22.90 mm2 in the female SIS group, and the SIS patients had significantly greater APAs (P < 0.001). The optimal APA cut-off in the male group was 165.14 mm2 with 90.2% sensitivity, 91.4% specificity, and an area under the curve (AUC) of 0.968. In the female group, the optimal cut-off was 122.50 mm2 with 85.2% sensitivity, 84.9% specificity, and an AUC of 0.928. Conclusions The newly devised APA is a sensitive parameter for assessing SIS; greater APA is associated with a higher possibility of SIS. We think that this result will be helpful for the diagnosis of SIS.

Shoulder impingement syndrome (SIS) is a common shoulder disorder with unclear genetic mechanism. In this study, Genome-wide Association Study (GWAS) was conducted to identify the candidate loci associated with SIS by using the UK Biobank samples (including 3,626 SIS patients and 3,626 control subjects). Based on the GWAS results, gene set enrichment analysis was further performed to detect the candidate gene ontology and pathways associated with SIS. We identified multiple risk loci associated with SIS, such as rs750968 (P = 4.82 × 10−8), rs754832 (P = 4.83 × 10−8) and rs1873119 (P = 6.39 × 10−8) of ANXA1 gene. Some candidate pathways have been identified related to SIS, including those linked to infection response and hypoxia, “ZHOU_INFLAMMATORY_RESPONSE_FIMA_DN” (P = 0.012) and “MANALO_HYPOXIA_UP” (P = 5.00 × 10−5). Our results provide novel clues for understanding the genetic mechanism of SIS.

OBJECTIVE To compare dual-target injection with standard US-guided subacromial injection in patients with SIS and possible disorders of the biceps long-head tendons. DESIGN Double-blind, randomized controlled trial. SETTING Rehabilitation outpatient clinic. PARTICIPANTS Patients with SIS (N=60). INTERVENTION (1) US-guided standard subacromial bursa and (2) dual-target (subacromial bursa plus proximal biceps long-head tendon) injection, with 40-mg triamcinolone acetonide administered to patients in each group. MAIN OUTCOME MEASURES Clinical assessments were performed at baseline. The outcomes, including results from a self-administered questionnaire, the Shoulder Pain and Disability Index (SPADI), and a self-pain report, the visual analogue scale (VAS) scores for pain at rest, at night, and during overhead activities, were evaluated at baseline and at the first and third months post-intervention. RESULTS No significant difference was observed in baseline evaluations between groups (n = 30 in each treatment arm) prior to injections. Both groups exhibited significant SPADI and VAS-score improvements after the first month. The dual-target injection group had less rebounding pain at the 3-month follow-up. The standard injection group had more patients reporting worsening pain within 1 day post-injection. CONCLUSION US-guided dual-target corticosteroid injection showed similar short-term efficacy to standard subacromial injections, but with an extended duration of symptom relief. Therefore, dual-target corticosteroid injections may be useful for shoulder-pain treatment in patients with SIS.

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BACKGROUND Shoulder impingement syndrome is considered to be associated with an altered muscular activity, which is related to strategy changes in the movement plan. The present study aimed to investigate the differences in timing and intensity of activity of shoulder girdle muscles while performing a forehand topspin loop between elite table tennis players with and without shoulder impingement syndrome. The timing and activity amplitude of these shoulder girdle muscles have not been evaluated in other studies in table tennis elite athletes. METHODS Activation timing and activity levels of the upper trapezius, lower trapezius, and serratus anterior, anterior deltoid, supraspinatus, and biceps brachii muscles were measured in 30 table tennis players (Premier League tournament level or higher) with shoulder impingement syndrome and compared with 30 same-level healthy players while performing the forehand topspin loop. RESULTS The results indicated that the activity levels of the serratus anterior (P = .007) and supraspinatus (P = .001) muscles significantly decreased; however, the activity level of the upper trapezius significantly increased in the impingement compared with the healthy group (P = .009). The serratus anterior (P = .001) was activated significantly later, but the upper trapezius (P = .004) was activated significantly earlier in the impingement group. CONCLUSION Results of the present study support the theory that the activation and sequence of recruiting of the shoulder muscles are altered in people with impingement symptoms, suggesting that impingement syndrome may be associated with disturbed timing and activity level of shoulder girdle muscles.

Objective The aim of the present study was to compare the effectiveness of kinesio taping (KT) treatments and conventional physical therapy (PT) modalities that are applied to reduce pain and improve physical movements and functions of patients with sub acromial impingement syndrome (SIS). Materials and Methods Forty patients were randomly divided into two equal groups. The first group was assigned KT plus home exercise program (HEP) for 15 days. The second group was given 15 sessions of PT and HEP. Patients were assessed using active joint range of motion (ROM), Visual Analogue Scale (VAS; rest, movement, and night pain), the Society of the American Shoulder and Elbow Surgeons Evaluation (ASESS-100), Constant-Murley (C-M) scale, and Western Ontario Rotator Cuff (WORC) index at before and after treatment and at the end of the study (first month control visit). Results Physical therapy was found to be more effective than KT when these two treatment modalities were assessed based on ASESS-100, WORC index values, night pain, and movement pain. PT and KT treatments have similar effects in active ROM, rest pain, and C-M scale. At the end of the study, they were found to have similar effects except the night pain value. PT was found to be more effective for night pain than KT. Conclusion Physical therapy was concluded to be more effective after treatment. The application of KT does not appear to be an alternative treatment method for SIS, but it can provide a potential supportive care for SIS. However, the outcomes suggest that KT can provide a remarkable benefit.

Abstract Background: Shoulder impingement syndrome (SIS) is the second most common musculoskeletal condition that causes shoulder pain in the general population. Shoulder girdle muscle imbalance and posterior capsule tightness have been implicated as contributing factors. Objective: The purpose of this study was to investigate the effect of shoulder stability exercises (SSEs) on hand grip strength in patients with unilateral SIS. Methods: A total of 16 patients with a mean age of 32 ± 9.3 years diagnosed with stage II unilateral SIS participated in this study. A standardized SSE programme was conducted in the clinic under the direct 1-to-1 supervision of a physical therapist thrice weekly for 4 weeks for a total of 12 sessions on the affected and non-affected shoulders. The effect of the SSE programme on isometric hand grip strength was analysed. Results: A significant difference (p = .016) was observed in the hand grip strength of the affected shoulder side before and after the intervention, but no significant difference (p = 1.0) was found in the hand grip strength of the non-affected shoulder side post-intervention. Conclusion: The reduction in isometric hand grip strength of the affected shoulder side compared to that of the non-affected shoulder side in the same subject before the intervention shows that SIS significantly affects the hand grip strength of the affected side. SSEs significantly affect the isometric hand grip strength of SIS patients.

Objective The aim of this study was to assess and compare the effects of different electrotherapy methods and exercise therapy on pain, function and quality of life in shoulder impingement syndrome. Methods Eighty-three patients (66 females, 17 males; mean age: 48.2 ± 7.33 years) with shoulder impingement syndrome were selected and 79 of them were randomly allocated into four groups. Group 1 (n = 19, mean age: 47.89 ± 7.12 years) was given hot pack and exercises, Group 2 (n = 20, mean age: 47.70 ± 6.51 years) was given hot packs, exercises and interferential current, Group 3 (n = 20, mean age: 48.50 ± 8.34 years) was given hot packs, exercises and TENS and Group 4 (n = 20, mean age: 48.55 ± 7.89 years) was given hot packs, exercises and ultrasound three times a week for four weeks. Assessments were made before treatment, right after it and three months after that using the visual analog scale (VAS), Short Form-36 (SF-36) and the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measures. Results At the fourth week and third month assessments, all groups showed significant improvements in terms of pain, DASH and SF-36 physical component scores (p < 0.05). In intragroup comparisons, a significant difference between pre- and post-treatment results was found only in SF-36 mental component scores of Group 2. No significant difference was observed between the groups in any stage of the study period (p > 0.05). Conclusion Application of ultrasound, interferential current and TENS in addition to exercise therapy in shoulder impingement syndrome treatment had similar improvements in terms of pain, function and physical component of quality of life. However, interferential current treatment showed significantly better outcomes for the mental component of quality of life. Level of evidence Level I, Therapeutic study.

CONTEXT Chronic musculoskeletal disorders in the shoulder joint are often associated with myofascial trigger points (MTrPs), particularly in the upper trapezius (UT) muscle. Dry needling (DN) is a treatment of choice for myofascial pain syndrome. However, local lesions and severe postneedle soreness sometimes hamper the direct application of DN in the UT. Therefore, finding an alternative point of treatment seems useful in this regard. OBJECTIVE To compare the efficacy of UT versus infraspinatus (ISP) DN on pain and disability of subjects with shoulder pain. The authors hypothesized that ISP DN could be as effective as the direct application of DN in UT MTrP. DESIGN Single-blind randomized clinical trial. SETTING Sports medicine physical therapy clinic. PARTICIPANTS A total of 40 overhead athletes (age = 36 [16] y; 20 females and 20 males) with unilateral shoulder impingement syndrome were randomly assigned to the UT DN (n = 21) and ISP DN (n = 19) groups. INTERVENTION An acupuncture needle was directly inserted into the trigger point of UT muscle in the UT DN group and of ISP muscle in the ISP DN group. DN was applied in 3 sessions (2-day interval between each sessions) for each group. MAIN OUTCOME MEASURES Pain intensity (visual analog scale), pain pressure threshold, and disability in the arm, shoulder, and hand were assessed before and after the interventions. RESULTS Pain and disability decreased significantly in both groups (P < .001) and pain pressure threshold increased significantly only in the ISP group (P = .02). However, none of the outcome measures showed a significant intergroup difference after treatments (P > .05). CONCLUSIONS Application of DN for active MTrPs in the ISP can be as effective as direct DN of active MTrPs in the UT in improving pain and disability in athletes with shoulder pain, and may be preferred due to greater patient comfort in comparison with direct UT needling.

Background The Fear-Avoidance Belief Questionnaire for physical activity (FABQ-PA) was originally developed for patients with low-back pain. Whether the FABQ-PA is suitable for use among patients with other musculoskeletal disorders has been sparsely evaluated. Purpose To evaluate test–retest reliability, measurement error, construct validity, and responsiveness of the FABQ-PA in patients with shoulder impingement syndrome (SIS). Methods This prospective cohort study included 45 patients with SIS. Data were collected with questionnaires at baseline, after 2–4 days, and at 3 months, which included the Danish versions of the FABQ-PA and the Oxford Shoulder Score (OSS). Test–retest reliability was assessed by intraclass correlation, and standard error of measurement was estimated and converted into the minimal detectable change (MDC). Construct validity was investigated by analyzing the correlation between the baseline scores of the FABQ-PA and the OSS. Responsiveness was investigated from longitudinal construct validity using a correlation analysis reflecting changes over time. Results Test–retest reliability showed an intraclass correlation of 0.80, and examination of the measurement error showed no systematic differences and a MDC of 7.95 (95% CI 6.57–10.07). Construct validity showed a correlation of –0.60 (95% CI −0.76 to −0.37) between the FABQ-PA and OSS at baseline. A weaker correlation between FABQ-PA- and OSS-change scores was observed (−0.43, 95% CI −0.67 to −0.12). Conclusion The Danish version of the FABQ-PA is suitable for assessing fear-avoidance beliefs in groups of patients with SIS, but its ability to evaluate individual patients and changes over time may be more limited.

Objective Capacitive and resistive electric transfer therapy (CARE) reduces pain and improves quality of life for many orthopaedic degenerative and inflammatory disorders. The research aim was to determine the effects of CARE on painful shoulder. The outcomes were pain reduction and recovery of shoulder function. Methods A retrospective, observational case-control study was conducted. Participants were 46 patients (22 in the CARE group and 24 in the SHAM group). Clinical data, pain (visual analogic scale, VAS) and functional scale scores (Disabilities of the Arm, Shoulder and Hand scale, and Constant–Murley Scale) were measured at baseline T0 (before treatment), T1 (after treatment) and follow-up T2 (2 months after the end of the treatment). Results VAS scores in the CARE group improved from 7.23 ± 1.11 at baseline to 2.68 ± 0.99 at follow-up. The SHAM group did not experience any improvement. Similarly, functional scale scores improved in the CARE group compared with the SHAM group. Conclusion Considering the small number of sessions needed, low cost and long-term benefits, CARE could be a useful therapeutic option for the conservative management of shoulder pain to restore pain-free and powerful movement to the shoulder joint.

Abstract Kim, J-H, Kwon, O-Y, Hwang, U-J, Jung, S-H, Ahn, S-H, and Kim, H-A. Comparison of shoulder external rotator strength and the asymmetry ratio between workers with and without shoulder impingement syndrome. J Strength Cond Res 35(12): 3364–3369, 2021—Shoulder impingement syndrome (SIS) is the most common shoulder problem causing shoulder pain. Several studies have indicated that shoulder external rotator muscles provide dynamic stability to the shoulder joint. However, the relationship of SIS to changes in shoulder external rotator muscle strength remains controversial. The purpose of the study was to compare the shoulder external rotator strength and asymmetry ratio between workers with SIS and the normal group in a side-lying position. Twelve male industrial workers with SIS and the normal group of 12 workers participated in this study. A pulling sensor measured shoulder external rotator muscle strength in a side-lying position with the shoulder at 0° and 90° of flexion. The asymmetry ratio was calculated by a specific formula using the shoulder external rotator muscle strength of the dominant side and the unaffected side. Two-way analysis of variance was used to determine between-group differences in shoulder external rotator muscle strength and the asymmetry ratio among the 2 positions. Subjects with SIS did not exhibit significant differences in shoulder external rotator muscle strength in the side-lying position with the shoulder at 0° and 90° of flexion relative to the normal group. However, subjects with SIS had a significantly increased asymmetry ratio of shoulder external rotation strength in the side-lying position with the shoulder at 90° of flexion compared with the normal group. In conclusion, workers with SIS had an asymmetry of shoulder external rotator strength in side-lying with the shoulder at 90° of flexion.

CONTEXT Scapular proprioception is a key concern in managing shoulder impingement syndrome (SIS). However, no study has examined the effect of elastic taping on scapular proprioception performance. OBJECTIVE To investigate the immediate effect of kinesiology taping (KT) on scapular reposition accuracy, kinematics, and muscle activation in individuals with SIS. DESIGN Randomized controlled study. SETTING Musculoskeletal laboratory, National Yang-Ming University, Taiwan. PARTICIPANTS Thirty overhead athletes with SIS. INTERVENTIONS KT or placebo taping over the upper and lower trapezius muscles. MAIN OUTCOME MEASURES The primary outcome measures were scapular joint position sense, measured as the reposition errors, in the direction of scapular elevation and protraction. The secondary outcomes were scapular kinematics and muscle activity of the upper trapezius, lower trapezius, and serratus anterior during arm elevation in the scapular plane (scaption). RESULTS Compared with placebo taping, KT significantly decreased the reposition errors of upward/downward rotation (P = .04) and anterior/posterior tilt (P = .04) during scapular protraction. KT also improved scapular kinematics (significant group by taping effect for posterior tilt, P = .03) during scaption. Kinesiology and placebo tapings had a similar effect on upper trapezius muscle activation (significant taping effect, P = .003) during scaption. CONCLUSIONS Our study identified the positive effects of KT on scapular joint position sense and movement control. Future studies with a longer period of follow-up and clinical measurement might help to clarify the clinical effect and mechanisms of elastic taping in individuals with SIS.

BACKGROUND The numeric pain rating scale (NPRS) and shoulder pain and disability index (SPADI) are commonly used patient-reported outcome measures (PROMs) in patients with rotator cuff tendinopathy. To date, there are gaps in the evidence supporting the clinimetric properties of these PROMs for patients treated with subacromial pain syndrome (SAPS). METHODS A clinimetric analysis (n = 145) was performed to examine the reliability, construct validity, responsiveness, interpretability, minimal detectable change (MDC95) and minimum clinically important difference (MCID) of the NPRS and SPADI for "improved" (global rating of change from +3 to +7) and "much-improved" (global rating of change from +5 to +7) patients at 3-months follow-up. RESULTS The NPRS (ICC: 0.86; 95 %CI, 0.33-0.96) and SPADI (ICC: 0.79; 95 %CI 0.12-0.94) exhibited good reliability and excellent responsiveness (NPRS: area under the curve (AUC) = 0.96, 95 %CI 0.92-0.99; SPADI: AUC = 0.90, 95 %CI 0.84-0.95) in this patient population. Both outcomes demonstrated strong construct validity (Pearson's r; p < 0.001). The MDC95 was a 1.7- and 20.5-point change for the NPRS and SPADI, respectively. For the NPRS, the MCID was a 1.5-point change in the "improved" group and a 2.5-point change in the "much improved" group. For the SPADI, the MCID was an 18-point or 50 % change for the "improved" group, and a 25-point or 70 % change in the "much improved" group. CONCLUSIONS The NPRS and SPADI demonstrated sound clinimetric properties in patients with SAPS. The MCID exceeded measurement error in the "much improved" group. Diagnosis, type of intervention, level of improvement, and measurement error should be considered when applying the MCID.

Background: Subacromial pain syndrome has no universally accepted definition. Patients with shoulder pain are often diagnosed with subacromial pain syndrome without consideration of conflicting or concomitant diagnoses. Purpose: To investigate the prevalence of conflicting and concomitant diagnoses in patients with signs and symptoms of subacromial pain syndrome. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Using standardized diagnostic criteria, a prospective cohort of patients with signs and symptoms of subacromial pain syndrome was divided into 2 mutually exclusive groups: (1) patients with conflicting diagnoses—e.g., frozen shoulder or glenohumeral osteoarthritis (OA); (2) patients with subacromial pain syndrome. Patients with subacromial pain syndrome were further divided into 2 groups: (1) isolated subacromial pain syndrome; (2) subacromial pain syndrome with concomitant diagnoses—e.g., acromioclavicular OA, full-thickness rotator cuff tears, shoulder instability, long head biceps tendon pathology, labral lesions, and calcified tendinopathy. Standardized physical examination tests, radiographs, ultrasound, and magnetic resonance imaging scans were utilized. Tests were performed by experienced orthopaedic specialists in accordance with predefined standardized protocols. Results: We systematically screened 3321 patients, of whom 576 had signs and symptoms of subacromial pain syndrome (mean age, 56 years; 57% women). Of these, 168 (29%) patients had conflicting diagnoses, with frozen shoulder accounting for the majority of these diagnoses. The remaining 408 patients were diagnosed with subacromial pain syndrome. Of these, 172 (42%) had at least 1 concomitant diagnosis, and 55 (13%) had multiple concomitant diagnoses. In total, 22 different combinations of concomitant diagnoses were observed across the 172 patients. Acromioclavicular OA and full-thickness rotator cuff tears, particularly of the supraspinatus, were the most common concomitant diagnoses. Biceps tendon pathology, calcified tendinopathy, minor shoulder instability, and superior labrum anterior to posterior (SLAP) lesions were less common. Conclusion: Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. This heterogeneity is a clinical challenge that necessitates a systematic and transparent diagnostic approach in patients presenting with signs and symptoms of subacromial pain syndrome. ClinicalTrials.gov: NCT05549674.

Abstract Objective To assess the long term efficacy of arthroscopic subacromial decompression (ASD) versus placebo surgery (diagnostic arthroscopy) and exercise therapy in patients with subacromial pain syndrome. Design Randomised, placebo surgery controlled trial. Setting Orthopaedic department of three public hospitals in Finland. Participants 210 adults aged 35 to 65 years with symptoms consistent with subacromial pain syndrome for more than three months, enrolled from 1 February 2005 with 10 year follow-up to 20 September 2023. Participants and outcome assessors were blinded to group allocation in the primary (ASD versus placebo surgery) comparison. Interventions ASD, placebo surgery, and exercise therapy (1:1:1). Exercise therapy was used as a pragmatic comparator. Main outcome measures The primary outcomes were shoulder pain at rest and on arm activity, both assessed at 10 years using a visual analogue scale (VAS, ranging from 0 to 100, with 0 denoting no pain). The minimally important difference was defined as 15. A mixed model repeated measures analysis of variance was used, treating participants as random factors, incorporating baseline values as covariates. Results Participants were randomly assigned to ASD (n=59), placebo surgery (n=63), and exercise therapy (n=71). Of these, a total of 168 participants (87%) completed the 10 year follow-up. In the primary intention-to-treat analysis (ASD versus placebo surgery), no between group differences were observed for the two primary outcomes at 10 years: the mean difference between groups (ASD minus placebo surgery) was −1.5 points (95% confidence interval (CI) −8.6 to 5.6) in VAS pain score at rest and −3.2 points (−13.0 to 6.5) in VAS pain score on arm activity. No significant between group differences were found for any of the secondary outcomes or adverse events. In the pragmatic comparison, the mean difference between groups (ASD minus exercise therapy) was −4.0 points (−11.0 to 3.0) in VAS pain score at rest and −9.4 points (−19.0 to 0.3) in VAS pain score on arm activity. No significant between group differences were observed for the secondary outcomes or adverse events. Conclusion In patients with subacromial pain syndrome, ASD offered no benefit over placebo surgery or exercise therapy during 10 year follow-up. Trial registration ClinicalTrials.gov NCT00428870.

BACKGROUND Subacromial pain syndrome is the most common cause of shoulder pain and is associated with altered humeral and scapular kinematics. Symptoms can be improved by rehabilitation. Accurate tools to analyze shoulder kinematic curves are lacking. METHODS A single-center prospective pilot study using inertial measurement units located on both arms and scapulae to assess bilateral arm elevation in the sagittal, scapular and frontal planes. Reparameterization and signal registration algorithms compared similarity of global shoulder and scapular kinematic curves from participants with subacromial pain syndrome before and after a short rehabilitation program, with a control template combining the curves of asymptomatic participants. A similarity score used curve comparisons; the more closely the curve shapes matched, the closer the score was to zero. We used a paired Wilcoxon test to compare the scores. FINDINGS We included 9 right-handed symptomatic participants (10 shoulders): 2 males (22 %), mean (SD) age 53.8 (13.7) years, symptom duration 29 (23) months, pain (Numeric Rating Scale) 61.1 (22.4)/100, activity limitation (Quick-Dash): 48.3 (26.6)/100 points, and 10 asymptomatic age-matched right-handed participants (20 shoulders): 4 males (40 %), 54.2 (5.4) years old. Post-rehabilitation similarity scores decreased non-significantly for shoulder elevation (scapular and frontal planes), scapular lateral rotation (sagittal and scapular planes) and anterior-posterior tilt (scapular plane) and significantly for shoulder sagittal elevation (P = 0.004). Participant heterogeneity was high. INTERPRETATION The similarity methodology, used for the first time in the context of subacromial pain syndrome, offers a new quantitative tool to assess kinematic changes, measure movement-related impairments and monitor patient progress.

No abstract available

Subacromial pain syndrome (SAPS) is the most common shoulder pain condition in primary care. Despite the importance of shared decision‐making (SDM) being increasingly recognised, its application in SAPS care remains poorly understood. The primary aim of this study was to explore the influence of a decision aid on patient and observer perceptions of SDM, and secondarily to explore correlations between these ratings in the primary care management of patients with SAPS.

OBJECTIVE: To compare, during shoulder proprioceptive testing (kinesthesia, active and passive joint position sense), (1) proprioception acuity between participants with and without subacromial pain syndrome (SPS), and (2) proprioception acuity and pain intensity across various arm and body positions. DESIGN: Cross-sectional study. METHODS: Forty participants with SPS and forty asymptomatic participants were included. Proprioceptive testing was performed to assess passive and active joint position sense, and kinesthesia, during lateral and medial shoulder rotations using an isokinetic dynamometer. Testing was conducted in two positions: sitting with 60° of shoulder elevation in the scapular plane, and supine with 90° shoulder abduction. Pain intensity was recorded after each test. RESULTS: The SPS group showed greater errors in passive joint position sense (lateral rotation) in the sitting position, as well as in kinesthesia in the sitting (for both medial and lateral rotations) and supine (for medial rotation) positions. The SPS group had greater errors in the sitting position, while the supine position was reported as more painful during kinesthesia tests for medial and lateral rotations. CONCLUSION: Certain subcategories of shoulder proprioception, such as passive joint position sense and kinesthesia, may be impaired in individuals with SPS. The position of the participant’s arm appeared to influence proprioceptive acuity.

Objective: This study aimed to clearly identify systemic problems, functional impairments, psychological status, and quality of life differences between patients with subacromial pain syndrome (SAPS) and asymptomatic controls, to support the development of multidimensional rehabilitation programs. Additionally, the determinants of symptom severity in SAPS patients were investigated. Methods: This case-control study included 80 participants (40 SAPS patients and 40 controls). The assessments included the prevalence of metabolic syndrome, NSAID consumption, pain severity, upper extremity function, elbow function, wrist-hand function, grip strength, psychological status (kinesiophobia, anxiety, depression, and pain catastrophising), and quality of life. Results: Patients with SAPS showed higher pain levels, DASH scores, NSAID consumption, and prevalence of metabolic syndrome compared to the control group (p

BACKGROUND AND HYPOTHESIS Shoulder exercise and subacromial injection are the first line of treatment for patients with subacromial pain syndrome (SAPS) and have been shown to be effective in about 70% of patients. Weakness is common in these patients although its true source is uncertain. The purpose of this study is to determine the changes in rotator cuff voluntary activation (VA), i.e. central drive and force, immediately after a pain-relieving subacromial injection, and following a 6-week exercise program and examine baseline differences in patients with SAPS and healthy controls. METHODS Voluntary Activation, peak normalized External Rotation (ER) Torque, pain and self-report function were assessed in 43 patients with positive shoulder impingement. Subjects were tested at baseline (T1), immediately after a pain-relieving injection (T2), and after 6 weeks of exercise (T3). Forty-four matched controls were tested at baseline (T1). Participants received two stimuli on their infraspinatus, one while contracting maximally and one at rest, to determine the VA. RESULTS Subjects with SAPS demonstrated lower ER normalized torque, 27.3% lower compared to controls, P=0.005, and lower infraspinatus VA, median 0.99 in controls and 0.71 in patients, P<0.001. As expected, the VA increased (P=0.004) from T1 to T2 and remained unchanged at T3 as compared to T2. ER normalized torque increased across all time points. Pain (P<0.001) decreased with the injection and exercise and function (P<0.001) improved from baseline to discharge. DISCUSSION Understanding neural adaptations with exercise is critical to learning how to best modify the system and optimize current rehabilitation strategies, for example including exercises focused on motor-control training, biofeedback or neuromuscular electric stimulation.

The study aimed to compare the effectiveness of chiropractic manipulation and Mulligan’s mobilization in reducing pain, improving range of motion, and enhancing functional outcomes in individuals with subacromial pain syndrome. This was a randomized controlled trial (RCT) at DHQ Jhelum, CMH Jhelum, and Jhelum Sports Complex, Pakistan. A total of 62 participants with subacromial pain syndrome were randomly assigned to a chiropractic manipulation group (n = 31) or a Mulligan’s mobilization with movement (MWM) group (n = 31). Both groups received their respective interventions over a set treatment period. Pain intensity (VAS), functional disability (SPADI), and shoulder range of motion (flexion, extension, abduction, internal and external rotation) were measured pre- and post-intervention. The mean age was 46.71 ± 8.30 years in the chiropractic group and 47.03 ± 7.74 years in the MWM group. Baseline VAS scores were 7.58 ± 1.12 and 7.32 ± 1.14, decreasing post-intervention to 2.45 ± 1.34 and 4.32 ± 1.33, respectively. SPADI scores improved from 63.93 ± 6.24 to 32.97 ± 6.67 in the chiropractic group and from 62.74 ± 5.62 to 42.58 ± 5.46 in the MWM group. Flexion, extension, abduction, internal rotation, and external rotation ROM all increased in both groups, with chiropractic improving from 117.42°, 38.70°, 94.21°, 37.65°, and 52.11° to 155.32°, 47.64°, 126.68°, 50.75°, and 69.13°, and MWM from 118.10°, 38.36°, 95.82°, 37.23°, and 52.74° to 145.56°, 44.91°, 118.34°, 46.12°, and 65.70°, respectively. Both chiropractic manipulation and Mulligan’s mobilization with movement effectively reduced pain, improved range of motion, and enhanced function in individuals with subacromial pain syndrome. Chiropractic manipulation consistently produced superior outcomes across all parameters, likely due to combined biomechanical and neuro-physiological effects.

BACKGROUND The etiology of subacromial pain syndrome (SAPS) remains enigmatic. It is theorized that the supraspinatus tendon and the subacromial bursa are the primary pain-generating structures. The supraspinatus tendon and the subacromial bursa are considered to be thickened in patients with SAPS but this assumption lacks validation. The aim of this study was to ultrasonographically measure the subacromial structures and evaluate the presence of impingement in patients with SAPS and to compare it with their asymptomatic shoulder. METHODS Patients were recruited consecutively from an orthopedic outpatient clinic using validated criteria for SAPS. Patients with contralateral shoulder pain and patients with acromioclavicular osteoarthrosis, rotator cuff tears, calcified tendinopathy, biceps tendon or labral pathology were excluded. Validated ultrasonographical methods were used. Thickness of the supraspinatus tendon and the subacromial bursa were measured perpendicular to the tendon longitudinal axis two cm from the lateral border of the supraspinatus tendon footprint with the shoulder in slight internal rotation. Acromio-humeral distance was measured as the shortest distance from the anterolateral acromion to the humerus with the shoulder in neutral position. Ultrasonographic impingement was defined as visual bulging of the subacromial bursa during active shoulder abduction and internal rotation. RESULTS We examined 58 patients with unilateral SAPS and intact rotator cuff tendons. We found significantly more cases of ultrasonographic impingement in painful shoulders compared to the pain-free (45 vs 18, Chi-Square p = 0.04). There were no significant differences between affected and unaffected shoulders regarding supraspinatus tendon thickness (5.4 vs 5.5 mm), subacromial bursa thickness (1.9 vs 1.9 mm) or the acromio-humeral distance (11.1 vs 11.0 mm). The mean age of the included patients was 51 years, 64% were women, the median symptom duration was 18 months, and the dominant shoulder was affected in 71% of cases. CONCLUSION In this cohort of patients with isolated unilateral SAPS, we found more cases of ultrasonographic impingement in affected shoulders compared to unaffected, but no significant differences in supraspinatus tendon thickness, subacromial bursa thickness or acromio-humeral distance. These findings question ultrasonography's ability to discriminate between shoulders with and without SAPS based on measurements of subacromial structures alone.

The purpose of the study is to demonstrate the effectiveness of the experimental methodology of physical rehabilitation aimed at restoring active flexibility in shoulder joint flexion and reducing the intensity of pain syndrome in individuals of middle age with subacromial pain syndrome. Research methods and organization: analysis and generalization of foreign scientific literature, pedagogical experiment, mathematical and statistical data processing. The developed methodology was tested in the conditions of the scientific and practical center for physical rehabilitation "Savita" based at Lesgaft National State University of Physical Education and the ANO DPO "Academy of Physical and Rehabilitation Medicine." Research results and conclusions. The reliable improvement in active flexibility and the reduction in the intensity of pain syndrome identified during the study indicate a positive impact on the recovery of motor functions in middle-aged individuals with subacromial shoulder pain syndrome.

No abstract available

Pain and disability in patients with subacromial pain syndrome are associated with pain sensitization rather than with rotator cuff-related factors.

OBJECTIVE The purpose of this study was to evaluate the intrarater and interrater reliability of glenohumeral and scapulothoracic muscle strength measured in individuals with chronic, unilateral subacromial pain syndrome. METHODS Fifty individuals with shoulder pain were evaluated in 2 sessions using a belt-stabilized handheld dynamometer (HHD) for maximum isometric strength of the glenohumeral flexion, extension, abduction, lateral and medial rotation, and elevation, protraction, retraction, and retraction with scapular depression. Reliability was determined using the intraclass correlation coefficient (ICC2,3) with the standard error of measurement (SEM), the minimal detectable change (MDC), and a percentage of average strength (%SEM and %MDC). RESULTS The values of intraclass correlation coefficient, SEM, and %SEM for glenohumeral muscles ranged from 0.93 to 0.98, 1 kg, and 7% to 14%, respectively, and for scapulothoracic muscles from 0.90 to 0.98, 2 to 4 kg, and 10% to 17%, respectively. The MDC and %MDC values ranged from 2 to 4 kg and 19% to 38% for glenohumeral muscles and 4 to 11 kg and 27% to 47% for scapulothoracic muscles, respectively. CONCLUSION Belt-stabilized handheld dynamometer demonstrated excellent reliability to measure scapulothoracic and glenohumeral muscle strength in patients with chronic, unilateral subacromial pain syndrome. Guidelines for correct positioning and measurement of the strength of the shoulder complex along with their clinical viability are presented.

Long term trial data confirm minimal benefit

INTRODUCTION Pain sensitivity is the main finding of central sensitization (CS) and can occur in patients with chronic shoulder pain. However, there is limited evidence concerning the distribution of pain sensitivity in shoulders, forearms, and legs in patients with CS associated with chronic shoulder pain. The present study aimed to determine the distribution of pain sensitivity in patients with CS associated with chronic subacromial pain syndrome (SPS). METHOD This cross-sectional study included 58 patients with chronic SPS and CS (patient group) and 58 healthy participants (control group). The presence of CS was determined using the Central Sensitization Inventory (CSI). To determine the distribution of pain sensitivity, pressure pain threshold (PPT) measurements were performed from the shoulders, forearms, and legs. RESULTS There was no significant difference between the two groups in terms of sociodemographic data (p > 0.05). The patient group had a significantly higher CSI score (p < 0.001) and lower PPTs in all regions (p < 0.05) than the control group. Unlike the control group, the patient group had lower PPTs on the affected side for the shoulder [mean difference (MD) 95% confidence interval (CI): 1.2 (-1.7 to -0.6)], forearm [MD 95% CI: 1.1 (-1.7 to -0.6)], and leg [MD 95% CI: 0.9 (-1.4 to -0.3)] compared with the contralateral side (p < 0.001). CONCLUSION Pain sensitivity is more pronounced in the affected shoulder and the forearm and leg located on this side than in those on the contralateral side in patients with CS associated with chronic SPS.

Background Although patients with shoulder complaints are frequently referred to physiotherapy, putative predictive factors for outcomes are still unclear. In this regard, only a limited amount of scientific data for patients with subacromial pain syndrome exist, with inconsistent results. An improved knowledge about the ability of baseline variables to predict outcomes could help patients make informed treatment decisions, prevent them from receiving ineffective treatments, and minimize the risk of developing chronic pain. Aim The aims of this secondary longitudinal analysis are threefold: First, to investigate baseline differences between patients with and without successful long-term outcomes following physiotherapy. Second, to compare the predictive ability of two sets of putative predictive variables on outcomes, one based on the literature and one based on the data of the original trial. Third, to explore the contribution of short-term follow-up data to predictive models. Methods Differences between responders and nonresponders were calculated. The predictive ability of variables defined through literature and of variables based on the Akaike Information Criterion (AIC) from the original trial dataset on the Shoulder Pain and Disability Index and the Patients’ Global Impression of Change at the one-year follow-up were analyzed. To test the robustness of the results, different statistical models were used. To investigate the contribution of follow-up data to prediction, short-term data were included in the analyses. Results A sample of 87 patients with subacromial pain syndrome was analyzed. 77% ( n  = 67) of these participants were classified as responders. Higher expectations and short-term change scores were positive, and higher fear avoidance beliefs, greater baseline disability and pain levels were negative predictors of long-term outcomes in patients with subacromial pain syndrome. Conclusions Although our results are in line with previous research and support the use of clinical factors for prediction, our findings suggest that psychological factors, especially patient expectations and fear avoidance beliefs, also contribute to long-term outcomes and should therefore be considered in the clinical context and further research. However, the hypotheses and recommendations generated from our results need to be confirmed in further studies due to their explorative nature. Trial registration The original trial was registered at Current Controlled Trials under the trial registration number ISRCTN86900354 on March 17, 2010.

Background: There are a variety of different treatments for patients living with subacromial pain syndrome (SAPS). All treatments have small to moderate effect sizes, and it is challenging when healthcare practitioners and patients need to decide on which treatment options to choose. The aim of this study was to explore and understand the decisional needs of patients with SAPS, to inform and support the decision-making process. Methods: A qualitative research study, using semi-structured individual interviews with patients with SAPS. The interview guide was informed by the Ottawa Decision Support Framework (ODSF), previous research related to treatment decision-making, other decisional needs assessment studies, and inputs from patients with SAPS and healthcare practitioners. Data were analysed by using reflexive thematic text analysis and ODSF. The analysis was conducted in NVivo 12. Results: We invited 22 participants of which 17 (age 22-71 years) took part in the study. We found three main themes related to individual decisional needs in the context of decision-making: 1) The necessity of certainty and adequate information as fundamental prerequisites for effective decision-making, 2) The importance of person-centred care to achieve a desirable decision, and 3) The need for a supportive environment to facilitate adaptation and acceptance of the decision. Conclusion: The decision-making process faced by patients with SAPS is complex and involves several decisional needs. Our findings highlight the importance of healthcare professionals identifying and addressing patients decisional needs in consultations with patients with SAPS. Implications: Our study provides guidance to clinical practice in terms of increased understanding of the decisional needs experienced by patients with SAPS. Furthermore, these results should inform future development of decision aids for patients with SAPS. Keywords: subacromial pain syndrome; qualitative interviews; decisional needs; decision-making.

Abstract Purpose Subacromial Pain Syndrome (SAPS) is a common persistent pain condition. Exercise-based care is first-line recommendation, but an insufficient exercise dose hampers effectiveness. This study explores individual and contextual barriers and facilitators for delivery of and adherence to exercise-based care in people with SAPS. Materials and Methods Participants in this exploratory qualitative study were involved in the management of SAPS in Denmark. Triangular interviews and analyses were conducted within 3 themes (delivery of recommended services, adherence to recommendations, and frames of the clinical pathways) using the Theoretical Domains Framework (TDF) and the Behavioural Change Wheel model (BCW) to map barriers and facilitators into the Capability, Opportunity, Motivation and Behaviour (COM-B) model. Results From interviews with 10 persons with SAPS and 37 healthcare practitioners and double-deductive analyses, 30 subjects of target behaviour within 13 TDF domains emerged across perspectives and COM-B components. Central barriers to delivery and adherence were inconsistencies in diagnostic terminology, cross-professional disagreements, beliefs, and expectations towards pathway services. Conclusion We identified interrelated individual and contextual barriers to delivery and adherence across all aspects of the BCW, underpinning the complexity of the subject. Findings support that effectiveness of exercise-based care is linked to contextual barriers to delivery and adherence. IMPLICATIONS FOR REHABILITATION Exercise-based care is the recommended first-line care for Subacromial Pain Syndrome (SAPS), but an insufficient exercise dose hampers effectiveness. Inconsistencies in terminology and care, diverging beliefs and cross-professional disagreements, and varying expectations of pathway services are the main challenges to delivery of and adherence to recommended exercise-based care. Easy access to key information, examination and treatment suggestions, a person-centred approach, and alignment in patient information between HCPs facilitate adherence to clinical recommendations.

This study aimed to investigate the efficacy of manual therapy and exercise versus synchronized telerehabilitation with self-manual therapy and exercise in treating Subacromial Pain Syndrome (SAPS). Sixty individuals diagnosed with SPS, aged 18–50 years, were randomly assigned to home exercise (HE), manual therapy (MT), and telerehabilitation (TR) groups. Treatment protocols were administered over 8 weeks and included specific exercises and therapy interventions. Outcome measures included the Visual Pain Scale (VAS), shoulder range of motion (ROM) via goniometric measurements, Quick Disability Arm-Shoulder-Hand Problems Survey (Q-DASH), and patient satisfaction. Results revealed that both MT and TR groups exhibited reduced pain, increased ROM, lower Q-DASH scores, and higher patient satisfaction than the HE group. However, no significant differences were found between the MT and TR groups regarding pain levels, ROM, Q-DASH scores, or patient satisfaction. The study concludes that both telerehabilitation and manual therapy effectively alleviate pain and are well-received by patients with SPS. Additionally, manual therapy demonstrates superiority in enhancing functional levels compared to exercise-based interventions (Registration: NCT05200130).

OBJECTIVE The present study aimed to compare the effects of two treatment methods, including comprehensive physiotherapy (CPT), and routine physiotherapy (RPT) on pain, function, and quality of life in patients with subacromial pain syndrome (SAPS). METHODS Forty patients with SAPS were randomly allocated into two groups. The RPT group (7 males, 13 females), (56.45 ± 9.65 years) received manual therapy and exercise therapy for shoulder joint. The CPT group (8 males, 12 females), (52.20 ± 7.39 years) received the above treatments administered to the RPT group plus scapular muscle stretching and strengthening exercise, scapular muscle motor control retraining, thoracic mobilization, and postural correction. Pain (visual analog scale; VAS), function (shoulder pain and disability index; SPADI and quick version of shoulder and hand questionnaire; quick DASH), and quality of life (Western Ontario rotator cuff questionnaire; WORC) were measured before, immediately, one, and six months after treatment. RESULTS Interaction of group by time was significant for pain (VAS) (f = 3.79, p = 0.01, partial eta-squared (ηp 2 = 0.103), quick DASH (f = 5.34, p = 0.003, ηp 2 = 0.139, WORC (f = 3.99, p = 0.01, ηp 2 = 0.207) and was not significant for SPADI total score (f = 2.45, p = 0.07, ηp 2 = 0.069). Although the two groups were similar immediately and 1 month post intervention, the CPT group performed better than the RPT group 6 months after intervention. At 6-month assessment, more patients in the CPT group reached the minimal clinically important differences as compared to control groups. CONCLUSIONS After six months, CPT was found to be more effective than RPT in improving pain, function, and quality of life.

BACKGROUND Subacromial pain syndrome (SPS) is the most frequent shoulder pathology. The aims of this prospective randomized study were to evaluate the effects of some specific shoulder joint mobilizations ("spin correction"), and the effectiveness of a rehabilitation program, named Shoulder Global Concept, in SPS patients. METHODS 45 patients with SPS were randomly assigned to two groups, to benefit from a different first session of mobilizations: the experimental group received all specific mobilizations, while the control group received the same program but without the spin correction mobilizations. The second session was identical for both groups, with all specific mobilizations. Before and after the first two sessions, range of motion (ROM) in flexion, abduction, external and internal rotations, pain and functional status with Constant score and Quick Dash were evaluated. Evaluation was repeated with 24 patients after 11 rehabilitation sessions. Rehabilitation with Shoulder Global Concept included 13 mobilizations aiming at improving the ROM with passive and active-assisted mobilizations, static stretching, and muscle strengthening. RESULTS All ROM were improved at the end of the first session for both groups, but significantly more in the experimental group for glenohumeral (GH) abduction and external rotation (p < 0.05). Functional scores, pain and strength were significantly improved after 11 rehabilitation sessions with the Shoulder Global Concept. CONCLUSION This manual therapy method was able to improve shoulder mobility in one session. The additional joint mobilizations (spin correction) specifically increased GH abduction and external rotation. Rehabilitation of SPS with Shoulder Global Concept allowed to improve functional capacity and decrease pain.

Abstract Purpose To develop recommendations to support the range of patient education interventions relevant in the management of patients with subacromial pain syndrome (SAPS) in physical therapy. Materials and methods A 3-round modified Delphi consultation was used to obtain consensus agreement on the relevance of 12 preliminary recommendations. These were developed from a literature review and an expert consultation on general educational strategies and specific patient education interventions for the management of SAPS. The analysis assessed the rate of consensus on the relevance of these recommendations. Delphi panelists were rehabilitation professionals including physical (n = 21) and occupational therapists (n = 1) with SAPS experience, and patient-partners (n = 2) presenting shoulder pain. Results The Delphi consultation resulted in 13 revised consensus recommendations. Six consensus recommendations addressed general educational strategies to facilitate patient education, including teaching methods and materials, and seven addressed specific educational interventions, including teaching symptom self-management and tailoring activities and participation. These recommendations were incorporated into a clinical decision-making tool to support the selection of the most relevant patient education interventions. Conclusion The recommendations developed in this study are relevant to guide physical therapist’s clinical decisions making regarding interventions using patient education for SAPS. They promote active engagement and empowerment of individuals with SAPS. IMPLICATIONS FOR REHABILITATION Patient education, as a strategy to promote self-management of the condition, can help empower individuals with subacromial pain syndrome. Patient education may be relevant to addressing psychosocial factors that are often not adequately addressed in subacromial pain syndrome. Consensus and comprehensive patient education recommendations are relevant to support physical therapists’ decision making in the management of subacromial pain syndrome. Such recommendations and a decision-support tool based on a scoping review of the literature, expert opinion and consensus are now available.

No abstract available

OBJECTIVE To identify the extent of the literature on patient education for subacromial pain syndrome (SAPS). METHODS A scoping review was conducted in accordance with PRISMA-ScR standards. Nine databases were searched until November 2022 to identify articles describing patient education interventions for the management of SAPS. Interventions were extracted and described according to the Template for intervention description and replication (TIDieR) checklist and the core sets for shoulder-related health conditions of the International Classification of Functioning, Disability and Health (ICF). RESULTS Sixty studies of various designs met the inclusion criteria, including thirty RCTs. Patient education was a primary intervention in seven of the included RCTs. In most of the educational interventions identified in the included studies, the descriptions did not adequately cover a majority of the TIDieR's checklist items. Patient education content was often mentioned and covered most, but not all, of the ICF core sets for shoulder disorders. CONCLUSION Available data in current literature on patient education interventions for SAPS is scarce and lacks description. PRACTICE IMPLICATIONS This study presents the content elements of patient education for the management of SAPS that are described in the literature and that clinicians could consider when treating individuals with SAPS.

Background A clavicle fracture often changes the mechanical axes of the shoulder girdle due to displacement and shortening, potentially leading to scapular protraction and decreased subacromial space. If protraction of the scapula is a major risk factor for developing subacromial pain syndrome (SAPS), a previous clavicle fracture could increase the risk of later SAPS. The purpose of this study was to investigate if a previous clavicle fracture correlates with a higher occurrence or earlier diagnosis of SAPS. Methods In this retrospective case-control study with data from the Danish National Patient Register, all persons aged 18-60 years, with any hospital contact due to a clavicle fracture (DS420) between January 1, 1996, and December 31, 2005, were identified as cases. For each case, five controls, matched on age and sex, were identified. Primary outcome was the first hospital contact with a SAPS diagnosis (DM751-755) registered more than 180 days following the fracture. Follow-up was until November 01, 2021. Results 21.973 cases and 109.865 controls were included. The incidence of clavicle fractures was 76 fractures per 100.000 persons per year. Twenty-three percent were female. 1.640 (7.46%) cases and 8.072 (7.35%) controls received a SAPS diagnosis within the following 15-25 years, demonstrating no significant difference in the occurrence of SAPS (P = .56). The mean time from fracture to SAPS diagnosis was shorter for cases compared to controls (4040 vs. 4442 days, P < .001), and cases were slightly younger when receiving the diagnosis (51.3 vs. 53.6 years, P < .001). 1614 cases underwent surgical fixation. This subgroup had a statistically significant higher occurrence of later SAPS diagnosis (205 cases, 13%, P < .001). Conclusions Persons with a previous clavicle fracture did not have an increased occurrence of receiving a SAPS diagnosis compared to matched controls. However, the diagnosis was given 1-2 years earlier for people with a previous fracture. Based on these findings, no strong argument for protraction of the scapula as a major risk factor for the development of SAPS was found.

OBJECTIVE To evaluate the effect of individualized exercises based on movement fault (MF) control on pain intensity and disability in subjects with chronic subacromial pain syndrome (SAPS). DESIGN Randomized Controlled Trial (IRCT20221126056621N1) SETTING: Rehabilitation clinics PARTICIPANTS: Thirty-eight participants with chronic SAPS (aged 52.23(8.47), 60 %woman). INTERVENTIONS The participants were randomly allocated to one of the intervention groups (individualized exercises based on MFs control test designed to target specific movement faults) or the control group (commonly prescribed general scapular stabilization exercises). Both groups received exercise sessions twice a week for four weeks. MAIN OUTCOME MEASURES The primary outcome measures were pain intensity at rest (PR) and during arm raising (PAR) using a visual analog scale. Disability was assessed as a key secondary outcome, including the disabilities of the arm, shoulder, and hand (DASH) questionnaire and the Shoulder Pain and Disability Index (SPADI). RESULTS Following completion of all exercise sessions, PAR was significantly lower in the intervention group compared to the control group (mean [CI]: 9.17 [0.31 to 18.03], p=0.04), with a large effect size [0.68]. The reduction of PAR remained significantly lower in the intervention group than in the control group after four months of follow-up (mean [CI]: 18.29 [9.09 to 27.48], p=0.00) with a large effect size [1.27]. Disability significantly decreased at two month (mean=14.58, p=0.002 on SPADI index; mean=10.26, p=0.006 on DASH index) and four month (mean=19.85, p=0.00 on SPADI index; mean=12.09, p=0.001 on DASH index) follow ups in the intervention group compared to the control group. CONCLUSION Individualized exercises based on MFs control of the shoulder region was accompanied by decreased PAR and disability in subjects with SAPS.

Myofascial tissue plays a critical role in shoulder joint mobility disorders. Myofascial release therapy (MFR) is frequently utilized to restore the extensibility of fascial tissue and is considered beneficial for various clinical conditions such as low back pain and ankle injuries. However, no studies have yet evaluated the effects of MFR on periscapular muscles activation and shoulder mobility in patients with subacromial pain syndrome(SAPS). The purpose of this study was to compare the effectiveness of MFR combined with supervised exercise(SE) and SE alone in patients with SAPS. Assessor-blinded randomized controlled trial. Sir Run Run Shaw Hospital, Zhejiang University School of Medicine. Subacromial pain syndrome patients. Fifty participants were divided into two groups: SE group and MFR + SE group, each group 25 cases. Both treatment methods were performed 5 times a week for 4 weeks. Shoulder pain severity was assessed by visual analog scale (VAS); shoulder range of motion (ROM) by a goniometer; functionality by shoulder Pain and Disability Index (SPADI); and periscapular muscles activation by sEMG. All measurements were evaluated both pre- and post-treatment. An ANOVA analysis indicated no significant group by time interactions for flexion ROM and resting VAS (p > 0.05). However, significant group by time interactions were found for SPADI, abduction and external rotation ROM, and activity VAS (p < 0.05). Post-hoc tests revealed significant improvements in SPADI, abduction and external rotation ROM, and activity VAS in both groups compared to pre-treatment (p < 0.05). Additionally, there were significant group by time interactions for the sEMG values of the upper trapezius and serratus anterior (p < 0.05). Post-hoc tests showed that compared to pre-treatment, the MFR + SE group had decreased upper trapezius sEMG values and increased serratus anterior sEMG values(p < 0.05), while the SE group showed increased serratus anterior sEMG values(p < 0.05). After the 4-week intervention, there were significant between-group differences in SPADI, abduction and external rotation ROM, activity VAS, and sEMG values of the upper trapezius and serratus anterior(p < 0.05). Four weeks of MFR combined with SE can increase shoulder ROM, improve pain, and thus enhancing functional activities in patients with SAPS. Additionally, it can further improve the balance between the upper trapezius and serratus anterior to improve the dynamics of the periscapular muscles. ChiCTR2200061054. Date of registration 15/06/2022.

Background: Subacromial pain syndrome (SPS) is the most common cause of shoulder pain. Therapeutic exercise is the first-line treatment for SPS; however, the ideal exercise type remains unclear. Here, we compared the effects of eccentric and concentric strengthening in patients with SPS. Hypothesis: Adding isolated eccentric strengthening to a multimodal physiotherapy program (MPP) would lead to greater improvements in outcomes compared with either MPP alone or adding isolated concentric strengthening to the MPP. Study Design: Randomized controlled trial. Level of Evidence: Level 2. Methods: A total of 45 patients were randomized to eccentric strengthening (ESG), concentric strengthening (CSG), and control (CG) groups; all groups received the MPP. The strengthening groups also performed group-specific strengthening. Shoulder pain, abduction and external rotation (ER) strength, joint position sense (JPS), the Constant-Murley Score (CMS), and the Disabilities of the Arm, Shoulder and Hand score were collected at baseline, after 12 weeks of treatment, and at week 24. Results: For CMS, ESG exhibited a greater, but not clinically meaningful, improvement than CSG and CG (P < 0.05). Eccentric abduction strength increased in ESG compared with CG. From baseline to follow-up, abduction strength increased in ESG compared with CSG and CG. Eccentric abduction strength increased in CSG compared with CG. JPS at abduction improved in the ESG compared with CG. Other between-group comparisons were not significant (P > 0.05). Conclusion: In SPS, eccentric strengthening provided added benefits, improving shoulder abduction strength and JPS at abduction, and was superior to concentric strengthening for improving shoulder abduction strength. Neither strengthening approach had an additional effect on shoulder function, pain, ER strength, or rotational JPS. Clinical Relevance: Clinicians could implement eccentric strengthening as a motor control retraining for strength and proprioception gain rather than for pain relief and reducing disability.

Aims Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. Methods The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection. Conclusion The results of this trial will demonstrate if there is a difference in shoulder pain and function after a subacromial space steroid injection between the anterolateral versus posterior approach in patients with subacromial pain syndrome. This will help to guide treatment for patients with subacromial pain syndrome. Cite this article: Bone Jt Open 2024;5(9):729–735.

OBJECTIVE To compare localized (primary) and widespread (secondary) hyperalgesia using pressure pain threshold (PPT) of patients with normal imaging findings, rotator cuff tear, or other pathologies. DESIGN This was a cross-sectional design with data collected at a single time point. SETTING This study was performed at two large, urban, academic medical centers. SUBJECTS Participants included had chronic subacromial pain syndrome for three months or longer. Each participant was categorized into one of three imaging groups: normal imaging, rotator cuff tear, or other structural pathology. METHODS Primary hyperalgesia was assessed with PPT at the midsection of the painful shoulder's lateral deltoid. Secondary hyperalgesia was assessed with PPT at the contralateral tibialis anterior muscle (TA). An ANOVA and ANCOVA was performed for each objective. ANCOVA covariates included age, sex, education level, and pain duration. RESULTS The 103 participants included 55 males, had a median age of 55 years, median pain duration of 14.0 months, and a median composite Shoulder Pain and Disability Index (SPADI) score of 43.1%. The ANCOVA for primary hyperalgesia showed no significant difference in square-root adjusted deltoid PPT between imaging groups (F = 1.04, p = 0.3589). The ANCOVA for secondary hyperalgesia showed no significant difference in log-adjusted TA PPT between imaging groups (F = 0.24, p = 0.7900). CONCLUSIONS No significant difference was observed in the analysis of ipsilateral deltoid or contralateral TA PPT between patients with differing structural shoulder pathologies. These findings suggest that the three types of structural shoulder abnormalities we examined are not significantly associated with differences in one measure of hyperalgesia.

Background/objective Previous studies have indicated that mind-body exercises can reduce pain and improve function for patients with musculoskeletal conditions. Yi Jin Bang is a novel home-based Chinese mind-body Qigong exercise for shoulder pain. However, few studies have evaluated its effects on subacromial pain syndrome. This study aimed to compare the effects of Yi Jin Bang with conventional exercises for subacromial pain syndrome. Methods Adults with subacromial pain syndrome (N = 105; mean [SD] age, 37 [16] years; 73 females [70%]; median [IQR] duration of symptoms, 12 [6–24] months) were randomly assigned to either the experimental group (n = 53) or the control group (n = 52). The experimental group performed home-based Yi Jin Bang exercises, whereas the control group performed home-based conventional exercises (stretching, strengthening, and motor control exercises). Both interventions were performed four times a week for 16 weeks. The primary outcome was the Shoulder Pain and Disability Index (SPADI). Secondary outcomes included current shoulder pain intensity, active shoulder range of motion, back scratch test, isometric shoulder strength, and health-related quality of life. Assessments were performed at baseline and weeks 4, 8, 12, and 16. The primary endpoint was week 16. Results No significant between-group difference was observed in the SPADI score at week 16 (mean difference, Yi Jin Bang minus conventional exercise, 0.14, 95% confidence interval −2.96 to 3.24; p = 0.93). Conclusion There were no differences between Yi Jin Bang and conventional exercises in improving pain, disability, shoulder mobility, shoulder strength, and quality of life for people with subacromial pain syndrome.

Background/Objectives: Shoulder pain is a common treatment outcome in breast cancer survivors. While various risk factors and mechanisms for shoulder pain have been proposed, evidence is inconsistent. Increased risk of subacromial pain syndrome exists, which can lead to disability and reduced quality of life if untreated. Ultrasound is a valuable tool for detecting rotator cuff changes aiding in timely diagnosis of subacromial pain syndrome. This study aimed to assess the prevalence of rotator cuff changes to better understand chronic shoulder pain in breast cancer survivors. Methods: This cross-sectional study included 74 breast cancer survivors from the University Hospital Split. Data were collected via questionnaires and clinical interviews. Bilateral shoulder ultrasounds were performed by two blinded investigators. Categorical variables were analyzed using Chi-squared tests, and continuous variables were analyzed with T-tests or Mann–Whitney tests. Results: Pathological findings were similarly prevalent on the operated and non-operated sides (p = 0.3 and p = 0.6). Among participants with shoulder pain, ultrasound-detected pathology was present in 91% of right shoulders and 96% of left shoulders (p < 0.005). Non-painful shoulders exhibited pathology in 59% of right and 57% of left shoulders. Ipsilateral pain to the site of breast surgery was reported by 57.7% of participants, with supraspinatus pathology in 56%, acromioclavicular joint pathology in 39%, and subacromial–subdeltoid bursitis in 41%. Conclusions: Similar pathology distribution on operated and non-operated sides and frequent asymptomatic findings highlight unresolved causes of shoulder pain in breast cancer survivors. Ultrasound is valuable but requires integration with clinics for accurate diagnosis of the underlying causes of shoulder pain.

There is limited high level research supporting the use of dry needling for mechanical shoulder pain. Dry needling is often used as an adjunct or primary treatment for musculoskeletal pain to address impairments related to muscle pain, range of motion (ROM), and strength deficits. This case study describes a 68-year-old female referred from her Physician to physical therapy (PT) with diagnosis of shoulder impingement syndrome. She underwent 12 sessions of traditional PT including manual therapy and therapeutic exercises with moderate pain reductions, improved ROM, and optimal functional outcomes using the Quick DASH. However, when progress was stalled, Dry needling (DN) was included in the plan of care. Dry needling was then performed as primary treatment to the anterior muscles of the shoulder (pectoralis major, pectoralis minor near the musculotendinous junction), and the latissimus, subscapularis and anterior deltoid) for two treatments resulting in significant improvements with ROM, reduced pain and improved functional outcomes which continued at 6-months with follow-up with patient.

Introduction There is no recognised terminology, nor diagnostic criteria, for patients with subacromial pain syndrome (SAPS). This is likely to cause heterogeneity across patient populations. This could be a driver of misconceptions and misinterpretations of scientific results. We aimed to map the literature regarding terminology and diagnostic criteria used in studies investigating SAPS. Materials and methods Electronic databases were searched from inception to June 2020. Original peer-reviewed studies investigating SAPS (also known as subacromial impingement or rotator cuff tendinopathy/impingement/syndrome) were eligible for inclusion. Studies containing secondary analyses, reviews, pilot studies and studies with less than 10 participants were excluded. Results 11 056 records were identified. 902 were retrieved for full-text screening. 535 were included. 27 unique terms were identified. Mechanistic terms containing ‘impingement’ are used less than before, while SAPS is used increasingly. For diagnoses, combinations of Hawkin’s, Neer’s, Jobe’s, painful arc, injection test and isometric shoulder strength tests were the most often used, though this varied considerably across studies. 146 different test combinations were identified. 9% of the studies included patients with full-thickness supraspinatus tears and 46% did not. Conclusion The terminology varied considerably across studies and time. The diagnostic criteria were often based on a cluster of physical examination tests. Imaging was primarily used to exclude other pathologies but was not used consistently. Patients with full-thickness supraspinatus tears were most often excluded. In summary, studies investigating SAPS are heterogeneous to an extent that makes it difficult, and often impossible, to compare studies.

INTRODUCTION Subacromial pain syndrome (SPS) is a common cause of shoulder pain, and is associated with functional limitation, workdays lost, disability, and poor quality of life. PURPOSE Our purpose was to investigate the effects of scapular stabilization exercises in patients with SPS. METHOD Sixty-four patients with SPS who also exhibit observable scapular dyskinesis defined by the scapular dyskinesis test were recruited and randomized to scapular stabilization exercise training group or to control group. All participants received the same rehabilitation protocol including glenohumeral and scapular mobilization, pendulum exercises, shoulder stretching, range of motion exercises, strengthening, and proprioceptive exercises. Patients in the scapular stabilization exercise training group performed additional scapular stabilization exercises. The presence of scapular dyskinesis, shoulder pain severity, motion, muscle strength, scapular upward rotation, and shoulder disability were assessed before and after the four-week rehabilitation program. RESULTS The scapular stabilization exercise training group had better improvement in scapular dyskinesis, pain, muscle strength, and shoulder disability compared to the control group (p < 0.05). However, there was no statistically significant time-group interaction regarding shoulder motion and scapular upward rotation (p > 0.05). CONCLUSIONS Scapular stabilization exercises added to the shoulder mobilization, stretching, and strengthening are effective in improving scapular dyskinesis, reducing pain, increasing muscle strength and shoulder function in patients with SPS accompanied by scapular dyskinesis.

RR = 1.36, 95% CI: 1.04, 1.76). Con fi dence of all meta-analyses was low, as most studies were assessed at high risk of bias because they were not randomized clinical trials and because of serious inconsistency (I 2 > 50%). Conclusion: Although clinical guidelines are important to improve the quality of care for people with LBP, it is not always effective in clinical practice. The quality of evidence found was low. Better quality studies are still needed to con fi rm these fi ndings. Implications: Clinical guidelines are important tools that are effective in reducing imaging, prescribing opioids and promoting active approaches and were ineffective for referrals and prescribing non-opioids.

Background and purpose In 2013, the first clinical practice guideline for subacromial pain syndrome (SAPS) was developed in the Netherlands to support healthcare professionals. SAPS refers to non-traumatic, non-rheumatologic shoulder complaints that are particularly painful during arm elevation. It includes conditions such as supraspinatus tendinosis, calcific tendinitis, and degenerative supraspinatus tears. Over 50,000 patients annually consult orthopedic surgeons for these issues. In response to new evidence and clinical needs, an updated guideline was developed. Part 2 focuses on supraspinatus tears, biceps tendon pathology, and calcific tendinosis. Using a multidisciplinary, evidence-based approach, the guideline aims to answer key clinical questions around SAPS. Methods Initiated by the Dutch Orthopedic Society, the guideline committee identified knowledge gaps through group sessions. Each module was based on a PICO-formatted key question and reviewed by professionals from different fields. The AGREE and GRADE methods were applied to ensure a systematic evaluation of evidence, leading to conclusions and recommendations. Results (i) Start with exercise-based therapy (with corticosteroid injection) for isolated, symptomatic, non-traumatic supraspinatus tears. Consider cuff repair if no improvement after 3–6 months. (ii) Avoid biceps tenotomy/tenodesis on a healthy tendon unless at risk during cuff repair. (iii) Evaluate patient- and tear-specific factors; use MRI for detailed assessment. (iv) Consider barbotage for calcific tendinosis; repeat once if needed. Reserve surgery for persistent large calcifications. (v) Postoperative immobilization should not exceed 3 weeks. Conclusion The updated guideline provides multidisciplinary recommendations for surgical management.

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This study aimed to identify independent predictors of rotator cuff retear and to develop a predictive model using preoperative ultrasonography data.

Introduction: Calcific tendinitis of the rotator cuff is a common musculoskeletal disorder characterized by calcium salt deposits in the tendons of the shoulder's rotator muscles. Initially asymptomatic, it can cause persistent pain, limited mobility, and a reduced quality of life as the condition progresses. Diagnosis is typically made using clinical evaluation and imaging, with ultrasonography being the preferred non-invasive method, while treatment options range from conservative approaches to advanced ultrasound-guided percutaneous interventions.   Aim: The aim of this article is to explain the pathogenesis of calcific tendinitis of the rotator cuff of the shoulder joint and to discuss the use of ultrasound in the diagnosis and treatment of the condition.   Review methods: A detailed analysis of recent scientific studies on the treatment and diagnosis of calcific tendinitis of the rotator cuff was conducted. The studies available in PUBMED were analyzed, and the following keywords were used to search for sources: rotator cuff, calcific tendinitis, ultrasonography, percutaneous treatment.       Conclusion: Owing to its real-time imaging capabilities and clinical accessibility, ultrasonography plays a central role in both the diagnosis and minimally invasive treatment of calcific tendinitis. The procedure contributes to significant pain relief, improved shoulder function, and faster return to daily activities for affected patients.

Background This study aimed to evaluate the severity of adhesion between muscles in the shoulder joint using dynamic ultrasonography and to confirm whether adhesions cause range of motion (ROM) restrictions. Methods Twenty-four shoulders from 15 frozen shoulder patients and 24 shoulders from 18 rotator cuff disorder patients were enrolled. We obtained ultrasound video sequences of the subscapularis (SSC) and deltoid muscles during shoulder external rotation. The mean stretching velocities of the deltoid and SSC were subsequently analyzed using a personal computer. If adhesions occurred between both muscles, the deltoid was stretched more vigorously, and we calculated mean stretching velocity of the deltoid / SSC as adhesion severity. The coracohumeral ligament thickness was measured using the same images. Shoulder ROM was measured by using a universal goniometer. Results The intraclass correlation coefficients (1.1) and (2.1) of the adhesion severity measurements were 0.85 and 0.91, respectively. Multiple linear regression analysis revealed that the adhesion severity is a significant predictor for external rotation ROM in the rotator cuff disorder group (R2 = 0.44, F = 10.1, P < .01, t = −2.9), while coracohumeral ligament thickness predicts ROM in the frozen shoulder group (R2 = 0.28, F = 5.5, P = .01, t = −3.0). Conclusion The proposed method is reliable. Muscle adhesion causes ROM restriction of the shoulder joint. The primary cause of shoulder ROM restriction differed between the diagnostic groups.

PURPOSE Improve the accuracy of one-stage object detection by modifying the YOLOv7 with Convolutional Block Attention Module (CBAM), known as YOLOv7-CBAM, which can automatically identify torn or intact rotator cuff tendon to assist physicians in diagnosing rotator cuff lesions through ultrasound. METHODS Between 2020 and 2021, patients who experienced shoulder pain for over 3 months and had both ultrasound and MRI examinations were categorized into torn and intact group. To ensure balanced training, we included the same number of patients on both groups. Transfer learning was conducted using a pre-trained model of Yolov7 and an improved model with CBAM. The mean average precision (mAP), sensitivity and F1-score were calculated to evaluate the models. Gradient-weighted Class Activation Mapping (Grad-CAM) method was employed to visualize important regions using a heatmap. Simulation dataset was recruited to evaluate the diagnostic performance of clinical physicians using our AI-assisted model. RESULTS A total of 280 patients were included in this study, with 80% of 840 ultrasound images randomly allocated for model training. The accuracy for test set was 0.96 for Yolov7 and 0.98 for Yolov7-CBAM, the precision and sensitivity were 0.94 and 0.98 for Yolov7, 0.98 and 0.98 for Yolov7-CBAM. F1-score and mAP@0.5 were higher for Yolov7-CBAM (0.980 and 0.993) than Yolov7 (0.961 and 0.965). Furthermore, the Grad-CAM method elucidated that the deep learning model primarily emphasized hypoechoic anechoic defect within the tendon. Following adopting an AI-assisted model (YOLOv7-CBAM model), diagnostic accuracy improved from 80.86% to 88.86% (p=0.01) and interobserver reliability improved from 0.49 to 0.71 among physicians. CONCLUSION The YOLOv7-CBAM model demonstrate high accuracy in detecting torn or intact rotator cuff tendon from ultrasound images. Integrating this model into the diagnostic process can assist physicians in improving diagnostic accuracy and interobserver reliability across different physicians. CLINICAL RELEVANCE The attentional deep learning model aids physicians in improving the accuracy and consistency of ultrasound diagnosis of torn or intact rotator cuff tendons.

PURPOSE OF THE STUDY In this study, we aimed to evaluate acromiohumeral distance (AHD) and supraspinatus tendon (ST) thickness measurements and their relationship with pain and function in ST pathologies. MATERIAL AND METHODS The study included 111 patients and 25 healthy controls (HC). Patients were divided into 3 groups according to their diagnosis: non-tear tendinopathy (NTT), partial thickness tear (PTT), and full thickness tear (FTT). The AHD and ST thickness of the participants were measured with ultrasound. The pain and functional status of the patients were evaluated with the Numeric Rating Scale (NRS), The QuickDASH shortened version of the DASH Outcome Measure - Disabilities of the Arm Shoulder and Hand (QDASH), and Simple Shoulder Test (SST). RESULTS The AHD value was significantly higher in the NTT group (p=0.000). The AHD value was significantly lower in the FTT group (p=0.000). ST thickness value was significantly lower in the PTT group compared to the NTT group (p=0.000). There was a positive correlation between ST thickness and BMI (r=0.553,p<0.01). There was a negative correlation between ST thickness and SST and a positive correlation between ST thickness (r=-0.223,p<0.05) and QDASH (r=0.276,p<0.05). CONCLUSIONS We found that AHD and SST thicknesses significantly differed in the NTT, PTT, FTT, and HC groups. This difference may be important for diagnosis. In addition, the effect of obesity on ST thickness and the relationship between ST thickness and functional scores may be considered. Weight control may be effective at this point. KEY WORDS acromiohumeral distance, supraspinatus tendon thickness, ultrasound.

Purpose This study aimed to compare the ability of B-mode ultrasonography and magnetic resonance imaging (MRI) to predict the repairability of large-to-massive rotator cuff tears (RCTs). Methods This cross-sectional study included participants with large-to-massive RCTs who underwent arthroscopic repair. B-mode ultrasonography and MRI were conducted prior to arthroscopic repair. B-mode ultrasonography was used to evaluate the echogenicity of the rotator cuff muscle using the Heckmatt scale. Intra-rater and inter-rater reliabilities were examined for two independent physicians. MRI was used to evaluate the degrees of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, two experienced orthopedic surgeons performed surgery and decided whether the torn stump could be completely repaired intraoperatively. Results Fifty participants were included, and 32 complete repairs and 18 partial repairs were performed. B-mode ultrasonography showed good intra-rater reliability and inter-rater reliability for assessment of the muscle echogenicity of the supraspinatus and infraspinatus muscles. The correlation coefficients between B-mode ultrasound findings and MRI findings showed medium to large effect sizes (r=0.4-0.8). The Goutallier classification of the infraspinatus muscles was the MRI predictor with the best discriminative power for surgical reparability (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.81 to 0.98), while the Heckmatt scale for infraspinatus muscles was the most accurate ultrasound predictor (AUC, 0.85; 95% CI, 0.74 to 0.96). No significant differences in AUCs among the MRI and ultrasound predictors were found. Conclusion B-mode ultrasonography was a reliable examination tool and had a similar ability to predict surgical reparability to that of MRI among patients with large-to-massive RCTs.

No abstract available

Background/objective It is important to assess the atrophy of the rotator cuff to better understand shoulder function and pain. Previously, magnetic resonance imaging has been used for the evaluation of atrophy of rotator cuff muscles, which is time consuming. Therefore, a measurement tool requiring little time and easy accessibility is clinically desirable to be used frequently in rehabilitation. Recently, rotator cuff muscles have been evaluated using ultrasonography. However, little is known about the agreement of evaluation in rotator cuff muscles between magnetic resonance imaging and ultrasonography. The purpose of this study was to demonstrate the agreement between the muscle thickness measurements of supraspinatus, infraspinatus, and teres minor muscles by ultrasonography and the cross-sectional area measured by magnetic resonance imaging in the patient with rotator cuff tears. Methods A total of 47 patients with rotator cuff tears were enrolled. There were the 37 small tears, four medium tears, and six large tears, and the involved rotator cuff muscles were the supraspinatus in 37 shoulders, and the supraspinatus and infraspinatus in 10 shoulders. The measuring variables were muscle thickness and cross-sectional area of supraspinatus, infraspinatus, and teres minor muscles by using magnetic resonance imaging. Further, the muscle thickness of the rotator cuff were assessed using ultrasonography. A single regression model was used for demonstrating the agreement between the cross-sectional area measurement by magnetic resonance imaging and the muscle thickness measured using ultrasonography and magnetic resonance imaging of rotator cuff muscles. Additionally, the Bland-Altman plots between magnetic resonance imaging and ultrasonography was analyzed. Results The cross-sectional area were correlated with the muscle thickness measurement of rotator cuff muscles by magnetic resonance imaging, significantly (supraspinatus: r = 0.84, infraspinatus: ρ = 0.63, teres minor: ρ = 0.61, all p < 0.001). There were significant agreements between the cross-sectional area measured by magnetic resonance imaging and muscle thickness measured by ultrasonography (supraspinatus: r = 0.80, infraspinatus: ρ = 0.78, teres minor: ρ = 0.74, all p < 0.001). Bland-Altman plots revealed significant correlations between the average and the difference of the two measurements in supraspinatus (r = 0.36, p = 0.012), infraspinatus (r = 0.38, p < 0.001), and teres minor (r = 0.42, p < 0.001). These results clarified the proportional bias between MRI and US. Conclusion This study showed that, similar to magnetic resonance imaging, ultrasonography is a useful tool for assessing muscle atrophy of supraspinatus, infraspinatus, and teres minor muscles.

Background: Rotator cuff injuries are a common cause of shoulder pain, leading to functional limitations and reduced quality of life. While magnetic resonance imaging (MRI) is the gold standard for diagnosis, high-resolution ultrasonography (USG) is a non-invasive, cost-effective alternative. Aims and Objectives: The aim of the study was to compare the diagnostic performance of high-resolution USG and MRI in detecting rotator cuff tears and assessing tear severity, size, and correlation with symptoms. Materials and Methods: This cross-sectional study included 60 patients with clinically suspected rotator cuff injuries at Tirunelveli Medical College Hospital, over 18 months. Both USG (6–12 MHz linear transducer) and 1.5 Tesla MRI were performed on all patients. Tear type, size, and symptom status were recorded. The sensitivity and positive predictive value (PPV) of USG were calculated. Statistical analyses were performed using the Statistical Package for the Social Sciences v27. Results: The mean age was 67.6±10.6 years, with 58.33% males. Most tears were small (≤3 cm, 68.33%), whereas large tears accounted for 31.67%. USG detected 58.33% of full-thickness and 30% of partial-thickness tears, with seven missed cases. MRI detected 61.67% of full-thickness and 38.33% partial-thickness tears, confirming all USG-detected tears, and the USG demonstrated a sensitivity of 88.33% and a PPV of 100%. Full-thickness tears were more frequently symptomatic than partial-thickness tears (USG P=0.103; MRI P=0.034). Both modalities showed that tear size did not significantly correlate with symptom presence. Conclusion: Both USG and MRI effectively detect rotator cuff tears, with MRI slightly more accurate. High-resolution USG shows high sensitivity and predictive accuracy, making it a reliable, non-invasive, and affordable first-line diagnostic tool.

No abstract available

Shoulder pain is a common cause of morbidity in the general population. Differential diagnosis may be difficult. Soft tissue shoulder disorders are the most common causes of shoulder pain. Noninvasive imaging techniques can reveal rotator cuff (RC) pathologies. These include ultrasonography (US) and MRI. Minimally invasive techniques such as magnetic resonance arthrography (MRA) can also be recruited when required. We conducted a retrospective study of 61 consecutive patients with shoulder pain, who had undergone preoperative imaging in the form of US or MRI and subsequently proceeded to arthroscopic surgery. Nineteen patients had a US and 42 had an MRI preoperative imaging evaluation. This evaluation was compared to the operative findings. The US sensitivity was 87%, while specificity was 63%. The MRI accuracy rose to a sensitivity of 95% when specificity was 72%. The positive predictive value (PPV) was 64% for US and 76% for MRI. The negative predictive value (NPV) was 87% for US and 94% for MRI. The overall accuracy of the ultrasound was 73% and of the MRI 83%.

The assessment of the six-week influence of Kinesio Taping combined with a rehabilitation on selected ultrasonography measurements, the level of disability, and the quality of life in patients with rotator cuff lesions. 60 participants were randomly assigned into a taping group (KT combined with a six-week rehabilitating protocol) and a control group (only rehabilitation protocol). In all patients the following assessments were performed twice: USG, UEFI and NHP questionnaires. In the examination of the subacromial space and the subacromial bursa in the taping group, no statistical significance was observed. A statistically significant change in the thickness of the muscles was obtained only for the thickness of the infraspinatus in the taping group. A statistically significant change was obtained in the assessment of tendinopathy only for the supraspinatus muscle in both groups. Within both groups a statistically significant difference was observed in the average UEFI and NHP scores; however, the differences in the scores obtained between the groups were not statistically significant. The use of KT with a rehabilitation program did not yield statistically significantly better results in the improvement of selected shoulder region indicators, the function of the upper limb and the quality of life.

Allogenous dermal scaffold augmentation enhances partial rotator cuff repairs by providing structural support and a biologic scaffold that promotes tissue regeneration, reduces mechanical strain, and compensates for poor tendon quality in large to massive rotator cuff tears. This approach helps lower the risk of retear and improves functional recovery. This study included 55 patients with large to massive rotator cuff tears, divided into two groups. Group A (28 patients) underwent arthroscopic partial repair, while Group B (27 patients) received allogenous dermal scaffold graft augmentation following partial repair to reinforce the repair and resurface the uncovered tendon footprint. Clinical assessments, including the University of California-Los Angeles score, Constant-Murley score, and visual analogue scale, were conducted preoperatively, at 3, 6, and 12 months postoperatively, and annually thereafter. Radiologic evaluations, including magnetic resonance imaging and ultrasonography, were performed preoperatively and postoperatively to assess tendon integrity. The mean follow-up period was 40 months for Group A and 36 months for Group B. Clinical functional scores significantly improved in both groups at the final follow-up. Postoperative radiologic assessment showed 9 retears in Group A and 4 in Group B (p < 0.05), respectively, with significantly greater postoperative tendon thickness in Group B compared to Group A (p-value < 0.05). Additionally, acromiohumeral distance improved significantly in both groups, from 7 mm to 9 mm in Group A and from 7 mm to 11 mm in Group B, with Group B demonstrating superior improvement (p < 0.01). This study suggests that allogenous dermal scaffold graft augmentation, in addition to partial repair, enhances tendon thickness and acromiohumeral distance. Furthermore, it results in lower retear rates compared to partial repair alone.

This study evaluates the functional outcomes and structural integrity following single-row (SR) arthroscopic repair in patients with full-thickness rotator cuff tears. The influence of pre-operative fatty atrophy and tear size on post-operative outcomes is also analyzed to determine their prognostic significance. Sixty patients who underwent SR arthroscopic rotator cuff repair were followed for a minimum of 24 months (mean follow-up: 35.93 ± 26.24 months). Functional outcomes were assessed using the Constant-Murley Score (CMS) and the University of California, Los Angeles (UCLA) score. Structural integrity was evaluated through ultrasonography using the Sugaya classification. The impact of tear size and fatty infiltration on post-operative outcomes was analyzed. Significant improvements were observed postoperatively. The mean CMS improved to 94.83 ± 7.78 (P < 0.001), and the mean UCLA score increased to 33.82 ± 6.7 (P < 0.001). Active forward flexion, external rotation, and muscle strength improved significantly, while pain scores decreased (Visual analog scale: 1.2 ± 0.75, P < 0.001). Structural assessment revealed 85% of patients with Sugaya type I repairs (mean CMS: 97.06 ± 5.21), 10% with type II (CMS: 82.67 ± 9.42), and 5% with type III or higher (CMS: 81.33 ± 6.35), all statistically significant (P < 0.001). Tear size and fatty atrophy did not significantly affect functional outcomes. SR arthroscopic repair for full-thickness rotator cuff tears yields excellent functional results and tendon healing at a minimum follow-up of 24 months. Superior outcomes were associated with intact tendon healing. Pre-operative tear size and fatty atrophy were not significant predictors of post-operative function.

Background This study aimed to investigate the initial site of calcification development in rotator cuff tendons using serial ultrasonographic evaluations. Methods A total of 21 patients with de novo calcifications were included. Ultrasonography was used to assess calcifications in the rotator cuff tendons. The distance from the tendon insertion on the humerus to the calcification site was measured, along with the long and short diameters and the long-to-short diameter ratio. Results In 19 patients (90%), calcifications were in direct contact with the tendon insertion on the humerus. In the remaining two patients (10%), the calcifications were located 1 mm proximal to the tendon insertion site. The mean long and short diameters of the calcifications were 9.4 ± 4.6 and 2.7 ± 1.2 mm (range: 3.0–17.0 and 1.0–4.5 mm), respectively. The mean long-to-short diameter ratio was 2.4 ± 2.2 mm (range: 1.8–10.0 mm). Regarding shoulder disorders, 1, 7, and 13 patients had a rotator cuff tendon tear, calcific tendinitis, and adhesive capsulitis, respectively. Conclusions Calcifications in the rotator cuff tendons appear to originate at the tenoperiosteal junction or in close periosteal proximity and extend along the tendon axis.

No abstract available

ABSTRACT Aim: The aim of this study is to assess the diagnostic accuracy of ultrasonography in comparison to magnetic resonance imaging for evaluating rotator cuff injuries, while also examining the reliability of ultrasonography as a primary imaging technique. Materials and Methods: A prospective observational study of 84 individuals focused on those with shoulder pain indicating rotator cuff disease. After an ultrasound, all patients had an MRI. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy were calculated for tendon and bursal structures. Results: The findings indicate that ultrasound exhibited the highest sensitivity for identifying supraspinatus tears at 83.85%. Additionally, it showed a notable specificity in assessing subscapularis (94.74%), biceps tendon (96.65%), and bursitis-related conditions. A statistically significant correlation was observed in the evaluation of the subscapularis using MRI, with a P value of 0.048. Conclusion: The high specificity and accessibility of this imaging tool underscore its importance as a primary option, while MRI continues to play a crucial role in addressing complex or posterior shoulder pathologies.

There is increasing interest among physiatrists in using bedside ultrasonography to assess rotator cuff tears.

Summary Background Rotator cuff tears (RCTs) represent a significant proportion of shoulder diseases, hence they are a frequent cause of patient visits in shoulder clinics. However, the diagnosis of rotator cuff tears is controversial. Investigation of cuff tears is based on ultrasonography (US) and magnetic resonance imaging (MRI). Both modalities have been in use for decades, and their advantages and limitations are known. A recent Cochrane review of the subject suggested that US and MRI both performed well with respect to full thickness rotator cuff tears (FTT). However, they were less accurate with respect to partial thickness tears (PTT). The aim of this study is to assess the accuracy of US and MRI in diagnosing rotator cuff tears. Material/Methods This is a retrospective analysis of a cohort of 255 patients who underwent shoulder arthroscopy. Of them, 125 patients had preoperative US, and 130 had preoperative MRI. The imaging results were compared with arthroscopic findings for patient. Results After calculating sensitivity, specificity, positive prediction value (PPV), and negative prediction value, we found no statistically significant difference between US and MRI in detection of rotator cuff tears of any type (RCT) or FTT. However, US is more specific in detecting PTT compared to MRI (P=0.00008) but with no significant difference in other parameters. Conclusions We concluded that US and MRI both have similar accuracy in diagnosing RCT of any sort and FTT. However, US is more specific than MRI in detecting PTT. In our institute, we now recommend US as the investigation of choice for diagnosing rotator cuff tears.

BackgroundRotator cuff tears are very common and their incidence increases with age. Shoulder ultrasonography has recently gained popularity in detecting rotator cuff tears because of its efficiency, cost-effectiveness, time-saving, and real-time nature of the procedure. Well-trained orthopedic surgeons may utilize shoulder ultrasonography to diagnose rotator cuff tears. The wait time of patients planned to have shoulder MRI (magnetic resonance imaging) to rule in rotator cuff tears may decrease after orthopedic surgeon start doing shoulder ultrasonography as a screening tool for that. Patients with rotator cuff tears may be detected earlier by ultrasonography and have expedited surgical repair. The efficacy in determination of rotator cuff tears will also increase.MethodsPatients were retrospectively reviewed from January 2007 to December 2012. They were divided into 2 groups: Ultrasound (-) group and the Ultrasound (+) group. Age, gender, wait time from outpatient department (OPD) visit to MRI exam, MRI exam to operation (OP), and OPD visit to OP, patient number for MRI exam, and number of patients who finally had rotator cuff repair within two groups were compared.ResultsThe wait time of OPD visit to OP and MRI to OP in patients who received shoulder ultrasonography was significantly less than that in patients did not receive shoulder ultrasonography screening. Only 23.8% of the patients with a suspected rotator cuff injury undergone arthroscopic rotator cuff repair before ultrasonography was applied as a screening tool. The percentage increased to 53.6% after orthopedic surgeon started using ultrasonography as a screening tool for rotator cuff tears.ConclusionsOffice-based shoulder ultrasound examination can reduce the wait time for a shoulder MRI. The efficacy of determination of rotator cuff tears will also increase after the introduction of shoulder ultrasonography.

No abstract available

INTRODUCTION The natural history of rotator cuff tears often involves progressive pain development, tear enlargement, and advancing muscle fatty degeneration. Both surgery and conservative management have proven to be effective treatments. Our study purpose was to compare the short to mid-term effects of rotator cuff repair on shoulder function, progression of tear size, and muscle degeneration compared to controls with asymptomatic tears that developed pain and were managed nonoperatively. METHODS This comparative study consists of two separate longitudinal study arms. The control group consisted of asymptomatic degenerative cuff tears followed until pain development and then managed nonoperatively with continued surveillance. The surgical group consisted of subjects with degenerative tears that failed nonoperative treatment and underwent surgical intervention with a minimum of 2 years follow-up. Outcomes included VAS pain, ASES, AROM, strength, and ultrasonography. RESULTS There were 83 controls and 65 surgical shoulders. The surgical group was younger at enrollment (58.9±5.3 yr vs. 61.2±7.8 yr, p=0.04). The median follow-up for control subjects after pain development was 5.1 years (IQR 3.6) and the median postoperative follow-up for the surgical group was 3.0 years (IQR 0.2). Baseline tear widths (median 14 mm, IQR 9 vs. 13 mm, IQR 8; p=0.45) and tear lengths (median 14 mm, IQR 13 vs. median 11 mm, IQR 8; p=0.06) were similar between the surgical group and controls. There were no differences in the baseline prevalence of fatty degeneration of the supraspinatus or infraspinatus muscles between groups (p=0.43 and p=0.58, respectively). At final follow-up, the surgical group demonstrated significantly lower VAS pain (0 [IQR 2] vs. 3.5 [IQR 4], p=0.0002), higher composite ASES (95 [IQR 13] vs. 65.8 [IQR 32], p=0.0002) and ADL scores (29 [IQR 4] vs. 22 [IQR 8], p=0.0002), greater abduction strength (69.6 N [SD 29] vs. 35.9 N [SD 29], p=0.0002), greater active forward elevation (155˚ [SD 8] vs. 142˚ [SD 28], p=0.002), greater active external rotation in abduction (mean 98.5˚, SD 12 vs. mean 78.2˚, SD 20; p=0.0002) compared to controls. Additionally, the prevalence of fatty muscle degeneration was lower in the surgical group for the supraspinatus and infraspinatus (25% vs. 41%, p=0.05; 17% vs. 34%, p=0.03; respectively). CONCLUSION This prospective longitudinal study comparing a surgical cohort undergoing rotator cuff repair with a control group treated nonoperatively supports the notion that surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease. Patients in the surgical group demonstrated clinically relevant differences in pain and functional outcomes. Surgical intervention was protective against progressive muscle degeneration compared to nonoperative treatment.

Background and Objectives: Few studies have investigated the socioeconomic factors associated with retear after rotator cuff repair. This study aimed to identify the risk factors, including socioeconomic factors, for rotator cuff retear in patients who underwent arthroscopic rotator cuff repair. Materials and Methods: This retrospective study included 723 patients diagnosed with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair from March 2010 to March 2021. The outcome variable was rotator cuff retear observed on postoperative magnetic resonance imaging or ultrasonography. Sex, age, obesity, diabetes, symptom duration, and tear size were the independent variables. Socioeconomic variables included occupation, educational level, type of medical insurance, and area of residence. We compared patients with and without retear and estimated the effects of the independent factors on retear risk. Results: The mean age of the patients, symptom duration, and tear size were 62.4 ± 8.0 years, 1.8 ± 1.7 years, and 21.8 ± 12.5 mm, respectively. The age, type of medical insurance, diabetes, tear size, and symptom duration differed significantly between patients with and without retearing (p < 0.05). Age, occupation, type of medical insurance, diabetes, initial tear size, and symptom duration significantly affected the risk of retear. Patients who performed manual labor had a significantly higher retear rate (p = 0.005; OR, 1.95; 95% CI, 1.23–3.11). The highest retear risk was seen in patients with Medicaid insurance (p < 0.001; OR, 4.34; 95% CI, 2.09–9.02). Conclusions: Age, initial tear size, and symptom duration significantly affect retear risk after arthroscopic rotator cuff repair. Occupation and type of medical insurance were also risk factors for retear. Socioeconomically vulnerable patients may be at a greater risk of retear. Proactive efforts are required to expand early access to medical care.

No abstract available

Rotator cuff calcific tendinopathy (RCCT) is a common disorder of the rotator cuff causing shoulder pain and dysfunction. RCCT is characterized by calcium deposition on and around the tendons of the rotator cuff muscles. Treatment is typically conservative, consisting of anti-inflammatory drugs (NSAIDs) and physical therapy, although certain patients require more invasive treatment. If first-line treatments do not resolve the pain, second-line treatments such as glucocorticoid injections, extracorporeal shock wave therapy (ESWT), barbotage, and surgery may be considered; however, there is no gold standard treatment for these refractory cases. In this case study, a 36-year-old female patient with confirmed RCCT achieved symptom remission with ultrasound-guided methylprednisolone injection followed by adjunctive physical therapy. Ultrasonography enabled precise, targeted delivery of steroids to the calcified lesions, with near 100% resolution of deposits on repeat radiography. With additional physical therapy, the patient was completely pain-free with a full range of motion and the ability to perform daily activities. This case report demonstrates that ultrasound-guided glucocorticoid injection can be an efficacious treatment option for refractory cases of RCCT.

Background Rotator cuff tears are often associated with synovitis, but the ability of noninvasive ultrasonography to predict the severity of synovitis remains unclear. We investigated whether ultrasound parameters, namely peak systolic velocity in the anterior humeral circumflex artery and Doppler activity in the glenohumeral joint and subacromial space, reflect synovitis severity. Methods A total of 54 patients undergoing arthroscopic rotator cuff repair were selected. Doppler ultrasound was used to measure peak systolic velocity in the anterior humeral circumflex artery and Doppler activity in the glenohumeral joint and subacromial space, and these values were compared with the intraoperative synovitis score in univariate and multivariate analyses. Results Univariate analyses revealed that tear size, peak systolic velocity in the anterior humeral circumflex artery, and Doppler activity in the glenohumeral joint were associated with synovitis in the glenohumeral joint (P=0.02, P<0.001, P=0.02, respectively). In the subacromial space, tear size, peak systolic velocity in the anterior humeral circumflex artery, and Doppler activity in the subacromial space were associated with synovitis severity (P=0.02, P<0.001, P=0.02, respectively). Multivariate analyses indicated that tear size and peak systolic velocity in the anterior humeral circumflex artery were independently associated with synovitis scores in both the glenohumeral joint and the subacromial space (all P<0.05). Conclusions These findings demonstrate that tear size and peak systolic velocity in the anterior humeral circumflex artery, which can both be measured noninvasively, are useful indicators of synovitis severity. Level of evidence IV.

Background The relationship between lower mobility, as measured by the elbow forward translation motion (T-motion) test, a new indicator of shoulder joint complex movement that measures elbow position when both dorsal hands are placed on the iliac crest while in a sitting position, and the parameters calculated by ultrasonography is unknown. The purpose of this study was to investigate the limiting factors of T-motion through motion analysis of the humeral head and rotator cuff muscles using ultrasonography in college baseball players. Methods Thirteen college baseball players participated in this cross-sectional study. The shortest distance from the posterior edge of the glenoid to the humeral head was measured in the static and T-motion positions, and the difference was calculated as the humeral head translation. The velocity of the infraspinatus was calculated during shoulder internal/external rotation using the particle image velocimetry method. These parameters were compared between the throwing and nonthrowing sides to examine the limiting factors of T-motion. Results This study indicated moderate-to-good reliability for the parameters calculated by ultrasonography. The mean anterior translation distance was significantly greater on the throwing side than on the nonthrowing side (r = 0.56, P = .015). The mean velocity of infraspinatus during internal rotation was significantly lower on the throwing side than on the nonthrowing side (r = 0.51, P = .028). Conclusion Increased anterior translation of the humeral head and decreased the velocity of infraspinatus are likely correlated with reduced T-motion mobility in college baseball players. These methods showed potential for physical therapy assessment and intervention to prevent shoulder dysfunction.

Background: Injuries to the shoulder and restricted range of motion often lead to decreased work productivity, increased use of medical resources, and impaired quality of life. The most frequent cause of shoulder discomfort and dysfunction is a disease related to the rotator cuff, such as bursitis, degenerative tears, and calcific tendinosis. This study evaluates ultrasonography's diagnostic efficacy in relation to magnetic resonance imaging (MRI). Methodology: Prospective research was conducted at a hospital to compare MRI and ultrasonography for shoulder cases involving rotator cuff injuries. There were 53 patients in the sample. Those who presented with pain and dysfunction in the shoulder were given both an MRI and an ultrasound (USG). Comparing the results of the MRI and USG allowed for the calculation of the diagnostic tests' accuracy, sensitivity, specificity, and positive and negative predictive values. Results: The results of the study demonstrated a substantial agreement (p value <0.05) between the identification of rotator cuff tears by MRI and USG shoulder imaging. With a total accuracy of 88.6%, the sensitivity and specificity of identifying rotator cuff tears were 91.2% and 81.8%, respectively. Conclusion: With similar sensitivity and specificity, MRI and USG are useful diagnostic techniques for rotator cuff injuries. USG is a great screening alternative due to its cost-effectiveness, noninvasiveness, and easy accessibility. However, when it comes to identifying the anatomical regions that need surgical repair, MRI is superior.

Introduction: Rotator cuff disease frequently causes shoulder pain and is diagnosed using various radiological methods alongside history and physical examination. Arthrography has traditionally been employed for this purpose, but newer non-invasive techniques such as ultrasonography (USG) and magnetic resonance imaging (MRI) are increasingly used. However, no single method is universally agreed upon as the best diagnostic tool, each having its own limitations. Objectives: To evaluate how effectively ultrasound and MRI can diagnose rotator cuff tears. Materials and methods: Seventy patients suspected of having a rotator cuff tear underwent investigations at the Radiology Department of Krishna Vishwa Vidyapeeth (Deemed to be University), Karad. USG and MRI examinations were done on the same day, along with a detailed history. USG was conducted using a GE LOGIQ P9 machine with a high-frequency 3-12 MHz transducer. MRI was conducted using a 1.5T Siemens Magnetom Avanto scanner. Results: Pain and stiffness are the most common complaints in rotator cuff tears. The predisposing factors include male predominance, increasing age, dominant hand use, and trauma history. The supraspinatus tendon is the most frequently injured, with partial tears, especially articular surface tears, being more common than full-thickness tears. Clinical examinations, USG, and MRI are valuable in diagnosing rotator cuff tears. Conclusion: Our findings indicate that USG may not be as reliable in detecting rotator cuff tears as once believed. A positive ultrasound result is more trustworthy than a negative one. In contrast, MRI demonstrates greater sensitivity and overall diagnostic accuracy compared to both ultrasonography and clinical assessment for detecting rotator cuff tears.

Background The long-term effects of extracorporeal shockwave therapy (ESWT) on rotator cuff repair are unknown. Objectives To investigate the functional outcomes and structural changes of ESWT at 3-year follow-up after rotator cuff repair. Methods A randomized clinical trial was conducted, including patients who underwent rotator cuff repair. The patients were assigned to two groups based on whether they underwent radial ESWT 3 months postoperatively. The ESWT Group received 5 weeks of rehabilitation and ESWT weekly, whereas the CONTROL Group received only rehabilitation. Visual analog scale (VAS) pain score and functional scores were analyzed at 3 months (baseline), 6 months, and 3 years follow-up. In addition, MRI and ultrasonography were used to assess tendon maturation, integrity, tendon quality, acromiohumeral distance (AHD), and muscle fatty infiltration. Results Finally, 32 participants completed all the assessments. At the final follow-up, 2 patients in the ESWT Group (16.5 %) versus one patient in the CONTROL Group (6.25 %) had rotator cuff failure (P = 0.176). The ESWT treatment showed similar clinical outcomes in VAS-pain score, functional scores, tendon quality, AHD, and muscle fatty infiltration versus the CONTROL Group (Ps > 0.05). MRI analysis indicated improved tendon healing after ESWT treatment at both 6-month (P = 0.036) and 3-year follow-up (P = 0.028). Conclusion Early intervention with radial ESWT sustained long-term effects on the healing of the repaired rotator cuff and similar functional outcomes at long-term follow-up compared with standard rehabilitation.

Background/Objectives: Rotator cuff lesions are common causes of shoulder pain. When not treated effectively, the functional loss associated with pain affects the quality of life and brings about psychosocial issues. In this study, prospective observational comparison of the effects of ultrasonography (USG) guided subacromial injection (SAI) versus subacromial injection combined with suprascapular nerve block (SSNB) on pain, functionality and sleep quality in the treatment of shoulder pain unresponsive to conservative treatments due to rotator cuff lesions is made. Methods: The data of 25 patients in both groups were compared prospectively. Patients were evaluated after 30 min, 1 week, 2 weeks, 1 month, and 3 months. Pain levels were measured with VAS, shoulder functions with SPADI and sleep quality with PSQI. Analgesic consumption and satisfaction were also recorded. Results: Both treatment groups effectively reduced pain at rest over the 3-month follow-up period. However, the SAI group did not achieve the targeted level of analgesia for pain control during movement. In comparison, the SAI + SSNB group demonstrated significantly superior outcomes, with lower VAS scores both at rest and during motion, as well as improved SPADI and PSQI scores. Additionally, analgesic consumption was significantly reduced in the SAI + SSNB group. No side effects or complications were observed during the treatment applications or the follow-up period. Conclusions: Pain control, shoulder functionality, sleep quality, and patient satisfaction were found to be higher in patients treated with SAI + SSNB in the short-to-medium term in the treatment of shoulder pain due to rotator cuff lesions, in addition to lower analgesic consumption.

Objective To investigate the utility of ultrasonography to objectively examine morphological changes (i.e., muscle atrophy and fatty infiltration) of the supraspinatus muscle. Methods Thirty-four patients were prospectively enrolled in this study. The degrees of muscle atrophy and fat infiltration were measured using ultrasonography 3–4 months after arthroscopic supraspinatus tendon repair. Shoulder function (i.e., shoulder active range of motion, visual analogue scale, and constant score) was examined. Using the symmetricity of the muscles in the human body, the degrees of morphological changes of the supraspinatus muscle were quantitatively measured. The associations between the morphological changes of the supraspinatus muscle and shoulder function were identified. Results There were statistically significant differences in the cross-sectional area (CSA) and echogenicity between the surgery and non-surgery sides (p<0.001). The CSA ratio, which represents the degree of muscle atrophy, was associated with shoulder forward flexion, external rotation, and constant score; however, the echogenicity ratio, which represents the degree of fat infiltration, was not associated with shoulder function after surgery. Conclusion This study demonstrated that shoulder function could be predicted by evaluating the morphological changes of the supraspinatus muscle using ultrasonography and that objective evaluation is possible through quantitative measurement using the symmetricity of the human body.

No abstract available

OBJECTIVE The study aimed to investigate the effects of the level of contraction during isometric shoulder abduction at different abduction angles on muscle thickness and stiffness of the shoulder girdle in asymptomatic individuals. DESIGN Measurement properties study. SETTING Biomechanics and motion analysis lab. PARTICIPANTS Twenty individuals volunteered to participate in this study. MAIN OUTCOME MEASURE The subjects were tested for morphological and mechanical properties, expressed by thickness and stiffness of the supraspinatus tendon and muscle, and upper trapezius muscle. Moreover, acromiohumeral distance was also evaluated using B-mode ultrasound and shear-wave elastography. INTERVENTION The thickness and stiffness of the supraspinatus and upper trapezius muscle were assessed at 3 angles of abduction (0°, 60°, and 90°) and 3 levels of contraction (0%, 10%, and 20% of the maximal voluntary isometric contraction) using ultrasonography with shear-wave imaging. Moreover, the acromiohumeral distance was measured to establish the occupation ratio during passive movement. RESULTS The supraspinatus and upper trapezius muscle thickness and stiffness were significantly greater at 60° shoulder abduction compared with 0°, and 90° compared with 60°, as well as significantly greater at 20% maximal voluntary isometric contraction compared with 0% and 10% maximal voluntary isometric contraction. Thickness and stiffness were significantly greater in the supraspinatus compared with the upper trapezius muscle at all 3 angles of shoulder abduction for all 3 level of contractions. The acromiohumeral distance decreased significantly from 0° to 60° and from 60° to 90°. CONCLUSION Morphological and mechanical properties of the supraspinatus and upper trapezius muscles depended on the relative level of muscle contraction and the angle of shoulder abduction.

Rotator cuff related shoulder pain (RCRSP) is an over-arching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears. For those diagnosed with RCRSP one aim of treatment is to achieve symptom free shoulder movement and function. Findings from published high quality research investigations suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery for; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, partial thickness rotator cuff (RC) tears and atraumatic full thickness rotator cuff tears. However considerable deficits in our understanding of RCRSP persist. These include; (i) cause and source of symptoms, (ii) establishing a definitive diagnosis, (iii) establishing the epidemiology of symptomatic RCRSP, (iv) knowing which tissues or systems to target intervention, and (v) which interventions are most effective. The aim of this masterclass is to address a number of these areas of uncertainty and it will focus on; (i) RC function, (ii) symptoms, (iii) aetiology, (iv) assessment and management, (v) imaging, and (vi) uncertainties associated with surgery. Although people experiencing RCRSP should derive considerable confidence that exercise therapy is associated with successful outcomes that are comparable to surgery, outcomes may be incomplete and associated with persisting and recurring symptoms. This underpins the need for ongoing research to; better understand the aetiology, improve methods of assessment and management, and eventually prevent these conditions.

Subacromial impingement syndrome (SIS) represents a spectrum of pathology ranging from subacromial bursitis to rotator cuff tendinopathy and full-thickness rotator cuff tears. The relationship between subacromial impingement and rotator cuff disease in the etiology of rotator cuff injury is a matter of debate. Both extrinsic compression and intrinsic degeneration may play a role. Management includes physical therapy, injections, and, for some patients, surgery. There remains a need for high-quality studies of the pathology, etiology, and management of SIS.

Disorders of the shoulder are extremely common, with reports of prevalence ranging from 30% of people experiencing shoulder pain at some stage of their lives up to 50% of the population experiencing at least one episode of shoulder pain annually. In addition to the high incidence, shoulder dysfunction is often persistent and recurrent, with 54% of sufferers reporting ongoing symptoms after 3 years. To a large extent the substantial morbidity reflects (i) a current lack of understanding of the pathoaetiology, (ii) a lack of diagnostic accuracy in the assessment process, and (iii) inadequacies in current intervention techniques. Pathology of the rotator cuff and subacromial bursa is considered to be the principal cause of pain and symptoms arising from the shoulder. Generally these diagnostic labels relate more to a clinical hypothesis as to the underlying cause of the symptoms than to definitive evidence of the histological basis for the diagnosis or the correlation between structural failure and symptoms. Diagnosing rotator cuff tendinopathy or subacromial impingement syndrome currently involves performing a structured assessment that includes taking the patient's history in conjunction with performing clinical assessment procedures that generally involve tests used to implicate an isolated structure. Based on the response to the clinical tests, a diagnosis of rotator cuff tendinopathy or subacromial impingement syndrome is achieved. The clinical diagnosis is strengthened with the findings from supporting investigations such as blood tests, radiographs, ultrasound, magnetic resonance imaging (MRI), computed axial tomography (CT), radionucleotide isotope scan, single photon emission computed tomography, electromyography, nerve conduction and diagnostic analgesic injection. This process eventually results in the formation of a clinical hypothesis, and then, in conjunction with the patient, a management plan is decided upon and implemented. This paper focuses on the dilemmas associated with the current process, and an alternative method for the clinical examination of the shoulder for this group of patients is proposed.

The etiology of rotator cuff tendinopathy is multi-factorial, and has been attributed to both extrinsic and intrinsic mechanisms. Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder. A unique extrinsic mechanism, internal impingement, is attributed to compression of the posterior articular surface of the tendons between the humeral head and glenoid and is not related to subacromial space narrowing. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes.

Shoulder pain is the third most common musculoskeletal complaint in orthopedic practice. It is usually due to a defect of the rotator cuff and/or an impingement syndrome. This review is based on pertinent literature retrieved by a selective search of the Medline database. Patients with shoulder impingement syndrome suffer from painful entrapment of soft tissue whenever they elevate the arm. The pathological mechanism is a structural narrowing in the subacromial space. A multiplicity of potential etiologies makes the diagnosis more difficult; it is established by the history and physical examination and can be confirmed with x-ray, ultra - sonography, and magnetic resonance imaging. The initial treatment is conservative, e.g., with nonsteroidal antiinflammatory drugs, infiltrations, and patient exercises. Conservative treatment yields satisfactory results within 2 years in 60% of cases. If symptoms persist, decompressive surgery is performed as long as the continuity of the rotator cuff is preserved and there is a pathological abnormality of the bursa. The correct etiologic diagnosis and choice of treatment are essential for a good outcome. The formal evidence level regarding the best treatment strategy is low, and it has not yet been determined whether surgical or conservative treatment is better. Randomized controlled therapeutic trials are needed so that a standardized treatment regimen can be established.

Shoulder pain represents a common patient complaint evaluated in a primary care setting. Approximately two thirds of these patients have rotator cuff injuries, with rotator cuff tears (RCTs) and subacromial impingement syndrome (SIS) accounting for a majority of causes. An accurate and efficient diagnostic strategy focused on physical examination findings may lead to improved outcomes and less functional disability. To identify the most accurate physical examination tests for the diagnosis of RCT and SIS, we performed a systematic review and meta-analysis. The database for our systematic review was compiled by using keywords and common indexing strategies to search PubMed, Ovid MEDLINE, Embase and the Cochrane Library from January 1, 1980, to March 15, 2024. Included studies evaluated a physical examination being performed prior to a reference standard diagnostic test for either RCT or SIS. Data was extracted in dual fashion and meta-analyses were performed regarding physical examination tests identified in our included studies. A total of twenty studies, which include 3,438 patients, met our inclusion criteria and had data extracted for statistical analysis. Data was adequate to perform meta-analyses on ten physical examination tests for RCT and five physical examination tests for SIS. There were six physical examination tests which had significant diagnostic odds ratios (DORs) when used in the diagnostic evaluation of suspected RCT, with the External Rotation Lag Sign at 90 Degrees having the highest magnitude of significance (DOR, 12.70; 95% CI, 3.68 - 43.86; P < .0001). Four physical examination tests had significant DORs for physical examination tests when used in the diagnostic evaluation of SIS, with the Yergason's Test having the highest magnitude of significance (DOR, 4.71; 95% CI; 2.16 - 10.32; P = .0001). We present a large body of low-quality evidence for the diagnostic accuracies of physical examination tests for the identification of both RCT and SIS. We have identified novel data for the accuracy of the External Rotation Lag Sign at 90 Degrees and the Internal Rotation Lag Sign that have high to moderate diagnostic accuracy for ruling in tears of the rotator cuff.

Several tests for making the diagnosis of rotator cuff disease have been described, but their utility for diagnosing bursitis alone, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears has not been studied. The hypothesis of this study was that the degree of severity of rotator cuff disease affects the diagnostic values of the commonly used clinical tests. Eight physical examination tests (the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test) were evaluated to determine their diagnostic values, including likelihood ratios and post-test probabilities, for three degrees of severity in rotator cuff disease: bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. A forward stepwise logistic regression analysis was used to determine the best combination of clinical tests for predicting the various grades of impingement syndrome. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the eight tests varied considerably. The combination of the Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for any degree of impingement syndrome. The combination of the painful arc sign, drop-arm sign, and infraspinatus muscle test produced the best post-test probability (91%) for full-thickness rotator cuff tears. The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests. The variable accuracy of these tests should be taken into consideration when evaluating patients with symptoms of rotator cuff disease.

Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

Subacromial impingement syndrome is the most common disorder of the shoulder, resulting in functional loss and disability in the patients that it affects. This musculoskeletal disorder affects the structures of the subacromial space, which are the tendons of the rotator cuff and the subacromial bursa. Subacromial impingement syndrome appears to result from a variety of factors. Evidence exists to support the presence of the anatomical factors of inflammation of the tendons and bursa, degeneration of the tendons, weak or dysfunctional rotator cuff musculature, weak or dysfunctional scapular musculature, posterior glenohumeral capsule tightness, postural dysfunctions of the spinal column and scapula and bony or soft tissue abnormalities of the borders of the subacromial outlet. These entities may lead to or cause dysfunctional glenohumeral and scapulothoracic movement patterns. These various mechanisms, singularly or in combination may cause subacromial impingement syndrome.

The important role played by the rotator cuff in the stability and movement of the glenohumeral joint make it susceptible to damage and injury in patients of all age groups. A number of extrinsic and intrinsic mechanisms have been described for the development of rotator cuff disease, although it is more likely that the actual etiology in any one individual is multifactorial. The key to successful management in a particular patient is an accurate diagnosis of the underlying cause by thorough clinical examination and the use of appropriate investigations. The mainstay of treatment of patients with rotator cuff disease is nonoperative. Surgical intervention is usually considered only after failure of at least 6 months of conservative therapy. However, there are a few situations where early surgical intervention is indicated.

Internal impingement is a general term usually applied to the pathologic combination of a superior labral anterior-posterior injury and a partial thickness rotator cuff injury that is commonly seen in the disabled throwing shoulder. Clinical presentation varies but involves a combination of internal derangement (popping, clicking, catching, sliding) and rotator cuff weakness. Evaluation should be precise to delineate all components of the injury. Treatment must be directed toward both of the components and any other coexisting pathology. Labral repair should aim at restoring all aspects of the roles of the labrum. Rotator cuff treatment should take into account the need for optimal rotation and may not include complete take down and repair. Pitfalls in diagnosing and treating internal impingement should be known and avoided. Comprehensive rehabilitation emphasizing kinetic chain principles and full ranges of motion should be used.

Rotator cuff impingement syndrome and associated rotator cuff tears are commonly encountered shoulder problems. Symptoms include pain, weakness and loss of motion. Causes of impingement include acromioclavicular joint arthritis, calcified coracoacromial ligament, structural abnormalities of the acromion and weakness of the rotator cuff muscles. Conservative treatment (rest, ice packs, nonsteroidal anti-inflammatory drugs and physical therapy) is usually sufficient. Some patients benefit from steroid injection, and a few require surgery.

The relationship between repetitive motion and subacromial impingement and rotator cuff disease is controversial and poorly understood. The potential etiology is multifactorial and involves patient related factors (age, supraspinatus outlet anatomy, and preexisting rotator cuff pathology) and worker related factors (arm position, lifting requirements, numbers of repetitions). Radiographic and magnetic resonance imaging abnormalities may represent preexisting disease that could have predisposed the patient to the development of impingement syndrome, but should be interpreted cautiously within the context of the remainder of the clinical picture. Treatment often involves temporary or permanent modifications of the work environment.

Knowledge of rotator cuff tears, especially in young people, and their cause has been vastly expanded in recent years. This is reflected in the understanding of the pathogenesis of these lesions and the specific therapy. In contrast to the mostly degenerative tears in older people, the causes in young, active people differ: traumatic disruption, internal impingement due to instability (PSI, ASI), SLAP lesion, and microtraumatic causes may be found. Recently, connections between the different pathologies like internal impingement and the SLAP lesion were shown. For an accurate diagnosis and differentiation between the different pathologies an exact clinical examination and a high-quality MRI scan with intra-articular contrast enhancer is necessary. The final therapy should be planned based on the causative pathology; then good long-term results will be achieved and return to sports is likely. If there is no structural damage, conservative therapy should be initiated. If there is any structural damage, e.g., SLAP lesion or rotator cuff tear, surgical treatment is indicated. Besides a SLAP repair and rotator cuff suturing, care must be given not to miss an accompanying instability. These instabilities should also be corrected, e.g., with arthroscopic ventral capsular plication, otherwise results are worse.

The theory of internal impingement holds that, in overhead athletes, repeated contact between the undersurface of the rotator cuff and the posterosuperior glenoid rim leads to articular-sided partial-thickness rotator cuff tears and superior labral lesions. However, we have noted this same constellation of lesions in our general patient population. These recreational athletic patients do not routinely assume the position of extreme abduction and external rotation, and thus are unlikely to experience significant internal impingement forces. The goal of this study was to document the prevalence of superior labral lesions in patients being treated for partial-thickness undersurface rotator cuff tears. Retrospective case series. We retrospectively reviewed the records of 75 shoulders arthroscopically treated for partial-thickness articular-sided rotator cuff tears. With the exception of one professional tennis player, no patients were playing sports at a professional or major college level. No professional or collegiate throwing athletes were included. The prevalence of these lesions and their association with recreational athletics was noted. We found that 55 of 75 (73.3%) shoulders with articular-sided partial-thickness rotator cuff tears also had superior labral lesions. A statistically significant increased prevalence of superior labral lesions in the dominant shoulder was seen (P =.03). In addition, our patients who engaged in overhand throwing had significantly fewer superior labral lesions in the dominant shoulders than did nonthrowers (P =.017). The "kissing lesions" of undersurface rotator cuff tears and posterosuperior labral damage may be explained by mechanisms other than "internal impingement."

Subacromial impingement syndrome is one of the most frequently seen causes of shoulder pain. The symptoms are often vague and may be difficult to differentiate from other shoulder problems. The purpose of this paper is to provide the clinician with a more thorough understanding of this entity by reviewing the pertinent anatomy and underlying etiology. Suggestions are made to aid in establishing the diagnosis, and treatment recommendations are proposed.

The unparalleled velocity achieved by overhead throwers subjects the shoulder to extreme forces, resulting in both adaptive changes and pathologic findings that can be detected at imaging. A key biomechanical principle of throwing is achieving maximum external rotation, which initially leads to adaptive changes that may result in a pathologic cascade of injuries. In addition to the well-established concepts of glenohumeral internal rotation deficit and internal impingement, osseous and soft-tissue injuries of the shoulder unique to overhead athletes are illustrated. The epidemiology and biomechanics of throwing injuries are reviewed, and examples from the authors' institutional experience with competitive, collegiate, and professional baseball players are provided to demonstrate the constellation of unique imaging findings seen in overhead throwing athletes. Given the widespread popularity of baseball, and other sports relying on overhead throwing motions at all playing levels from recreational to professional, it is important for radiologists in various practice settings to be familiar with the special mechanisms, locations, and types of shoulder injuries seen in the overhead throwing population.

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.

The role of MR imaging in the diagnosis of impingement and rotator cuff disorders is expanding greatly. This article discusses the clinically pertinent history, physical examination, and surgical treatment of rotator cuff problems. A rationale for consideration of open, "mini-open," and arthroscopic surgical intervention is proposed. The utilization of MR imaging by the orthopedic surgeon for nonoperative, preoperative, and postoperative decision-making are presented. A close working relationship between the radiologist and the orthopedist is emphasized.

Coactivation of the rotator cuff is vital to glenohumeral joint stability by centralising the humeral head within the glenoid fossa. Yet in individuals with subacromial impingement, it is hypothesised that rotator cuff coactivation abnormalities are present that could contribute to their shoulder pain. The purpose of this study was to determine if abnormal rotator cuff coactivation and deltoid activation patterns exist in participants with subacromial impingement. Rotator cuff (supraspinatus, infraspinatus, and subscapularis) coactivation and middle deltoid activation was assessed during an elevation task. ANOVA models were used to compare muscle activation patterns in 10 participants with subacromial impingement and 10 control participants. Participants with impingement exhibited decreased rotator cuff coactivation (subscapularis-infraspinatus and supraspinatus-infraspinatus) and increased middle deltoid activation at the initiation of elevation (0-30 degrees of humeral elevation). The participants with impingement also had higher subscapularis-infraspinatus and supraspinatus-infraspinatus coactivation above the level of the shoulder where pain is typically present (90-120 degrees of humeral elevation). The results indicate that individuals with subacromial impingement exhibit rotator cuff muscle coactivation and deltoid activation abnormalities during humeral elevation that might contribute to the encroachment of the subacromial structures associated with subacromial impingement.

This update examines recent articles and evidence for the role of ultrasound in the diagnosis and management of shoulder impingement syndromes and emphasizes its principal application in evaluation for external impingement. Shoulder ultrasound is commonly used as the initial investigation for patients with shoulder pain and suspected impingement. This is due to the high resolution of current ultrasound machines, wide availability, good patient tolerance, cost effectiveness, and, most importantly, its dynamic and interventional role.

Chronic shoulder pain and dysfunction are common complaints among overhead athletes seeking care from physical medicine and rehabilitation. Impingement is a frequently described pathological condition in the overhead athlete. Impingement symptoms may be the result of rotator cuff pathology, shoulder instability, scapular dyskinesis or muscle dysfunction, biceps pathology, SLAP lesions and chronic stiffness of the posterior capsule. At present, numerous different shoulder tests have been described in literature and discussed with respect to their individual diagnostic accuracy. However, in view of the number of shoulder tests, it is often a challenge for the clinician to select the appropriate tests for diagnosing the underlying pathology. The purpose of this paper is to present and discuss a clinical algorithm which may be used in the early detection of the underlying causes of impingement symptoms. In this algorithm, a specific chronology and selection of diagnostic tests may offer the clinician a guideline in his physical examination of the athlete with shoulder pain.

Structured exercise has been reported as the current treatment of choice for patients diagnosed with subacromial impingement syndrome (SIS). However, it has been suggested that this diagnostic term and the language used to explain this condition might negatively influence patient expectations and serve as a barrier to engagement with exercise, hence compromising clinical outcomes. To explore how patients rationalise their shoulder pain following a diagnosis of SIS and how this understanding might impact on their perception of physiotherapy and engagement with exercise. A qualitative study using semi-structured interviews and analysed using the Framework method. One NHS Physiotherapy department in South Yorkshire, England. Nine patients diagnosed with SIS were purposively sampled from those referred to the outpatient physiotherapy department by the orthopaedic team (consultant surgeons and registrars). Three main themes were generated: (1) The diagnostic experience, (2) Understanding of the problem, (3) Expectation of the treatment required; with one subtheme: (3b) Barriers to engagement with physiotherapy. The findings from this study suggest that diagnosis of shoulder pain remains grounded in a biomedical model. Understanding and explaining pain using the subacromial impingement model seems acceptable to patients but might have significant implications for engagement with and success of physiotherapy. It is suggested that clinicians should be mindful of the terminology they use and consider its impact on the patient's treatment pathway with the aim of doing no harm with the language used.

This article reviews the pathogenesis and clinical and imaging findings in shoulder impingement syndrome. Shoulder impingement is caused by compression of the supraspinatus tendon underneath the coracoacromial arch, mainly in forward flexion of the arm. Different stages of impingement syndrome are described. Stage I relates to edema and hemorrhage of the supraspinatus tendon. Stage II is characterized by bursal inflammation and fibrosis, as well as tendinopathy. In stage III there is a tear of the rotator cuff. Clinical signs may overlap. Moreover, calcifying tendinitis, fractures and pain originating from the cervical spine may mimic shoulder impingement syndrome. Imaging is important for the exact diagnosis. Standard radiographs are the basis of imaging in shoulder impingement syndrome. They may demonstrate subchondral sclerosis of the major tuberosity, subacromial spurs, and form anomalies of the acromion. They are also important in the differential diagnosis of shoulder impingement syndrome and demonstrate calcifying tendinitis, fractures and neoplasm. Ultrasonography has found acceptance as a screening tool and even as a final diagnostic method by many authors. However, there is a high interobserver variability in the demonstration of rotator cuff tears. Its usefulness has therefore been questioned. MR imaging is probably the method of choice in the evaluation of the rotator cuff and surrounding structures. Several investigations have demonstrated that differentiation of early findings, such as tendinopathy versus partial tears, may be difficult with MR imaging. However, reproducibility for fullthickness tears appears to be higher than for sonography. Moreover, specificity appears to be superior to sonography. MR arthrography is not universally accepted. However, it allows for more exact differentiation of discrete findings and may be indicated in preoperative planning. Standard arthrography and CT have a limited role in the current assessment of the rotator cuff.

Impingement, especially subacromial impingement, is one of the most frequent causes of shoulder pain. It results in soft tissue pathologies due to constriction of the subacromial space. It can lead to tendon pathologies and bursitis. In addition to the clinical examination, imaging methods such as magnetic resonance imaging (MRI), MRI arthrography, ultrasound and X‑ray examinations are helpful in making a diagnosis or evaluating the cause of pain. Conservative treatment approaches, such as rest, medication, physiotherapy, manual therapy and infiltrations should primarily be used. If the symptoms do not improve after 3-6 months of conservative treatment, surgical treatment should be considered. Impingement, insbesondere das subakromiale Impingement, ist eine der häufigsten Ursachen für Schulterschmerzen. Es kommt durch Einengung des Subakromialraums zu Pathologien an den Weichteilen. Es kann zu Sehnenpathologien und Bursitiden führen. Neben der klinischen Untersuchung sind Bildgebende Methoden wie Magnetresonanztomographie (MRT), MRT-Arthrographie, Ultraschall und Röntgen hilfreich zur Diagnosestellung bzw. zur Evaluation der Schmerzursache. Primär sollten konservative Behandlungsansätze wie Schonung, Medikamente, Physiotherapie, manuelle Therapie und Infiltrationen eingesetzt werden. Falls sich die Beschwerden nach 3 bis 6 Monaten unter konservativer Therapie nicht bessern, sollte die operative Therapie in Betracht gezogen werden.

Recent biomechanical evidence suggests that shoulder impingement syndrome (SIS) is closely linked with altered core-shoulder kinetic chain, resulting pain, altered external shoulder muscle activation, and external muscle weakness. We aimed to compare the effects of conventional isolated shoulder exercise (ISE) and core-shoulder chain exercises (CCE) during isokinetic shoulder rotation in baseball pitchers with SIS. Forty male college baseball pitchers with SIS were randomly allocated to ISE and CCE groups and they performed the exercises 3 times a week for 6 weeks. The standardised numerical pain rating scale (NPRS), shoulder pain and disability index (SPADI), electromyography (EMG) amplitude, and concentric (CON) and eccentric (ECC) torques were measured. Substantial improvements in NPRS and SPADI scores were observed after CCE compared to ISE (

To evaluate the effects of muscle shortening manoeuvre (MSM) by sonography (US) in professional water polo players with shoulder impingement syndrome (SIS). Twenty-four professional water polo players (mean age: 22.13 ± 3.34) with SIS were assigned to one of 2 different treatment interventions: Group (1) MSM: a series of fast accelerations in the upward direction was applied to the upper limb that's connected to a spring through a metal plate with a ring. The ring was linked to a pulley system that was submitted to forces acting in the opposite direction (added mass). Group (2) Simple traction: the series of fast accelerations were performed without the springs. Pain intensity, Yocum and Hawkins tests for SIS, Neer's impingement sign, range of motion, muscle strength and shoulder US were assessed. The examination was performed before, immediately after and 30 days after each treatment to study the US width of subacromial-subdeltoid bursa (SSB), thickness of supraspinatus (ST), long biceps tendons (LBT); hypoechoic halo of surrounding the long biceps (LBH) and subscapular tendons (STH); width of acromio-clavicular joint capsule (ACJ) and the distance between bone heads (ACD). Impingement sign (IS) was evaluated by dynamic examination. Immediately after treatment with MSM, pain was much reduced (p = 0.002); Yocum and Hawkins tests were decreased (p = 0.008, p = 0.031); Neer's impingement sign was negative; range of motion and muscle strength were increased. US showed that the following parameters were significantly reduced: SSB (p = 0.001), LBT (p = 0.014), LBH (p = 0.014), SSH (p = 0.002), ACJ (p = 0.004), ACD (p = 0.001). IS was no more detected. After 30 days, the improvement of clinical and US findings was maintained. In the control group, after simple traction, no clinical amelioration of US parameters was found immediately after the procedure. These data show that MSM could be significantly and rapidly effective against pain and the loss of function due to shoulder impingement in water polo players.

The study investigated the effectiveness of stretching, strengthening exercises, and the scapular stabilization exercises on the pain, shoulder range of motion (ROM), muscle strength, joint position sense (JPS), scapular dyskinesis and quality of life (OL) in the patients with subacromial impingement syndrome (SIS). 27 women and 13 men, mean age 51 (24-71) years old, were included in this study. All the patients were separated into 2 groups according to simple random table. Stretching and strengthening exercises were given to the group I (n=20) and scapular stabilization exercises were added to the group II (n=20). The pain severity, shoulder ROM, muscle strength, JPS, lateral scapular slide test (LSST), Western Ontario Rotator Cuff (WORC) Index were evaluated before and after treatment. Patients completed a 6-week rehabilitation program, three times a week. The results showed that all measurements improved statistically in both groups after treatment (p < 0.05). And the improvements in the muscle strength, JPS and scapular dyskinesia were significantly different in group II (p < 0.05). It is suggested that in the treatment of SIS; scapular stabilization exercises, given with stretching and strengthening exercises, can be more effective in increasing the muscle strength, developing the JPS and decreasing the scapular dyskinesis.

Pain from rotator cuff pathology is a common problem in upper extremity athletes. Impingement of the rotator cuff tendons on the subacromial arch is an important cause. Primary age-related degeneration and instability, however, should not be forgotten as causes for cuff pathology. Conservative treatment is successful in many athletes. Surgical subacromial decompression is reserved for resistant cases. Although often helpful, surgical treatment generally requires a long recovery for throwing athletes and can be associated with residual symptoms.

Posterior shoulder stretching exercises (PSSEs) aim to reduce posterior shoulder tightness (PST). Position modification of traditional PSSEs has been suggested to minimize inadequate control of scapular and glenohumeral rotation, possibly leading to increased subacromial impingement. Modified PSSEs will have positive effects on shoulder mobility, pain, and dysfunction. Randomized controlled trial. Level 1. A total of 67 symptomatic patients with subacromial impingement syndrome (SIS) and shoulder internal rotation asymmetry were randomly assigned to 3 groups: modified cross-body stretch (MCS) (n = 22; treatment program + MCS), modified sleeper stretch (MSS) (n = 22; treatment program + MSS), and a control group (n = 23; treatment program consisting of only modalities, range of motion [ROM], and strength training but no PSSEs) for 4 weeks. Pain, PST, shoulder rotation ROM, and dysfunction were evaluated. Pain, PST, shoulder rotation ROM, function, and disability improved in all groups ( All treatments improved pain, shoulder mobility, function, and disability in patients with SIS. However, modified PSSEs in addition to a treatment program was superior to the treatment program alone (without PSSEs) in improving pain with activity, internal rotation ROM, and dysfunction. Moreover, stretching provided clinically significant improvements. Modified PSSEs, in addition to a treatment program, are beneficial for patients with SIS. Both modified cross-body and sleeper stretches are safe and efficacious for improving shoulder mobility, pain, and dysfunction.

To evaluate the effectiveness of scapular stabilization exercises (SSE) in the treatment of subacromial pain syndrome (SAPS). Clinical randomized controlled trials (RCTs) on SSE in the treatment of SAPS were searched electronically in PubMed, Science Direct, Cochrane Central Register of Controlled Trials (CENTRAL), EBSCOhost, Physiotherapy Evidence Database (PEDro), Web of Science, and other databases from 2000 to 2022, supplemented by manual search. Final RCTs were selected based on inclusion and exclusion criteria, and the Physiotherapy Evidence Database scale was used to evaluate the methodological quality of the study. A meta-analysis was conducted on data using the RevMan5.4 software. Eight RCTs involving 387 participants were included. The meta-analysis showed that the experimental group (SSE) had greater improvements in the Visual Analog Scale score [Weighted Mean Difference (WMD) = -0.94, 95% CI (-1.23, -0.65), Existing evidence moderately supports the efficacy of SSE for reducing pain and improving function in SAPS, without significant improvement in ROM. Future research should focus on larger, high-quality, standardized protocols to better understand SSE's effects across diverse SAPS populations, treatment, and outcome measures. https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=307437, CRD42022307437.

Graded resistance training is the recommended treatment for patients with subacromial pain syndrome. It is debated whether adding joint mobilization will improve the outcome. The aim of this study was to evaluate the clinical outcome of guided exercises with or without joint mobilization, compared with controls who did not receive any treatment. A 3-armed controlled trial in a primary care setting. A total of 120 patients, with clinically diagnosed subacromial pain syndrome, were randomized into guided exercise groups with and without additional joint mobilization, and a control group that did not receive any treatment. Data were analysed at baseline, 6 weeks, 12 weeks and 6 months. Primary outcome was the Constant-Murley score, and secondary outcomes were pain and active range of motion. Shoulder function improved in all groups, as measured with the Constant-Murley score. At 12 weeks and 6 months the exercise groups improved significantly compared with the control group (p ≤ 0.05). Add-on joint mobilization resulted in decreased pain in active range of motion at 6 and 12 weeks compared with guided exercise or no treatment (p ≤ 0.05). Range of motion increased over time in all 3 groups. In patients with subacromial pain syndrome guided exercises improved shoulder function compared with no treatment. Add-on joint mobilization decreased pain in the short-term compared with exercise alone or no treatment.

Scapular stabilization approaches have been a mainstay of therapeutic training programs in the recent past for patients with subacromial im-pingement syndrome, whereas its contributions solely in the clinical outcome of reducing shoulder pain and disability are largely unclear. This systematic review aims to evaluate and summarize the best evi-dence regarding the role of scapular stabilization interventions in allevi-ating shoulder dysfunction among subjects with subacromial impinge-ment syndrome. Six reviewers involved in this systematic review. Liter-ature was retrieved systematically through searching 5 electronic data-bases (PubMed, MEDLINE, CINAHL, Cochrane, and Google Scholar). Articles published from the year 2010 up to and including 2019 were in-cluded. The literature search included clinical trials those intervened subjects with scapular exercises or scapular stabilization exercises or scapular rehabilitation, as an intervention for subacromial impingement syndrome. Seven studies, totaling 228 participants were included in this systematic review. Articles included in this review were graded ac-cording to Lloyd-Smith hierarchy of evidence scale and critically ap-praised with a tool developed by National, Heart, Lung and Blood Insti-tute (United States), named as quality assessment of controlled inter-vention studies tool. There was a significant effect on the scapular sta-bilization exercise program on improving pain and disability among sub-jects with subacromial impingement syndrome. This systematic review provides sufficient evidence to suggest that scapular stabilization exer-cises offers effectiveness in reducing pain and disability among sub-jects with subacromial impingement syndrome. However, more trials with larger sample are needed to provide a more definitive evidence on the clinical outcomes of scapular stabilization exercises among pa-tients with impingement.

Subacromial pain syndrome (SPS) involving rotator cuff tendinopathy is a common cause of shoulder pain and disability. Evidence suggests that structured physiotherapy may be as effective as surgery in this condition with significant improvements demonstrated in trials involving scapular retraining, rotator cuff strengthening and flexibility exercises. Most published programs typically utilise isotonic concentric and/or eccentric strengthening modes. Recently, immediate analgesic effects and muscle strength gains following heavy-load isometric exercises in lower limb tendinopathy conditions have been observed. It is pertinent to ascertain whether such outcomes can be replicated in SPS/rotator cuff tendinopathy. The primary aim of this study is to establish the feasibility of undertaking a full-scale randomised controlled trial (RCT) that compares the effects of isometric, isotonic concentric and isotonic eccentric rotator cuff contractions when used as part of a semi-standardised exercise-based physiotherapy program in patients diagnosed with SPS. The secondary aim is to explore potential trends or treatment effects of the exercise intervention. Thirty-six participants diagnosed with SPS will be randomised to one of three intervention groups and undergo a one-on-one exercise-based physiotherapy intervention, involving scapular and rotator cuff muscle retraining and strengthening. Each group will utilise a different mode of rotator cuff strengthening-isometric, isotonic concentric or isotonic eccentric. Rotator cuff tendon responses to isometric loading are not yet established in the literature; hence, individualised, progressive loading will be used in this pilot study in accordance with symptoms. The intervention will involve two phases: during Phase 1 (weeks 1-6) participants undertake the active group-specific physiotherapy treatment; in Phase 2 (weeks 6-12), they undertake a progressive, but no longer group-specific exercise program. To determine feasibility, an evaluation of key study parameters including (a) ease of recruitment (rate and number as well as suitability of the assessment algorithm), (b) adherence to all phases of the exercise intervention including home program compliance and logbook completion, (c) participant non-completion (drop out number and rate) and (d) adverse events (nature and number) will be undertaken. Secondary outcomes will measure immediate effects: (i) within-treatment changes in pain perception (verbal rating scale (VRS) and shoulder muscle strength (hand-held dynamometer) as well as longer-term changes: (ii) shoulder-related symptoms and disability (Western Ontario Rotator Cuff Index (WORC) and Shoulder Pain and Disability Index (SPADI)), (iii) perception of pain (11-point numerical rating scale (NRS), (iv) shoulder muscle strength (hand-held dynamometer) and (v) perceived global rating of change score. The immediate within-treatment assessment of pain and muscle strength will be undertaken in treatments 2 and 3, and the longer term measures will be collected at the primary (conclusion of Phase 1 at 6 weeks) and secondary (conclusion of Phase 2 at 12 weeks) end-points of the study. The findings of this pilot study will permit evaluation of this study design for a full-scale RCT. Australian New Zealand Clinical Trials Registry, ACTRN12616001676404.

The authors of this systematic review with meta-analysis evaluated the evidence for the effectiveness of various applications of dry needling (DN) combined with other conservative treatments for subacromial pain syndrome (SAPS). Six databases (PubMED, CINAHL, Biosis, Web of Science, SPORTDiscus, and Cochrane Central Register of Controlled Trials) were searched after the study had been registered in PROSPERO. The authors included randomized clinical trials investigating the clinical effects of DN in combination with other conservative interventions for SAPS. Outcomes included pain and disability. Eight studies were selected. All eight studies involving 10 comparisons were included in the analyses (N = 538). A random-effects model was used to analyze between-group effects. Dry needling performed in combination with other conservative interventions produced favorable outcomes at all time points for pain and disability. Standard mean differences ranged from -0.57 (moderate) to -1.29 (large) for pain and -0.69 (moderate) to -1.07 (large) for disability, favoring groups receiving DN in addition to conservative treatment. Four of the eight studies were rated as having unclear or high risk of bias. The meta-analysis suggests that various applications of DN performed with other conservative interventions are more effective than conservative treatment alone for reducing pain and disability in patients with SAPS. Direct-comparison studies are needed to determine whether one application of DN is superior to another.

In subacromial pain syndrome (SPS), it is unknown whether posterior shoulder stretching exercises (PSSE) with rapid eccentric contraction, a muscle energy technique, improve clinical and ultrasonographic outcomes more than no stretching or static PSSE. PSSE with rapid eccentric contraction is superior to no stretching and static PSSE in improving clinical and ultrasonographic outcomes in SPS. Randomized controlled trial. Level 1. Seventy patients with SPS and glenohumeral internal rotation deficit were randomized into the modified cross-body stretching with rapid eccentric contraction group (EMCBS; n = 24), static MCBS group (SMCBS; n = 23), or control group (CG; n = 23). In addition to 4-week physical therapy, EMCBS received PSSE with rapid eccentric contraction, SMCBS static PSSE, and CG no PSSE. The primary outcome was internal rotation range of motion (ROM). Secondary outcomes were posterior shoulder tightness, external rotation ROM (ERROM), pain, modified Constant-Murley score, short form of the disabilities of the arm, shoulder, and hand questionnaire (QuickDASH), rotator cuff strength, acromiohumeral distance (AHD), supraspinatus tendon thickness, and supraspinatus tendon occupation ratio (STOR). Shoulder mobility, pain, function and disability, strength, AHD, and STOR improved in all groups ( In patients with SPS, PSSE with rapid eccentric contraction and static PSSE were superior to no stretching in improving clinical and ultrasonographic outcomes. Stretching with rapid eccentric contraction was not superior to static stretching, but improved ERROM compared with no stretching. In SPS, both PSSE with rapid eccentric contraction and static PSSE included in physical therapy program are beneficial to improve posterior shoulder mobility and other clinical and ultrasonographic outcomes. In the case of ERROM deficiency, rapid eccentric contraction might be preferred.

Subacromial impingement syndrome is a common problem in primary healthcare. It often include tendinopathy. While exercise therapy is effective for this condition, it is not clear which type of exercise is the most effective. Eccentric exercises has proven effective for treating similar tendinopathies in the lower extremities. The aim of this systematic review was therefore to investigate the effects of eccentric exercise on pain and function in patients with subacromial impingement syndrome compared with other exercise regimens or interventions. A secondary aim was to describe the included components of the various eccentric exercise regimens that have been studied. Systematic searches of PubMed, Cochrane Library and PEDro by two independent authors. Included studies were assessed using the PEDro scale for quality and the Cochrane scale for clinical relevance by two independent authors. Data were combined in meta-analyses. GRADE was applied to assess the certainty of evidence. Sixty-eight records were identified. Seven studies (eight articles) were included, six were meta-analysed (n = 281). Included studies were of moderate quality (median PEDro score 7, range 5-8). Post-treatment pain was significantly lower after eccentric exercise compared with other exercise: MD -12.3 (95% CI - 17.8 to - 6.8, I Evidence of low certainty suggests that eccentric exercise may provide a small but likely not clinically important reduction in pain compared with other types of exercise in patients with subacromial impingement syndrome. It is uncertain whether eccentric exercise improves function more than other types of exercise (very low certainty of evidence). Methodological limitations of existing studies make these findings susceptible to change in the future. PROSPERO CRD42019126917 , date of registration: 29-03-2019.

Narrative Review. One of the shoulder pain disorders in which the function of the scapula is comprised is the subacromial pain syndrome. Several rehabilitation guidelines and exercises have been proposed to improve scapulothoracic muscle dysfunction. Consideration of muscle activation patterns may help to select the most appropriate rehabilitation exercise in these patients. To date, suggesting rehabilitation exercises is often based upon the knowledge of the superficial lying scapulothoracic muscles' activity. In the assumption that the deeper lying scapulothoracic muscles' activity may hinder normal scapular movement in case of tightness or hyperactivity, exercise protocols for patients with altered pattern in scapulothoracic muscles should also integrate knowledge on the deeper lying scapulothoracic muscle activity. To help clinicians choosing the most appropriate exercise in patients with subacromial pain syndrome related to scapulothoracic muscle dysfunction. First, a summary of key alterations in scapulothoracic (muscle) function in patients with subacromial pain was accomplished. Second, promising practical rehabilitation strategies toward restoring scapulothoracic muscle dysfunction (with a focus on scapulothoracic exercises) were developed, integrating current new research evidence (including information about the deeper lying scapulothoracic muscles) with clinical practice. This review details clinical exercises and their muscular activity to guide clinicians to optimize individualized scapulothoracic training and treatment programs by selecting the most appropriate exercise, based on knowledge from the clinical examination. Level 5.

CME Sonography 103: Subacromial Pain Syndrome (SAPS) and Subcoracoid Impingement (SCI)

Shoulder pain is a common symptom in the adult population. The most common cause of shoulder pain is SIS, reflecting a problem with the rotator cuff or subacromial bursa. Determining the cause of a patient’s pain is usually a clinical diagnosis based on careful history taking and physical examination. Limited use of imaging studies will be needed in the setting of trauma, possible glenohumeral arthritis, or when a complete tendon tear is suspected. Therapy is based on pain control and therapeutic exercises in almost all cases. Despite the prevalence of shoulder pain, there is no consensus on the best way to achieve pain control or on the type of exercise most likely to achieve speedy recovery.

To compare the effectiveness of proprioceptive neuromuscular facilitation and myofascial release technique in patients with subacromial impingement syndrome on pain, range of motion, muscle strength, quality of life, functionality and disability. Thirty patients were randomly divided into two groups: proprioceptive neuromuscular facilitation group ( After the treatment, shoulder pain, range of motion, muscle strength, functionality and disability were improved in two groups ( The combined application of proprioceptive neuromuscular facilitation and myofascial release technique has a more acute and cumulative positive effect on pain, range of motion, muscle strength, functionality, disability and quality of life in patients with subacromial impingement syndrome.

Subacromial pain syndrome is the predominant cause of shoulder pain, accounting for approximately half of all shoulder complaints. This population presents with weakness of the involved shoulder. However, there is a gap in our understanding of how pain contributes to this weakness, and whether there are sex related differences. Regional and global isometric strength was tested at the involved shoulder joint and remote joints (uninvolved shoulder and both knees) in patients with subacromial pain syndrome. Data were collected before and after acute pain reduction with a subacromial injection. Patients demonstrated weakness at the involved shoulder while remote joints demonstrated normal strength. When compared to healthy controls, male patients were shown to exhibit greater levels of weakness than female patients at the involved shoulder, based on comparisons with sex-matched controls using z-scores. Pain reduction (through an anesthetic injection) had no influence on strength in the short-term. Weakness in patients appears to be sex dependent and is not resolved with reduction of pain. This calls into question the assumptions of the physiological causes of this weakness.

To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression. Randomised, participant and single assessor blinded, controlled study. Department of orthopaedics in a Swedish university hospital. 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists. The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks. The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients' global impression of change because of treatment and decision regarding surgery. Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients' global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001). A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study. Clinical trials NCT01037673.

This study aimed to describe the shoulder anatomy, together with the anatomical relationships in adults and early stages of development. The shoulder muscles were studied from ultrasound, anatomical, and microscopic perspectives in a sample of 34 human shoulders. Thickness measurements were taken of the tendons and fasciae of the subscapularis, long head tendon of the biceps brachii, supraspinatus, infraspinatus, and teres minor. Ultrasound and dissection techniques are strongly correlated. However, the measurements obtained from the dissection technique were superior to those obtained from the ultrasound in all cases, except for the thickness of the long head tendon of the biceps brachii, the teres minor tendon, and the fascia thickness of the infraspinatus. In addition, the study of shoulder anatomy revealed no differences between females and males. Relevant findings from dissection included a clear overlap between the infraspinatus and supraspinatus, which shared tendon fibers, and a similar connection between the transverse ligament of the long head tendon of the biceps brachii and the subscapularis, which created a more interconnected shoulder function. The study of the anatomical measurements shows an underestimation of the shoulder measurements in the ultrasound compared with the dissection technique, but a high correlation between the measurements made by the two techniques. We present reference values for the tendon and fascia thicknesses of the rotator cuff, with no differences observed by gender. The relationships between shoulder structures described in the anatomical study imply as well that, in the event of an injury, adjacent tissues may be affected. This extended information may facilitate future optimal clinical explorations.

This article provides a brief overview of the current state of ultrasound (US) imaging of rotator cuff repairs with emphasis on current morphological assessment and development of newer techniques in which US may play an important role in assessing healing response. Emphasis is on the supraspinatus tendon inasmuch as it is the most commonly affected tendon in rotator cuff disease. Assessment of the tendon repair following joint replacement is also commented on in which the standard anterior approach may be associated with dehiscence of the subscapularis tendon.

Clinical examination for rotator cuff (RC) tear is rarely conclusive. Arthrography has been considered the standard diagnostic procedure for detection of rotator cuff tears. Ultrasonography (US) is less time-consuming and less expensive than arthrography and is, in addition, noninvasive. During recent years, many reports concerning US evaluation of RC tears have been published, but with different results about the diagnostic value of the examination. Recently, some authors have pointed out the ability of US in visualizing degenerative changes in the RC and that it is difficult to differentiate between tears and degenerative changes. By review of the English literature, we conclude that the experienced examiner with proper equipment can confidently differentiate between normal and pathological RC an that in quite a number of cases it is possible to differentiate tears from degenerative changes. In case of doubt, the examination should be supplemented by shoulder arthrography. In the hands of an experienced examiner with proper equipment US seems to be suitable as the initial imaging modality for evaluation of RC.

Deepening the understanding of morphology and corresponding sonographic features of the greater tuberosity and the various fracture lines in avulsion fracture like the "horizontal line sign" and "double-line sign" and sharp bony prominence besides the defect on the greater tuberosity, can make it simple to identify avulsion fracture accurately and quickly.

Periarticular shoulder disorders are common in clinical practice, and diagnosis is often difficult. Medicare statistics indicate that between 2001 and 2006 the use of diagnostic shoulder ultrasonography increased significantly. Rotator cuff disease, shoulder impingement syndrome and subacromial bursitis are among the most common diagnoses reported on shoulder ultrasonography. Shoulder ultrasonography is useful in the diagnosis of full thickness tears, but its utility for other rotator cuff disorders, shoulder impingement syndrome and subacromial bursitis is less well established.

Asymptomatic rotator cuff tears (RCTs) are prevalent in the general population; they are positively associated with age and are common in the contralateral shoulder of individuals who are being treated for shoulder pain or a symptomatic RCT. Asymptomatic RCTs are likely to become symptomatic over time, corresponding with decreased patient-reported function, strength, and range of motion. Previous studies have largely reported inconsistent findings regarding patient-reported outcomes, strength, range of motion, and kinematics in individuals with asymptomatic RCTs. Future research would benefit from characterizing any functional alteration that is associated with asymptomatic rotator cuff pathology, including determining whether such alterations are detrimental or compensatory and understanding the mechanism by which an asymptomatic RCT becomes symptomatic.

Shoulder ultrasonography is revised in the evaluation of complete rotator cuff tears. Also another technique known as artro-ultrasonography, which consist of a 10 mL solution injection inside the articular capsule to observe its escape to the subacromial-subdeltoidea bursae which implicates rotator cuff tear. It is compared against multiple standards like surgery, magnetic resonance, arthrography and rehabilitation to include positive and negative cases. 181 consecutive cases were studied with ultrasonography, 27 with artro-ultrasonography. The criteria for tear is the absence of the hyper-ecogenicity in the tendon, hypo-ecogenic gaps inside the rotator cuff and distention of the bursae due to the presence of liquid. 69% sensibility and 71% specificity for ultrasonography. 92% sensibility and specificity for artro-ultrasonography. The area under the COR curve is 70% for ultrasonography and 93% for artro-ultrasonography. The artro-ultrasonography modified the diagnosis in nine cases, the majority from normal to tear. Three Radiologists proved the agreement with good results. The study contributes to evaluate the performance of ultrasound against multiple standards to correct the great variability in results observed in literature. The contribution of artro-ultrasonography to diagnosis is evaluated. It can be useful in places where accuracy is important and more sophisticated methods like magnetic resonance are not available.

To confirm the neuromuscular integrity of the rotator cuff and to investigate the effect of different contraction patterns on shoulder function, we sonographically analyzed dynamic contraction patterns of this muscle group. Fifty supra- and 50 infraspinatus muscle contraction patterns of patients with different shoulder pathologies examined with a 7.5-MHz transducer were recorded and saved as video files. Both data sets were analyzed by 3 independent observers who then assigned a grade to each contraction pattern: normal, slightly disturbed, severely disturbed, or no contraction. Intra- and inter-observer variations were calculated. In 43 patients with isolated supraspinatus tears, the clinical relation to shoulder function as measured with the Constant score was evaluated. In the 100 cases tested, the intraclass correlations for the 3 observers were 0.82, 0.88, and 0.88. The inter-observer reliability was 0.74. No pair of first and second readings for either the supraspinatus or infraspinatus muscle differed by more than 1 grade. In patients with a supraspinatus tear, the contraction type of the supraspinatus correlated significantly with the Constant score (p=0.02). When dynamic ultrasonography is used to assess the contraction patterns of the supra- and infraspinatus muscles, good intra- and inter-observer reliability is attained. Because a better contraction type correlates significantly with better shoulder function, this new diagnostic criterion may improve decision-making in the treatment of shoulder diseases.

It is possible to evaluate the size of rotator cuff tears by ultrasonography (US) or magnetic resonance imaging. However, there are only a few reports on the imaging assessment of the configuration of cuff tears, which could provide important preoperative information that assists performing an optimal anatomical repair. The purpose of this study was to determine quantitatively the reproducibility of three-dimensional US in the assessment of rotator cuff tear configuration. Ten embalmed cadaveric shoulders with rotator cuff tears were examined. After resecting the proximal humerus with the rotator cuff, we put it in water and scanned it using high-resolution US with a three-dimensional linear probe. Actual tear lengths and widths were compared with sonographic measurements (Pearson correlation coefficient). By superimposing the real photographic image on the reconstructed three-dimensional image, we calculated the concordance rate (ratio of the concordance area to the tear area). The actual tear length (16.6 +/- 7.1 mm; mean +/- SD) and width (8.4 +/- 4.4 mm) were correlated with the tear length (16.4 +/- 7.5 mm) and width (8.2 +/- 4.4 mm) measured from reconstructed three-dimensional ultrasonograms (r = 0.998 and 0.994, respectively). The mean concordance rate was 91.4%, indicating that almost exactly the same configuration was reconstructed by US. Three-dimensional US is useful for evaluating the configuration of rotator cuff tears. This is the first report to quantify the similarity between the configuration evaluated by US and the actual configuration. Using this method, we can visualize the configuration of rotator cuff tears preoperatively, facilitating optimal repair design.

Shoulder ultrasound is a commonly performed imaging study that can accurately determine the presence of rotator cuff tendinosis and tears, as well as subacromial-subdeltoid bursal and long head of biceps tendon pathology. High accuracy depends on an awareness of imaging pitfalls that can be encountered and lead to over- or underdiagnosis of rotator cuff pathology. Ten common pitfalls of rotator cuff ultrasound scanning are presented along with ways to avoid these pitfalls.

No abstract

This is a prospective study of ultrasonography of the rotator cuff mechanism as an alternative to arthrography for screening rotator cuff tears. Seventy-two patients (40 men and 32 women) with possible rotator cuff tears were referred for shoulder arthrography. Before arthrography, bilateral shoulder sonography was performed by a technician under the direction of a radiologist. Arthrograms and sonograms were read separately, and a decision as to the absence or presence of a rotator cuff tear was made without knowledge of the results of the other examination. The results showed 90% sensitivity and 91% specificity, with a positive accuracy of 87%, and a negative accuracy of 93%. Ultrasonography of the rotator cuff is a noninvasive, painless, and cost-effective screening method for patients with a suspected rotator cuff tear.

No abstract

There has been limited acceptance of shoulder ultrasonography by orthopaedic surgeons in the United States. The purpose of this retrospective study was to determine the diagnostic performance of high-resolution ultrasonography compared with arthroscopic examination for the detection and characterization of rotator cuff tears. One hundred consecutive shoulders in ninety-eight patients with shoulder pain who had undergone preoperative ultrasonography and subsequent arthroscopy were identified. The arthroscopic diagnosis was a full-thickness rotator cuff tear in sixty-five shoulders, a partial-thickness tear in fifteen, rotator cuff tendinitis in twelve, frozen shoulder in four, arthrosis of the acromioclavicular joint in two, and a superior labral tear and calcific bursitis in one shoulder each. All ultrasonographic reports were reviewed for the presence or absence of a rotator cuff tear and a biceps tendon rupture or dislocation. All arthroscopic examinations were performed according to a standardized operative procedure. The size and extent of the tear and the status of the biceps tendon were recorded for all shoulders. The findings on ultrasonography and arthroscopy then were compared for each parameter. Ultrasonography correctly identified all sixty-five full-thickness rotator cuff tears (a sensitivity of 100 percent). There were seventeen true-negative and three false-positive ultrasonograms (a specificity of 85 percent). The overall accuracy was 96 percent. The size of the tear on transverse measurement was correctly predicted in 86 percent of the shoulders with a full-thickness tear. Ultrasonography detected a tear in ten of fifteen shoulders with a partial-thickness tear that was diagnosed on arthroscopy. Five of six dislocations and seven of eleven ruptures of the biceps tendon were identified correctly. Ultrasonography was highly accurate for detecting full-thickness rotator cuff tears, characterizing their extent, and visualizing dislocations of the biceps tendon. It was less sensitive for detecting partial-thickness rotator cuff tears and ruptures of the biceps tendon.

Both MRI and ultrasound (US) demonstrate equivalent accuracy in the evaluation of the rotator cuff. Both modalities have their advantages, disadvantages, and pitfalls. Radiography is an important complementary modality in that it can demonstrate occult sources of shoulder pain. MRI is recommended for the evaluation of shoulder pain in patients < 40 years of age because labral pathology is frequently identified. However, in patients > 40 years, US should be the first-line modality because the incidence of rotator cuff pathology increases with age. US is useful to guide procedures such as subacromial injection and calcific tendinosis lavage. Radiologists should be knowledgeable of both MRI and US of the shoulder to tailor these examinations to the specific needs of their patients.