The Aetiology of Subacromial Impingement Syndrome

Effect of scapular stabilization exercises on subacromial pain (impingement) syndrome: a systematic review and meta-analysis of randomized controlled trials

Objective

To evaluate the effectiveness of scapular stabilization exercises (SSE) in the treatment of subacromial pain syndrome (SAPS).

Methods

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.

Results

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), p < 0.001] and the Shoulder Pain and Disability Index score [WMD = -10.10, 95% CI (-18.87, -1.33), p = 0.02] than the control group (conventional physical therapy). However, range of motion (ROM) was not found to be greater in the experimental group than in the control group.

Conclusion

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.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=307437, CRD42022307437.

Immediate response to injection is associated with conservative care outcomes at 12 weeks in subacromial shoulder pain

BACKGROUND

Subacromial injection is known to influence pain of subacromial origin, yet its association with conservative care outcomes is unknown. This study investigated whether immediate response to subacromial injection of corticosteroid and local anaesthetic is associated with conservative care outcomes at 12 weeks post injection and/or progression to surgery.

DESIGN

prospective prognostic cohort study.

METHODS

Sixty-four participants with subacromial related shoulder pain attending initial orthopaedic outpatient appointment at an Australian public hospital, received subacromial injection of corticosteroid and local anaesthetic followed by up to 12 weeks of physiotherapy. Immediate response to injection was measured by change in shoulder range of motion (ROM) and pain immediately (within 20 min) before and after injection. The Shoulder Pain and Disability Index (SPADI) was measured at baseline, 6 and 12-weeks.

RESULTS

Backward stepwise linear regression revealed immediate post-injection improvement in pain-free ROM (p = 0.001) and higher baseline symptoms (p = 0.016) were significantly associated with better 12-week SPADI outcomes. Longer symptom duration (p = 0.029) and higher age (p = 0.013) were significantly associated with poorer outcomes. Only 11 individuals progressed to surgery. The resultant model could explain 35% of the variation in change in SPADI at 12 weeks.

CONCLUSION

Improvement in pain-free shoulder ROM immediately post injection is significantly associated with better 12-week conservative care outcomes. This information, derived from within consultation injection responses, could help inform decisions about potential treatment options. Further research with higher numbers and longer-term patient-reported outcomes could further clarify these findings.

REGISTRATION

Australia and New Zealand Clinical Trials Registry 21 May 2012: 12612000532808.

A comparison of the effectiveness of lateral versus posterior approach to shoulder injection in patients with subacromial impingement syndrome: A pragmatic randomized controlled trial

OBJECTIVE

The aim of the study was to determine the effectiveness of the lateral approach to subacromial injection, compared with the posterior approach, for the treatment of subacromial impingement syndrome.

METHOD

A pragmatic randomized controlled trial was carried out in an outpatient community musculoskeletal service. The sample comprised 80 adults, aged 18 years or over, with subacromial impingement syndrome. The intervention group received a single subacromial injection, using a 21-gauge green needle, of 40 mg/ml triamcinolone acetonide (Kenalog) and 4 ml 1% lignocaine using a lateral approach. The control group received identical treatment, with the exception that the injection was given using a posterior approach. The outcome measures were pain measured using 0-10 numerical pain scale and shoulder pain and disability index (SPADI) scores at 8 and 12 weeks' follow-up.

RESULT

A moderate but statistically and clinically significant difference in improvement in daytime pain (mean change in score) occurred in favour of the lateral group (mean = 4.0) compared with the posterior group (mean = 2.0) between weeks 0 and 8 (1.4 points [95% confidence interval 0.3, 2.6; p = 0.018]). However, there were no statistically significant differences between the groups in night-time pain, shoulder function and SPADI scores. There was a statistically and clinically significant difference (p = 0.001) within the groups for all clinical outcomes between weeks 0 and 8, and between weeks 0 and 12.

CONCLUSION

There were no significant differences in the treatments; however, both forms of treatment were associated with a significant improvement in shoulder pain, function and disability.

Laser Acupuncture Treatment Improves Pain and Functional Status in Patients with Subacromial Impingement Syndrome: A Randomized, Double-Blind, Sham-Controlled Study

Objective

The present study aims to determine the effect of laser acupuncture in patients with subacromial impingement syndrome (SAIS).

Design

Randomized, double-blind, sham-controlled study.

Setting

Physical medicine and rehabilitation outpatient clinic.

Subjects

A total 73 patients with SAIS were randomly assigned into a treatment group (n = 36) and a control group (n = 37).

Methods

The treatment group received laser acupuncture, and the control group received sham laser acupuncture. Eleven acupuncture points (GB 21, LI 4, LI 11, LI 14, LI 15, LI 16, SI 9, SI 10, SI 11, TE 14, and TE 15) were irradiated using a gallium-aluminium-arsenide continuous wave diode-laser, with a wavelength of 850 nm and a power output of 100 mV. The laser acupuncture treatment at each acupuncture point was administered at 4 joules/cm 2 (total dose = 40 joules). All patients were also treated with a hot pack. The patients were assessed at baseline and after 15 sessions of laser treatment. Pain severity and doctor's and patient's global assessments were measured via visual analog scale (VAS). Range of motion (ROM) and functional status were measured using a digital inclinometer and the Shoulder Pain Disability Index, respectively.

Results

Statistically significant improvements were observed in all parameters in the treatment group. All parameters of pain and functional status in the treatment group were significantly better than those in the control group at week 3.

Conclusions

To the best of our knowledge, this is the first study that investigates the effect of laser acupuncture in SAIS. The positive results of the present study should lead to further laser acupuncture studies with combinations of different acupuncture points, at different wavelengths, and with long-term follow-up periods.

The presence and influence of posterior capsule tightness on different shoulder problems

BACKGROUND

In the literature it has been shown that posterior capsule flexibility is a precursor to shoulder problems. However, no study thus far has shown the influence of the flexibility of posterior capsule in different shoulder pathologies.

OBJECTIVE

This study set about to compare the role of posterior capsule tightness in different shoulder problems.

METHODS

One-hundred-twenty-five patients diagnosed with shoulder subacromial impingement syndrome (n= 52), partial rotator cuff tear (n= 31) or frozen shoulder (n= 42) and 30 asymptomatic peers participated in the study. Horizontal adduction was assessed in side-lying position for posterior capsule tightness. Pain was measured via the visual analogue scale and shoulder range of motion and active total elevation was assessed with goniometer. Hand behind the back (HBB) test was assessed the active internal rotation by measuring the distance between T5 and the thumb.

RESULTS

It was found that the affected side of the posterior capsules of the patients with subacromial impingement syndrome (p< 0.001), partial rotator cuff tear (p< 0.001) and frozen shoulder (p< 0.001) was stiffer than their healthy side. There were significant differences among groups in the level of tightness in the posterior capsule between the affected and the healthy sides (p< 0.001). All range of motion of the shoulder including HBB test and the posterior capsule tightness of the affected side are found to be correlated (p< 0.05).

CONCLUSIONS

This study emphasized that the posterior capsule's susceptibility to tightness is most evident in frozen shoulder among different shoulder problems.

Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis

Background

Exercise is frequently suggested as a treatment option for patients presenting with symptoms of subacromial impingement syndrome. Some would argue implementing a specific exercise strategy with special focus on correction of kinematic deficits would be superior to general exercise strategy. There is however a lack of evidence comparing such exercise strategies to determine which is the most effective in the treatment of subacromial impingement syndrome. The aim of this review is to evaluate whether implementing specific exercise strategies involving resistive exercises are more effective than a general exercise strategy for the treatment of patients with subacromial impingement syndrome.

Methods

Randomized controlled trials were identified through an electronic search on PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and PEDro. In addition, article reference lists and Clinicaltrials.gov were searched. Studies were considered eligible if they included interventions with resistive specific exercises as compared to general resistance exercise. Four reviewers assessed risk of bias and methodological quality guided by Cochrane recommendations. Results were synthesised qualitatively or quantitatively, where appropriate.

Results

Six randomized controlled trials were included with 231 participants who experienced symptoms of subacromial impingement syndrome. Four studies evaluated the effectiveness of specific scapular exercise strategy and two studies evaluated the effectiveness of specific proprioceptive strategy. Five studies were of moderate quality and one study was of low quality. No consistent statistical significant differences in outcomes between treatment groups were reported in the studies. Standardized mean difference (SMD) for pain was SMD −0.19 (95% CI −0.61, 0.22) and SMD 0.30 (95% CI −0.16, 0.76) for function.

Conclusions

There is insufficient evidence to support or refute the effectiveness of specific resistive exercise strategies in the rehabilitation of subacromial impingement syndrome. More high quality research is needed to accurately assess this. This review provides suggestions on how to improve the methodological design of future studies in this area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1518-0) contains supplementary material, which is available to authorized users.

Clinical assessment of subacromial shoulder impingement - Which factors differ from the asymptomatic population?

BACKGROUND

To date, the significance of factors purported to be associated with subacromial shoulder impingement (SSI) and what differences, if any, are present in those with SSI compared to a matched asymptomatic population has not been identified. Gaining information about differences between people with SSI and asymptomatic people may direct clinicians towards treatments that impact upon these differences.

OBJECTIVE

Compare the assessment findings of factors suggested to be associated with SSI; passive posterior shoulder range, passive internal rotation range, resting cervical and thoracic postures, active thoracic range in standing and scapula positioning between cases experiencing SSI and a matched asymptomatic group (controls).

STUDY DESIGN

Case Control Study.

METHOD

Fifty one SSI cases and 51 asymptomatic controls were matched for age, gender, hand dominance and physical activity level. The suggested associated factors were measured bilaterally. Independent t-tests were used to compare each of these measurements between the groups. Any variables for which a significant difference was identified, were then included in a conditional logistic regression analysis to identify independent predictors of SSI.

RESULTS

The SSI group had significantly increased resting thoracic flexion and forward head posture, as well as significantly reduced upper thoracic active motion, passive internal rotation range and posterior shoulder range than the matched asymptomatic group. No independent predictors of SSI were identified in conditional logistic regression analysis.

CONCLUSION

Thoracic posture, passive internal rotation range and posterior shoulder range were significantly different between cases experiencing SSI and a matched asymptomatic group.

LEVEL OF EVIDENCE

Level 3a.

Isokinetic clinical assessment of rotator cuff strength in subacromial shoulder impingement

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.

Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon

BACKGROUND

Role substitution is a strategy employed to assist health services manage the growing demand for musculoskeletal care. Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic standards. This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinically and cost effective as that from an orthopaedic surgeon.

METHODS

A double blind non-inferiority randomized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service, from January 2013 to June 2014. Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon. The main outcome measure was total Shoulder Pain and Disability Index (SPADI) score at baseline, six and 12 weeks, applying a non-inferiority margin of 15 points. Secondary outcomes tested for superiority included pain, shoulder movement, perceived improvement, adverse events, satisfaction, quality of life and costs.

RESULTS

278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon, with 64 randomised (physiotherapist 33, orthopaedic surgeon 31). There were no significant differences in baseline characteristics between groups. Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks (upper limit of the 95% one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks, respectively). There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks. From the perspective of the health funder, the physiotherapist was less expensive.

CONCLUSIONS

Corticosteroid injection for shoulder pain, provided by a suitably qualified physiotherapist is at least as clinically effective, and less expensive, compared with similar care delivered by an orthopaedic surgeon. Policy makers and service providers should consider implementing this model of care.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry 12612000532808.

An experienced physiotherapist prescribing and administering corticosteroid and local anaesthetic injections to the shoulder in an Australian orthopaedic service, a non-inferiority randomised controlled trial and economic analysis: study protocol for a randomised controlled trial

BACKGROUND

The early management of orthopaedic outpatients by physiotherapists may be useful in reducing public hospital waiting lists. Physiotherapists in Australia are prevented by legislation and funding models from investigating, prescribing, injecting and referring autonomously. This gap in service is particularly noticeable in the management of shoulder pain in early-access physiotherapy services, as patients needing corticosteroid injection face delays or transfer to other services for this procedure. This trial will investigate the clinical (decision making and outcomes) and economic feasibility of a physiotherapist prescribing and delivering corticosteroid and local anaesthetic injections for shoulder pain in an Australian public hospital setting.

METHODS/DESIGN

A double-blinded (patient and assessor) non-inferiority randomised controlled trial will compare an orthopaedic surgeon and a physiotherapist prescribing and delivering corticosteroid injections to the shoulder. Agreement in decision making between the two clinicians will be investigated, and economic information will be obtained for estimating disease burden and an economic evaluation. The surgeon and the physiotherapist will independently assess patients, and 64 eligible participants will be randomised to receive subacromial injection of corticosteroid and local anaesthetic from either the surgeon or the physiotherapist. Post-injection, all participants will receive physiotherapy. The primary outcome measure will be the Shoulder Pain and Disability Index measured at baseline, and at 6 and 12 weeks post-injection. Analysis will be conducted on an intention-to-treat basis and compared to a per-protocol analysis. A cost-utility analysis will be undertaken from the perspective of the health funder.

DISCUSSION

Findings will assist policy makers and services in improving access for orthopaedic patients.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: 12612000532808 First registered: 21 May 2012. First participant randomized: 16 January 2013.

Influence of fear-avoidance beliefs on disability in patients with subacromial shoulder pain in primary care: a secondary analysis

BACKGROUND

Little information exists about the role of fear-avoidance beliefs and catastrophizing in subacromial pain syndrome.

OBJECTIVE

The purpose of this study was to investigate the associations among pain, catastrophizing, fear, and disability and the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up.

DESIGN

A cross-sectional and longitudinal analysis was conducted.

METHODS

Baseline demographic and clinical data, including fear-avoidance beliefs and catastrophizing, of 90 patients were assessed for this analysis. Disability was measured with the Shoulder Pain and Disability Index at baseline and at 3-month follow-up. First, bivariate and partial correlations were calculated among pain, fear-avoidance beliefs, catastrophizing, and disability, based on the fear-avoidance model. Second, the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up was examined with hierarchical regression analyses.

RESULTS

Correlations between clinical variables and disability were largely in line with the fear-avoidance model. Regression analyses identified a significant contribution of fear-avoidance beliefs to baseline disability but not to disability at 3 months.

LIMITATIONS

Patients with subacromial pain syndrome were studied; therefore, the results should be transferred with caution to other diagnoses. A modified version of the Fear-Avoidance Beliefs Questionnaire was used, which was not validated for this patient group.

CONCLUSIONS

Fear-avoidance beliefs contribute significantly to baseline disability but not to disability change scores after 3-month follow-up. Duration of complaints and baseline disability were the main factors influencing disability change scores. Although the results help to improve understanding of the role of fear-avoidance beliefs, further studies are needed to fully understand the influence of psychological and clinical factors on the development of disability in patients with subacromial shoulder pain.

Treatment of shoulder pain utilizing mechanical diagnosis and therapy principles

This case report describes the effectiveness of mechanical diagnosis and therapy (MDT) in the management of a patient referred with a diagnosis of shoulder tendonitis. The patient was a 56-year-old male with a 3-month history of left anterior shoulder pain. Upon initial assessment, he presented with a positive open-can test, lift-off test, and Hawkins-Kennedy impingement test. A MDT assessment quickly ruled out cervical involvement and identified a loss of end-range shoulder mobility and pain during active shoulder movement. After the patient underwent a repeated movement examination and treatment based on responses to end-range movements over three visits, his shoulder pain was abolished and motion was fully restored. Despite having positive rotator cuff and impingement signs, this patient was effectively treated with repeated end-range movements over a short period of 2 weeks. This case demonstrates that treatment based on MDT sub-classification principles may be an effective way to manage shoulder pain as it is in the spine.

Motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults

OBJECTIVE

Evidence for effective management of shoulder impingement is limited. The present study aimed to quantify the clinical, neurophysiological, and biomechanical effects of a scapular motor control retraining for young individuals with shoulder impingement signs.

METHOD

Sixteen adults with shoulder impingement signs (mean age 22 ± 1.6 years) underwent the intervention and 16 healthy participants (24.8 ± 3.1years) provided reference data. Shoulder function and pain were assessed using the Shoulder Pain and Disability Index (SPADI) and other questionnaires. Electromyography (EMG) and 3-dimensional motion analysis was used to record muscle activation and kinematic data during arm elevation to 90° and lowering in 3 planes. Patients were assessed pre and post a 10-week motor control based intervention, utilizing scapular orientation retraining.

RESULTS

Pre-intervention, patients reported pain and reduced function compared to the healthy participants (SPADI in patients 20 ± 9.2; healthy 0 ± 0). Post-intervention, the SPADI scores reduced significantly (P < .001) by a mean of 10 points (±4). EMG showed delayed onset and early termination of serratus anterior and lower trapezius muscle activity pre-intervention, which improved significantly post-intervention (P < .05). Pre-intervention, patients exhibited on average 4.6-7.4° less posterior tilt, which was significantly lower in 2 arm elevation planes (P < .05) than healthy participants. Post-intervention, upward rotation and posterior tilt increased significantly (P < .05) during 2 arm movements, approaching the healthy values.

CONCLUSION

A 10-week motor control intervention for shoulder impingement increased function and reduced pain. Recovery mechanisms were indicated by changes in muscle recruitment and scapular kinematics. The efficacy of the intervention requires further examined in a randomized control trial.

Cadeia cinética aberta versus cadeia cinética fechada na reabilitação avançada do manguito rotador

INTRODUÇÃO: Síndrome do impacto do ombro é uma alteração osteomuscular prevalente que leva a uma redução significativa da saúde e à incapacidade funcional. Esta lesão é causada pelo uso repetitivo dos braços acima da linha do ombro ou condição patológica em que ocorre irritação do tendão supraespinhoso secundária a uma abrasão em sua superfície pelo terço anterior do acrômio. Fisioterapia é, muitas vezes, a primeira opção de tratamento, embora sua eficácia ainda esteja em debate. Clinicamente, a reabilitação em cadeia cinética tem sido eficaz na restauração da função do ombro com bons resultados terapêuticos. OBJETIVOS: Avaliar a efetividade de um protocolo de reabilitação do ombro em cadeia cinética fechada para síndrome de impacto do manguito rotador. MATERIAIS E MÉTODOS: Ensaio clínico randomizado de equivalência com 20 pacientes que apresentam lesão grau I e II de manguito rotador na classificação de Neer. Pacientes foram divididos em dois grupos: grupo I, com protocolo de exercícios em Cadeia Cinética Fechada (CCF), e grupo II, com exercícios em Cadeia Cinética Aberta (CCA). Os pacientes foram submetidos a 20 sessões, três vezes por semana, e foram avaliados quanto à dor, mobilidade ativa, passiva, força muscular, atividade elétrica muscular e funcionalidade. Essa avaliação ocorreu em três momentos: inicialmente, com 10 sessões e ao fim do tratamento. Para a análise estatística, foram utilizadas medidas paramétricas, como o teste t-Student (comparação entre os grupos) e ANOVA para medidas repetidas (comparação dentro de cada grupo), e medidas não paramétricas (Kruskal Wallis e teste de Friedman). RESULTADOS: Ambos os grupos apresentaram resultados significativos quanto aos escores obtidos na escala UCLA e Constant. A mobilidade ativa do ombro lesado aumentou no grupo CCF nos movimentos de flexão (p = 0,01), rotação externa (p = 0,000) e rotação interna (p = 0,000). O movimento de abdução melhorou nos dois grupos (p = 0,02 no grupo CCF e 0,04 no grupo CCA). A força muscular de flexão e abdução mostrou um aumento apenas no grupo CCF, enquanto que nos movimentos de rotação externa e interna esses aspectos foram significativos em ambos os grupos. CONCLUSÃO: Constatou-se que exercícios em CCF apresentam melhoras importantes na mobilidade, funcionalidade e força para os pacientes com síndrome de impacto de ombro.

Effectiveness of individualized physiotherapy on pain and functioning compared to a standard exercise protocol in patients presenting with clinical signs of subacromial impingement syndrome. A randomized controlled trial

Background

Shoulder impingement syndrome is a common musculoskeletal complaint leading to significant reduction of health and disability. Physiotherapy is often the first choice of treatment although its effectiveness is still under debate. Systematic reviews in this field highlight the need for more high quality trials to investigate the effectiveness of physiotherapy interventions in patients with subacromial impingement syndrome.

Methods/Design

This randomized controlled trial will investigate the effectiveness of individualized physiotherapy in patients presenting with clinical signs and symptoms of subacromial impingement, involving 90 participants aged 18-75. Participants are recruited from outpatient physiotherapy clinics, general practitioners, and orthopaedic surgeons in Germany. Eligible participants will be randomly allocated to either individualized physiotherapy or to a standard exercise protocol using central randomization.

The control group will perform the standard exercise protocol aiming to restore muscular deficits in strength, mobility, and coordination of the rotator cuff and the shoulder girdle muscles to unload the subacromial space during active movements. Participants of the intervention group will perform the standard exercise protocol as a home program, and will additionally be treated with individualized physiotherapy based on clinical examination results, and guided by a decision tree. After the intervention phase both groups will continue their home program for another 7 weeks.

Outcome will be measured at 5 weeks and at 3 and 12 months after inclusion using the shoulder pain and disability index and patients' global impression of change, the generic patient-specific scale, the average weekly pain score, and patient satisfaction with treatment. Additionally, the fear avoidance beliefs questionnaire, the pain catastrophizing scale, and patients' expectancies of treatment effect are assessed. Participants' adherence to the protocol, use of additional treatments for the shoulder, direct and indirect costs, and sick leave due to shoulder complaints will be recorded in a shoulder log-book.

Discussion

To our knowledge this is the first trial comparing individualized physiotherapy based on a defined decision making process to a standardized exercise protocol. Using high-quality methodologies, this trial will add evidence to the limited body of knowledge about the effect of physiotherapy in patients with SIS.

Trial registration

Current Controlled Trials ISRCTN86900354

The prevalence of neovascularity in patients clinically diagnosed with rotator cuff tendinopathy

Background

Shoulder dysfunction is common and pathology of the rotator cuff tendons and subacromial bursa are considered to be a major cause of pain and morbidity. Although many hypotheses exist there is no definitive understanding as to the origin of the pain arising from these structures. Research investigations from other tendons have placed intra-tendinous neovascularity as a potential mechanism of pain production. The prevalence of neovascularity in patients with a clinical diagnosis of rotator cuff tendinopathy is unknown. As such the primary aim of this pilot study was to investigate if neovascularity could be identified and to determine the prevalence of neovascularity in the rotator cuff tendons and subacromial bursa in subjects with unilateral shoulder pain clinically assessed to be rotator cuff tendinopathy. The secondary aims were to investigate the association between the presence of neovascularity and pain, duration of symptoms, and, neovascularity and shoulder function.

Methods

Patients with a clinical diagnosis of unilateral rotator cuff tendinopathy referred for a routine diagnostic ultrasound (US) scan in a major London teaching hospital formed the study population. At referral patients were provided with an information document. On the day of the scan (on average, at least one week later) the patients agreeing to participate were taken through the consent process and underwent an additional clinical examination prior to undergoing a bilateral grey scale and colour Doppler US examination (symptomatic and asymptomatic shoulder) using a Philips HDI 5000 Sono CT US machine. The ultrasound scans were performed by one of two radiologists who recorded their findings and the final assessment was made by a third radiologist blinded both to the clinical examination and the ultrasound examination. The findings of the radiologists who performed the scans and the blinded radiologist were compared and any disagreements were resolved by consensus.

Results

Twenty-six patients agreed to participate and formed the study population. Of these, 6 subjects were not included in the final assessment following the pre-scan clinical investigation. This is because one subject had complete cessation of symptoms between the time of the referral and entry into the trial. Another five had developed bilateral shoulder pain during the same period. The mean age of the 20 subjects forming the study population was 50.2 (range 32-69) years (SD = 10.9) and the mean duration of symptoms was 22.6 (range .75 to 132) months (SD = 40.1). Of the 20 subjects included in the formal analysis, 13 subjects (65%) demonstrated neovascularity in the symptomatic shoulder and 5 subjects (25%) demonstrated neovascularity in the asymptomatic shoulder. The subject withdrawn due to complete cessation of symptoms was not found to have neovascularity in either shoulder and of the 5 withdrawn due to bilateral symptoms; two subjects were found to have signs of bilateral neovascularity, one subject demonstrated neovascularity in one shoulder and two subjects in neither shoulder.

Conclusions

This study demonstrated that neovascularity does occur in subjects with a clinical diagnosis of rotator cuff tendinopathy and to a lesser extent in asymptomatic shoulders. In addition, the findings of this investigation did not identify an association between the presence of neovascularity; and pain, duration of symptoms or shoulder function. Future research is required to determine the relevance of these findings.

Clinical assessment of scapular positioning in musicians: an intertester reliability study

CONTEXT

The reliability of the measurement of the distance between the posterior border of the acromion and the wall and the reliability of the modified lateral scapular slide test have not been studied. Overall, the reliability of the clinical tools used to assess scapular positioning has not been studied in musicians.

OBJECTIVE

To examine the intertester reliability of scapular observation and 2 clinical tests for the assessment of scapular positioning in musicians.

DESIGN

Intertester reliability study.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty healthy student musicians at a single university.

MAIN OUTCOME MEASURE(S)

Two assessors performed a standardized observation protocol, the measurement of the distance between the posterior border of the acromion and the wall, and the modified lateral scapular slide test. Each assessor was blinded to the other's findings.

RESULTS

The intertester reliability coefficients (kappa) for the observation in relaxed position, during unloaded movement, and during loaded movement were 0.41, 0.63, and 0.36, respectively. The kappa values for the observation of tilting and winging at rest were 0.48 and 0.42, respectively; during unloaded movement, the kappa values were 0.52 and 0.78, respectively; and with a 1-kg load, the kappa values were 0.24 and 0.50, respectively. The intraclass correlation coefficient (ICC) of the measurement of the acromial distance was 0.72 in relaxed position and 0.75 with the participant actively retracting both shoulders. The ICCs for the modified lateral scapular slide test varied between 0.63 and 0.58.

CONCLUSIONS

Our results demonstrated that the modified lateral scapular slide test was not a reliable tool to assess scapular positioning in these participants. Our data indicated that scapular observation in the relaxed position and during unloaded abduction in the frontal plane was a reliable assessment tool. The reliability of the measurement of the distance between the posterior border of the acromion and the wall in healthy musicians was moderate.

Expert therapists use specific clinical reasoning processes in the assessment and management of patients with shoulder pain: a qualitative study

QUESTION

What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the assessment and management of patients with shoulder pain?

DESIGN

Qualitative study using a three-round Delphi procedure.

PARTICIPANTS

Twenty-six experts in the UK consented to be involved and were contactable, of whom 20 contributed, with 12, 15, and 15 contributing to the different rounds.

RESULTS

Clinical reasoning was mostly about diagnostic reasoning, but also involved narrative reasoning. Diagnostic reasoning involved both pattern recognition and hypothetico-deductive reasoning. Diagnostic reasoning emphasised general history items, a constellation of signs and symptoms to identify specific diagnostic categories, and standard physical examination procedures. Narrative reasoning was highlighted by the communication involved in expert history taking, seeing patients in their functional and psychological context, and collaborative reasoning with the patient regarding management.

CONCLUSIONS

These expert clinicians demonstrated the use of diagnostic pattern recognition, and hypothetico-deductive and narrative clinical reasoning processes. The emphasis was on the history and basic physical examination procedures to make clinical decisions.

Scapular Positioning in Patients With Shoulder Pain: A Study Examining the Reliability and Clinical Importance of 3 Clinical Tests

OBJECTIVE

To examine the interobserver reliability, internal consistency, and clinical importance of 3 clinical tests for the assessment of scapular positioning in patients with shoulder pain.

DESIGN

Prospective repeated-measures design.

SETTING

Private practices for physical therapy and hospital outpatient physical therapy divisions.

PARTICIPANTS

Twenty-nine patients with shoulder pain who were diagnosed by a physician as having a shoulder disorder.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Study participants filled in a visual analog scale for pain and the Shoulder Disability Questionnaire. Next, 2 assessors performed the following tests: measurement of the distance between the posterior border of the acromion and the table, measurement of the distance from the medial scapular border to the fourth thoracic spinous processes, and the lateral scapular slide test.

RESULTS

The interobserver reliability coefficients were greater than .88 (intraclass correlation coefficients) for the measurement of the distance between the posterior border of the acromion and the table, were greater than .50 for the measurement of the distance from the medial scapular border to the fourth thoracic spinous processes, and were greater than .70 for the lateral scapular slide test. The Cronbach alpha coefficient for internal consistency for all tests was .88. No associations between the outcome of the tests and self-reported pain severity or disability were found.

CONCLUSIONS

These data provide evidence favoring the interobserver reliability of 2 of 3 tests for the assessment of scapular positioning in patients with shoulder pain. The clinical importance of the tests' outcomes, however, is questionable.

Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion

The re-education of spinal posture is an integral part of shoulder impingement management yet supporting evidence is limited. The purpose of this study was to evaluate the effect of slouched versus erect sitting posture on shoulder pain intensity and range of motion (ROM) in subjects with impingement. A same-subject repeated-measures design was utilized. Maximum active shoulder flexion and associated pain intensity were measured in 28 subjects in slouched and erect sitting postures, using video-analysis and visual analogue scales, respectively. An intra-tester reliability study of the video-analysis system was completed and intra-class correlation coefficients calculated. Shoulder flexion differences between slouched and erect sitting posture were analysed using a repeated-measures analysis of variance (ANOVA). The intra-tester reliability of the video-analysis method was found to be 'excellent' (ICC = 0.99). Flexion ROM was significantly greater in the erect sitting posture (F = 100.3, P < 0.0001); the mean ROM difference between postures was 17.67 degrees (+/- 9.17 degrees). There was no significant difference in pain intensity between postures (F = 1.9, P = 0.179). An erect sitting posture appeared to increase active shoulder flexion in subjects with shoulder impingement, although there were no differences in reported pain intensity. Further research is required to investigate the long-term effects of postural re-education.

Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement

STUDY DESIGN

Random allocation of subjects into a placebo-controlled, crossover study.

OBJECTIVES

To investigate the effect of changing thoracic and scapular posture on shoulder flexion and scapular plane abduction range of motion in asymptomatic subjects, and in subjects with subacromial impingement syndrome.

BACKGROUND

Changes in upper body posture and concomitant imbalance of the muscle system have been proposed as one of the etiological mechanisms leading to subacromial impingement syndrome. Although clinicians commonly assess posture and devise rehabilitation programs to correct posture, there is little evidence to support this practice.

METHODS AND MATERIALS

Selected postural, range of movement, and pain measurements were investigated in 60 asymptomatic subjects and 60 subjects with subacromial impingement syndrome, prior to and following thoracic and scapular taping intended to change their posture.

RESULTS

Changing posture had an effect on all components of posture measured (P<.001) and these changes were associated with a significant increase (P<.001) in the range of motion in shoulder flexion and abduction in the plane of the scapula. Changing posture was not found to have a significant effect on the intensity of pain experienced by the symptomatic subjects, although the point in the range of shoulder elevation at which they experienced their pain was significantly higher (P<.001).

CONCLUSIONS

The findings of this investigation suggest that changing 1 or more of the components of posture may have a positive effect on shoulder range of movement and the point at which pain is experienced.

Rotator Cuff Impingement

OBJECTIVE

To present a case of shoulder impingement syndrome managed with a conservative multimodal treatment approach.

CLINICAL FEATURES

A patient had anterior shoulder pain and a diffuse ache in the right upper arm, with tenderness in the shoulder region on palpation. Shoulder range of motion was limited with pain and catching, coupled with limited and painful cervical motion. After physical and orthopedic examination, a clinical diagnosis of shoulder impingement syndrome was made.

INTERVENTIONS AND OUTCOME

The patient underwent a multimodal treatment protocol including soft tissue therapy, phonophoresis, diversified manipulation; and rotator cuff and shoulder girdle muscle exercises. Outcomes included pain measurement; range of motion of the shoulder, and return to normal daily, work, and sporting activities. At the end of the treatment protocol the patient was symptom free with all outcome measures normal. The patient was followed up at 4 and 12 weeks and continued to be symptom free with full range of motion and complete return to normal daily and pre-treatment activities.

CONCLUSION

This case report shows the potential benefit of a multimodal chiropractic protocol in resolving symptoms associated with shoulder impingement syndrome.