The relationship between subacromial bursa thickness on ultrasound and shoulder pain in open water endurance swimmers over time

Clinical and ultrasound findings of 'swimmer's shoulder' and its association with training history in elite Portuguese swimmers: a cross-sectional study

OBJECTIVES

To assess the prevalence of shoulder injuries and ultrasound findings in elite Portuguese swimmers and their association with symptoms and personal or training-related factors.

METHODS

This cross-sectional study was conducted at the Portuguese Open and Youth Swimming National Championships between 27 and 30th July 2022. Each athlete entered details regarding personal and training history into a questionnaire and underwent a physical and ultrasound shoulder examination.

RESULTS

A total of 102 swimmers out of 662 Portuguese athletes were included in the study. Shoulder pain experienced during the previous season was reported by 42% of the athletes. A high prevalence of shoulder structural abnormalities was noted, specifically supraspinatus tendinosis (91%), tears (29%), and subacromial bursitis (29%). Specific training for injury prevention was associated with higher rates of infraspinatus tendinosis (p = 0.047), and supraspinatus tears were linked to greater swimming distances per week (p < 0.001) and practice (p < 0.001), more years of practice (p = 0.018), shoulder pain at the time of evaluation (p = 0.023), a higher number of missed competitions (p = 0.041), and shoulder injections (p = 0.009). Subacromial bursitis was associated with shoulder pain at the time of evaluation (p = 0.002) and during the previous season (p < 0.001), missed competitions (p < 0.001), and requirement for physical therapy (p = 0.006).

CONCLUSIONS

A high prevalence of shoulder morphological changes was found in surveyed swimmers and there were several associations with training load, regardless of individual characteristics of each athlete. It is essential to understand the true impact of current injury prevention programs and to develop effective measures to protect swimmers' health.

Rehabilitation of Supraspinatus Impingement in a Volleyball Athlete: A Case Report

Volleyball players with supraspinatus tendinopathy commonly present with a spectrum of symptoms, including shoulder pain, especially during the overhead phases of the game. They may experience pain during serves, spikes, or attempting to block at the net. Weakness in the affected shoulder and limited range of motion can impede performance and overall playing experience. Physiotherapy plays a crucial role in managing supraspinatus tendinopathy, focusing on reducing pain, improving shoulder joint range and function, and preventing recurrence. The research question arises as to how the rehabilitation process impacts the recovery and performance outcomes in a volleyball athlete with supraspinatus impingement which is explained as detailed in a case report. The present case is a 21-year-old male volleyball athlete complaining of pain in the anterolateral and posterior aspects of the right shoulder joint and a restricted range of motion while doing abduction and flexion at the shoulder joint for three months. After the orthopedic physical assessment, the patient was diagnosed with supraspinatus tendinopathy. This case report introduces an exact understanding of the rehabilitation tailored specifically to volleyball athletes with supraspinatus impingement.

Risk and protective factors for shoulder complaints in indoor volleyball players: A comprehensive systematic review

OBJECTIVE

This systematic review aimed to answer the question: "What are the risk and protective factors for shoulder complaints (pain, injury, or problem) in indoor volleyball players?".

METHODS

Searches were conducted in electronic databases: PubMed/MEDLINE, Embase, CINAHL, and SPORTDiscus, as well as reference lists of the included studies. We included studies evaluating potential intrinsic and extrinsic factors associated with shoulder complaints in indoor volleyball players of any country, age, sex, and competitive level. The Quality in Prognosis Studies (QUIPS) tool was used to assess the risk of bias.

RESULTS

The risk factors for shoulder complaints in volleyball players were identified through four prospective studies, which exhibited a moderate to low risk of bias. These factors included previous shoulder pain or injury, playing in outside and opposite positions, subacromial bursa thickening, and having an average external rotator (ER) isokinetic eccentric torque lower than the average internal rotator (IR) concentric torque. Protective factors were enhancing shoulder IR and ER isokinetic eccentric strength, being male sex, being older, and maintaining a concentric strength ratio ER/IR within the 0.60-0.75 range.

CONCLUSIONS

This systematic review highlights risk factors that clinicians and researchers should consider when assessing and tracking indoor volleyball players.

Subscapularis tendinopathy is highly prevalent in elite swimmer's shoulders: an MRI study

OBJECTIVES

The aim of this study is to determine the prevalence of abnormal anatomical change present on MRI in elite swimmers' shoulders compared to age-matched controls.

DESIGN

Descriptive epidemiological study.

METHODS

Sixty (aged 16-36 years) elite Australian swimmers and 22 healthy active, age and gender matched controls (aged 16-34 years). All participants completed a demographic, and training load and shoulder pain questionnaire and underwent shoulder MRI. Tests for differences in the population proportion was used for comparison between swimmers dominant and non-dominant shoulders and those of the controls.

RESULTS

Subscapularis and supraspinatus tendinopathy was the most common tendon abnormality identified in swimming participants, being reported in at least one shoulder in 48/60 (73 %) and 46/60 (70 %) swimmers, respectively. There was no significant difference between dominant and non-dominant shoulders for either tendinopathy, however, grade 3 tendinopathy was significantly more prevalent in subscapularis than in supraspinatus (P < 0.01). Compared with controls, significantly more abnormalities were reported in swimmers' shoulders in both subscapularis and supraspinatus tendons along with the labrum and acromioclavicular joint. Pathology was not a predictor of current pain.

CONCLUSIONS

This data confirms that tendon abnormality is the most common finding in elite swimmers' shoulders. Furthermore, that subscapularis tendinopathy is not only as common as supraspinatus but has a greater prevalence of grade 3 tendinopathy. With significant varied abnormalities including tendinopathy being so common in both symptomatic and asymptomatic shoulders of swimming athletes', clinicians should consider imaging findings alongside patient history, symptom presentation and clinical examination in determining their relevance in the presenting condition.

Ultrasonographic Evaluation of the Shoulders and Its Associations with Shoulder Pain, Age, and Swim Training in Masters Swimmers

Background and objectives: The long head of the biceps (LHB) and rotator cuff tendinopathy is the major cause of shoulder pain in competitive swimmers. The risk of tendinopathy increases with aging; however, the structural changes of LHB and rotator cuff in populations of masters swimmers have not been well examined. The purpose of this study was to investigate the prevalence of ultrasonographic abnormalities of the shoulders in masters swimmers, and the association of pain, age, and swim training with structural changes in this population. Materials and Methods: A total of 60 subjects participated in this study, with 20 masters swimmers with shoulder pain, 20 asymptomatic masters swimmers, and 20 sex- and age-matched controls. All swimmers completed a self-reported questionnaire for shoulder pain, their history of competition, and training volume. Each subject underwent ultrasonographic examination of both shoulders for pathologic findings in the LHB tendon, rotator cuff (supraspinatus (SSP) and subscapularis (SSC)) tendons, and subacromial bursa (SAB) of both shoulders and had thickness measured. Results: The prevalence of tendinosis (LHB, 48.8%; SSP, 17.5%; SSC, 15.9%), partial tear (SSP, 35.0%), and calcification (SSC, 10.0%) were higher in swimmers than in controls. LHB and SSP tendinosis were associated with shoulder pain. Older age and later start of competition were associated with an increased risk of LHB tendinosis and SSC calcification. Earlier initiation of swimming and longer history of competition were associated with an increased risk of SSP and SSC tendinosis. The thicker SSP tendon significantly increased the risk of tendinosis and partial tear. Conclusions: A high prevalence of structural changes in the rotator cuff and biceps tendons in masters swimmers reflects the effect of shoulder symptoms, aging, and swim training.

Shoulder complaints more likely in volleyball players with a thickened bursa or supraspinatus tendon neovessels

Shoulder problems are common in volleyball and greatly impede both training and player performance. Subacromial bursa (SAB) thickening and tendon neovascularity have shown relevance in other populations, but their relationship with the development of shoulder complaints has not been investigated in volleyball players or overhead-throwing athletes. The study aim was to examine the role of SAB thickness, neovascularization of the supraspinatus tendon, shoulder strength, range of motion (ROM), player position, and age in the development of shoulder complaints in professional volleyball players. Players underwent preseason baseline testing (n = 86) and reported shoulder complaints during the subsequent 12-week period. Generalized estimating equations were used to model for probabilities of complaints after adjusting for player position, SAB side-to-side difference, neovessel presence, shoulder external rotation (ER) ROM, and age. Outside hitters and opposites were 12.2-fold more likely to develop complaints, and greater shoulder ER ROM increased risk by 8% for each additional degree. A side-to-side difference in SAB thickness ≥0.3 mm in the dominant compared with the non-dominant arm was associated with a 10.2-fold increased risk. Those with neovessels were 6.5 times more likely to develop complaints. Players without neovessels and with normal SAB thickness were very unlikely to develop complaints. This stark contrast to players with neovessels or increased SAB thickness, where nearly half of the players developed complaints, is of interest. Players with current complaints at baseline presented with greater IR:ER strength ratios; however, neither strength nor IR ROM at baseline was associated with an increased risk of developing complaints.

Development and Reliability of the Joint Tissue Activity and Damage Examination for Quantitation of Structural Abnormalities by Musculoskeletal Ultrasound in Hemophilic Joints

OBJECTIVES

Musculoskeletal ultrasound (US) is used increasingly to examine hemophilic arthropathy. However, quantitative algorithms to document findings are lacking. We developed and sought to validate a protocol quantifying hemophilic joint abnormalities.

METHODS

Thirty-one patients with hemophilia were examined serially for 2 years with musculoskeletal US (≈600 joint examinations and ≈6000 images). Based on the spectrum of pathologies, a quantitative algorithm, named Joint Tissue Activity and Damage Examination (JADE), was developed for soft tissue and osteochondral measurements, including power Doppler, using nominal group techniques. To study intra- and inter-rater reliability, 8 musculoskeletal US-experienced hemophilia providers performed anatomic landmark recognition and tissue measurements on 86 images with arthropathic changes, with repetition 1 month later. Twenty-three musculoskeletal US-inexperienced providers performed similar assessments. Inter-operator reliability was established by 6 musculoskeletal US-experienced hemophilia providers, each acquiring images and JADE assessments of 3 hemophilic arthropathic joints. A radiologist and musculoskeletal sonographer functioned as adjudicators. The statistical analysis was performed with the intraclass correlation coefficient (ICC), Fleiss κ, and Cohen κ where appropriate.

RESULTS

The musculoskeletal US-experienced providers showed excellent intra-and inter-rater reliability for tissue measurements (ICCs, 0.94-0.96). Agreement was good to excellent for landmark recognition (Fleiss κ, 0.87-0.94). Inter-operator reliability was excellent for measurements and landmark recognition (ICC, 0.90; Fleiss κ, 1.0). Agreement with adjudicators was mostly good to excellent. Musculoskeletal US-inexperienced providers showed excellent inter-rater reliability for measurements (ICC, 0.96) and moderate agreement for landmark recognition (Fleiss κ, 0.58).

CONCLUSIONS

The JADE protocol appears feasible for quantifying hemophilic intra-articular abnormalities. Musculoskeletal US-trained hemophilia providers showed high intra-rater, inter-rater, and inter-operator reliability, supporting JADE as a protocol for clinical management and research.

What Imaging-Detected Pathologies Are Associated With Shoulder Symptoms and Their Persistence? A Systematic Literature Review

Objective

Shoulder symptoms are common, and imaging is being increasingly used to help with management. However, the relationship between imaging and symptoms remains unclear. This review aims to understand the relationship between imaging‐detected pathologies, symptoms, and their persistence.

Methods

A systematic review using Medline, EMBASE, Cochrane, and grey literature was conducted to April 2017. The cross‐sectional and longitudinal relationships between imaging‐detected abnormalities and symptoms were analyzed and associations qualitatively characterized by a best‐evidence synthesis based on study design, covariate adjustment, and the Grade of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Modalities included ultrasound, magnetic resonance imaging (MRI), radiographs, positron emission tomography (PET), bone scintigraphy, and computed tomography.

Results

A total of 6,569 abstracts was screened and 56 articles were included. In total, 50 studies did not adjust for covariates and 36 analyzed individual pathologies only. The majority of studies showed conflicting results. There was no significant association between most imaging features and symptoms among high‐quality, cross‐sectional studies. There was low‐quality evidence that enhancement of the joint capsule on MRI and increased uptake on PET were associated with symptoms in adhesive capsulitis. Based on high‐quality longitudinal studies, enlarging rotator cuff tears were associated with an increased incidence of symptoms.

Conclusion

There were conflicting results on the association of imaging features with shoulder symptoms and their persistence. The existing evidence was very low in quality, based on the GRADE methodology. Further high‐quality studies are required to understand the relationship between imaging and shoulder symptoms and to determine the appropriate role of imaging in care pathways.

Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum

Synopsis The hallmark characteristics of rotator cuff (RC) tendinopathy are pain and weakness, experienced most commonly during shoulder external rotation and elevation. Assessment is complicated by nonspecific clinical tests and the poor correlation between structural failure and symptoms. As such, diagnosis is best reached by exclusion of other potential sources of symptoms. Symptomatic incidence and prevalence data currently cannot be determined with confidence, primarily as a consequence of a lack of diagnostic accuracy, as well as the uncertainty as to the location of symptoms. People with symptoms of RC tendinopathy should derive considerable comfort from research that consistently demonstrates improvement in symptoms with a well-structured and graduated exercise program. This improvement is equivalent to outcomes reported in surgical trials, with the additional generalized benefits of exercise, less sick leave, a faster return to work, and reduced costs to the health care system. This evidence covers the spectrum of conditions that include symptomatic RC tendinopathy and atraumatic partial- and full-thickness RC tears. The principles guiding exercise treatment for RC tendinopathy include relative rest, modification of painful activities, an exercise strategy that initially does not exacerbate pain, controlled reloading, and gradual progression from simple to complex shoulder movements. Evidence also exists for a specific exercise program being beneficial for people with massive inoperable tears of the RC. Education is an essential component of rehabilitation, and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep management) may enhance outcomes. Outcomes may also be enhanced by subgrouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation and the patient's response to shoulder symptom modification procedures outlined herein. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve clinical outcomes. J Orthop Sports Phys Ther 2015;45(11):923-937. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5941.