Diagnosis and relation to general health of shoulder disorders presenting to primary care

In people with shoulder pain, mobilisation with movement and exercise improves function and pain more than sham mobilisation with movement and exercise: a randomised trial

QUESTION

In people with shoulder pain, what is the effect of adding mobilisation with movement (MWM) to a standard exercise program on function and pain compared with sham MWM and the same exercise program?

DESIGN

A randomised trial with concealed allocation, blinded outcome assessment and intention-to-treat analysis.

PARTICIPANTS

Seventy people with chronic atraumatic rotator cuff related pain, with a mean age 48 years (SD 10).

INTERVENTIONS

The experimental group received MWM plus exercise and the control group received sham MWM plus exercise. Treatments were delivered twice per week for 5 weeks.

OUTCOME MEASURES

The primary outcome measures were function (0 to 100 Shoulder Pain and Disability Index) and pain (0 to 10 Numerical Pain Rating Scale). Secondary outcomes were self-efficacy, perceived improvement and active pain-free range of movement. Assessment time points were at baseline (week 0), the end of the treatment period (week 5) and a follow-up 1 month after the end of treatment (week 9).

RESULTS

At week 5, the experimental group improved more than the control group in function (MD -15 points, 95% CI -24 to -7), pain at night (MD -2.1, 95% CI -3.1 to -1.1), pain on movement (MD -1.5, 95% CI -2.5 to -0.6) and active range of movement in flexion (MD 16 deg, 95% CI 1 to 30), abduction (MD 23 deg, 95% CI 6 to 40), external rotation (MD 11 deg, 95% CI 4 to 17) and hand behind back (MD 20 deg, 95% CI 8 to 32). At week 9, benefits were seen in the Shoulder Pain and Disability Index (MD -9 points, 95% CI -17 to -1), pain at night (MD -1.9, 95% CI -2.9 to -0.8) and on movement (MD -1.3, 95% CI-2.3 to -0.3). The effects of the experimental intervention on other outcomes were mostly unclear due to wide confidence intervals. Blinding was successful.

CONCLUSIONS

Adding MWM to exercise improved function, pain and active range of movement in people with shoulder pain. These benefits were not placebo effects.

REGISTRATION

NCT04175184.

Patient education for the management of subacromial pain syndrome: A scoping review

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.

2024 Kappa Delta Ann Doner Vaughan Award Nonsurgical Treatment of Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears-a Prospective Multicenter Cohort Study With 10-Year Follow-Up

The Multicenter Orthopaedic Outcomes Network Shoulder Group conducted a prospective cohort study of 452 patients with symptomatic atraumatic rotator cuff tears treated with a physical therapy program to determine the predictors of failure of nonsurgical treatment, to provide insight into indications for surgery. After 10 years, we found the following: (1) Physical therapy was effective for over 70% of patients. (2) PROMs showed statistical and clinical improvement after 12 weeks of therapy and did not decline over 10 years. (3) Cuff tear severity did not correlate with pain, duration of symptoms, or activity level. (4) Of those who had surgery, 56.7% had surgery in the first 6 months while 43.3% had surgery between 6 months and 10 years. (5) Early surgery was primarily driven by low patient expectations regarding the effectiveness of therapy. (6) Later surgery predictors included workers' compensation status, activity level, and patient expectations. (7) Only 1 patient had a reverse arthroplasty (0.2% of the cohort). These data suggest that physical therapy is an effective and durable treatment of atraumatic symptomatic rotator cuff tears and most patients successfully treated with physical therapy do not exhibit a decline in patient-reported outcomes over time. Reverse arthroplasty after nonsurgical treatment is exceptionally rare.

Factors predicting long-term outcomes following physiotherapy in patients with subacromial pain syndrome: a secondary analysis

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.

Which Multimodal Physiotherapy Treatment Is the Most Effective in People with Shoulder Pain? A Systematic Review and Meta-Analyses

The study aimed to determine if combined physiotherapy treatments offer additional benefits over exercise-only programs for shoulder pain and to identify the most effective combined treatment. A systematic review, registered in PROSPERO (CRD42023417709), and meta-analyses were conducted. Quality analysis was performed using the PEDro scale on randomized clinical trials published from 2018 to 2023. Twenty articles met the inclusion criteria. The most commonly used combination was exercise plus manual therapy, without being statistically superior to exercise alone. The meta-analysis indicated that combining exercise with low-level laser therapy (mean difference of -1.06, 95% CI: -1.51 to -0.60) and high-intensity laser therapy (mean difference of -0.53, 95% CI: -1.12 to 0.06) resulted in the greatest reduction in SPADI scores. Adding manual therapy provided limited additional benefit (mean difference of -0.24, 95% CI: -0.74 to 0.27). Progressive exercise with advice or telerehabilitation yielded modest improvements. The multimodal meta-analysis for DASH scores showed significant improvement (mean difference of -1.06, 95% CI: -1.51 to -0.60). In conclusion, therapeutic exercise is the cornerstone of shoulder pain treatment, with the addition of laser therapy showing substantial benefits. Manual therapy and educational interventions offer some benefits but are not consistently superior. More rigorous studies are needed.

Novel Posterior Shoulder Stretching With Rapid Eccentric Contraction and Static Stretching in Patients With Subacromial Pain Syndrome: A Randomized Trial

BACKGROUND

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.

HYPOTHESIS

PSSE with rapid eccentric contraction is superior to no stretching and static PSSE in improving clinical and ultrasonographic outcomes in SPS.

STUDY DESIGN

Randomized controlled trial.

LEVEL OF EVIDENCE

Level 1.

METHODS

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).

RESULTS

Shoulder mobility, pain, function and disability, strength, AHD, and STOR improved in all groups (P < 0.05).

CONCLUSION

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.

CLINICAL RELEVANCE

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.

A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

Background

This systematic review aims to comprehensively summarise and present the available evidence for the treatment of primary acromioclavicular joint (ACJ) osteoarthritis (OA).

Methods

Five databases were searched for studies investigating the management of ACJ OA. Included were studies with participants with clinical/radiological signs of primary ACJ OA, an intervention and included a functional outcome measure.

Results

Forty-eight studies were included. Treatments consisted of physiotherapy (n = 1 study), medical only (n = 11) and operative management (n = 36). Operative studies included five comparative trials - physiotherapy versus surgery (n = 1) and open versus arthroscopic resection (n = 4). A total of 1902 shoulders were treated for ACJ OA, mean age (51 years), 58% male and mean follow-up (28.5 months). Treatment with injection showed a mean improvement of 50% in pain levels at follow-up (mean = 7.5 months). The commonest surgical procedure was arthroscopic excision of the distal clavicle and operative studies averaged 6 months of conservative management and a mean functional outcome of 87.8%.

Conclusion

Studies varied in indication, intervention and quality but it did not provide evidence that both non-operative and operative interventions are effective. There was no significant difference between open or arthroscopic distal clavicle excision (DCE). Participants having between 0.5 and 2 cm of clavicle excised had good outcomes and those requiring concomitant shoulder procedures had similarly good outcomes.

Education can reassure people with rotator cuff-related shoulder pain: a 3-arm, randomised, online experiment

ABSTRACT

We aimed to investigate the immediate effect of best practice education (with and without pain science messages) and structure-focused education on reassurance among people with rotator cuff-related shoulder pain. We conducted a 3-arm, parallel-group, randomised experiment. People with rotator cuff-related shoulder pain were randomised (1:1:1) to (1) best practice education (highlights that most shoulder pain is not serious or a good indicator of tissue damage and recommends simple self-management strategies); (2) best practice education plus pain science messages (which attempt to improve understanding of pain); and (3) structure-focused education (highlighting that structural changes are responsible for pain and should be targeted with treatment). Coprimary outcomes were self-reported reassurance that no serious condition is causing their pain and continuing with daily activities is safe. Secondary outcomes measured management intentions, credibility and relevance of the education, and similarity to previous education. Two thousand two hundred thirty-seven participants were randomised and provided primary outcome data. Best practice education increased reassurance that no serious condition is causing their pain (estimated mean effect 0.5 on a 0-10 scale, 95% confidence interval [CI] 0.2-0.7) and continuing with daily activities is safe (0.6, 95% CI 0.3-0.8) compared with structure-focused education . Adding pain science messages to best practice education slightly increased both measures of reassurance (0.2, 95% CI 0.0-0.4). Clinicians treating patients with rotator cuff-related shoulder pain should highlight that most shoulder pain is not serious or a good indicator of tissue damage and recommend simple self-management strategies. The benefit of adding pain science messages is small.

Effects of Eccentric Versus Concentric Strengthening in Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial

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.

Management of rotator cuff injuries using allogenic platelet-rich plasma

Rotator cuff injuries are a major cause of shoulder pain, affecting the quality of life and producing a significant burden on healthcare systems. Conservative management modalities are prioritized, resorting to surgery only when required. The field of regenerative medicine involving the use of biologics, such as platelet-rich plasma (PRP), has evolved and shown potential for managing rotator cuff injuries. Nonetheless, limitations including subpar outcomes have led clinicians to question the efficacy of autologous PRP. To circumvent this, the possibility of utilizing a standardized and well-characterized allogenic PRP for RCI has been explored. In this manuscript, we qualitatively present the evidence from in vitro, pre-clinical, clinical and ongoing studies investigating the applications of allogenic PRP in the context of rotator cuff disorders. Administration of allogenic PRP is safe and potentially efficacious to manage rotator cuff injuries, though more adequately powered randomized controlled trials with longer follow-ups are warranted to further establish the efficacy of allogenic PRP and justify its routine clinical use.

Rotator Cuff Tears: Correlation Between Clinical Examination, Magnetic Resonance Imaging and Arthroscopy

Background Arthroscopy in diagnosing a rotator cuff injury has surgical and anaesthesia-related risks. Magnetic resonance imaging (MRI), a non-invasive procedure, is expensive, and lacks dynamic components making it less favourable. Clinical examination narrows the diagnosis, but lacks diagnostic accuracy due to overlap of clinical signs and symptoms. We aimed to determine the diagnostic accuracy of clinical examination and MRI in rotator cuff tears by correlating it with arthroscopy. Methods This prospective, cross-sectional validation study included patients (N=28) with shoulder pain with clinical characteristics suggestive of rotator cuff tears. Clinical diagnoses and MRI were done preoperatively, following which each patient underwent arthroscopic surgery. Shoulder arthroscopy findings were correlated with those of clinical examination and MRI. Results The mean age of patients was 50.21±9.66 years, with 60.71% being males. Clinical examination was 100% sensitive and 73.8% specific for detecting rotator cuff tears. MRI was 92.85% sensitive and 98.8% specific in detecting rotator cuff tears. Shoulder MRI demonstrated a higher agreement with arthroscopy than clinical results for subscapularis, supraspinatus, infraspinatus, teres, and biceps tendon appearance. Conclusion MRI results in identifying rotator cuff pathologies are comparable with arthroscopy. Clinical examination findings are variable due to an examiner's bias and therefore its diagnostic scope is limited. However, clinical examination with MRI together might accurately identify the rotator cuff injury.

Establishing Normative Values for Acromion Anatomy: A Comprehensive MRI-Based Study in a Healthy Population of 996 Participants

Shoulder pain is a common issue often linked to conditions such as subacromial impingement or rotator cuff lesions. The role of the acromion in these symptoms remains a subject of debate. This study aims to establish standardized values for commonly used acromion dimensions based on whole-body MRI scans of a large and healthy population and to investigate potential correlations between acromion shape and influencing factors such as sex, age, BMI, dominant hand, and shoulder pain. The study used whole-body MRI scans from the Study of Health in Pomerania, a German population-based study. Acromion index, acromion tilt, and acromion slope were measured. Interrater variability was tested with two independent, trained viewers on 100 MRI sequences before actual measurements started. Descriptive statistics and logistic regression were used to evaluate the results. We could define reference values based on a shoulder-healthy population for each acromion parameter within the 2.5 to 97.5 percentile. No significant differences were found in acromion slope, tilt, and index between male and female participants. No significant correlations were observed between acromion morphology and anthropometric parameters such as height, weight, or BMI. No significant differences were observed in acromion parameters between dominant and non-dominant hands or stated pain intensity. This study provides valuable reference values for acromion-related parameters, offering insight into the anatomy of a healthy shoulder. The findings indicate no significant differences in acromion morphology based on sex, weight, BMI, or dominant hand. Further research is necessary to ascertain the clinical implications of these reference values. The establishment of standardized reference values opens new possibilities for enhancing clinical decision making regarding surgical interventions, such as acromioplasty.

Surgical Repair for Rhomboid Major Tear: A Case Report

Rhomboid tears are a rare type of tendon injury. Although rhomboid tears can present with periscapular pain and scapular dyskinesis, their clinical presentations and diagnostic procedures remain largely unknown. In addition, few reports are available on the surgical treatment of rhomboid tears. We report a rhomboid repair case for a complete rhomboid major tear diagnosed based on physical findings and magnetic resonance imaging (MRI). A 28-year-old man presented with right medial scapular pain that appeared after carrying a heavy box. He had right medial scapular tenderness, with worsening pain during shoulder joint elevation. The inferior pole of the right scapula was lateral compared with the left scapula, and a dent was observed on the medial scapula. Magnetic resonance imaging revealed a tear in the right rhomboid major at its insertion, with muscle retraction. Two months of conservative treatment failed to improve his symptoms; therefore, we performed a surgical repair. We created the bone holes on the medial border of the scapula and repaired the torn rhomboid major muscle to its insertion using the Krackow stitch technique. He had a satisfactory functional outcome without postoperative retearing. This case report provides new information on the clinical presentation and surgical procedure of rhomboid major tears and the first MRI finding that depicts a rhomboid tear clearly. In cases of rhomboid tears, persistent medial scapular pain and winging scapula can be clinically problematic, requiring surgery. In addition to physical findings, a periscapular MRI is useful in diagnosing rhomboid tears. The results of this case study suggest that surgical repair using locking sutures is an option for treating complete rhomboid tears with muscle retraction.

Comparing the effect of physiotherapy and physiotherapy plus corticosteroid injection on pain intensity, disability, quality of life, and treatment effectiveness in patients with Subacromial Pain Syndrome: a randomized controlled trial

PURPOSE

To compare the short and medium-term effects of physiotherapy plus corticosteroid injection (combined) with physiotherapy alone on pain intensity, disability, Quality of Life (QoL), and treatment effectiveness in patients with Subacromial Pain Syndrome (SAPS).

METHODS

In this double-blind, parallel Randomized Controlled Trial (RCT), 50 patients with SAPS were randomly assigned into combined (N = 25, a single injection 3-6 days before physiotherapy) and physiotherapy alone group (N = 25). Pain, disability, QoL, and treatment-effectiveness were measured at pre-intervention, post-intervention, and 3 and 6-month follow-up with Visual Analog Scale (VAS), Shortened Disability of the Arm, Shoulder, and Hand (Quick-DASH), Shoulder Pain and Disability Index (SPADI) (primary outcome measure), Western Ontario Rotator Cuff (WORC), and Global Rating of Change (GRC) respectively. A 2 × 4 (group × time) mixed model analysis of variance (ANOVA) was applied for analysis.

RESULTS

The ANOVA revealed statistically significant group-in-time interaction for all outcome measures (p-value < 0.05). The independent t-test showed more effectiveness in the combined group at medium-term, as the mean scores of almost all outcome measures were substantially lesser (p < 0.01). Moreover, in short-time, despite a greater number of patients stating "completely recovered" in the combined group, there was no statistically significant difference between groups.

CONCLUSIONS

Effects of physiotherapy plus corticosteroid injection could be more long-lasting than physiotherapy alone in improving pain intensity, disability, QoL, and treatment effectiveness in patients with SAPS.

TRIAL REGISTRATION NUMBER

IRCT20201010048980N1.IMPLICATIONS FOR REHABILITATIONShoulder pain is common, persistent, and predominantly results from subacromial pain syndrome (SAPS).Physiotherapy and corticosteroid injections are effective interventions for this condition.Comprehensive physiotherapy alone can be as effective as corticosteroid injection combined with physiotherapy in the short term.A combined approach versus physiotherapy alone may have more medium-term effects on SAPS patients' pain, disability, quality of life, and treatment effectiveness.

Testing the association between shoulder pain prevalence and occupational, physical activity, and mental health factors in two generations of Australian adults

BACKGROUND

Shoulder pain is common among the adult population, but it appears to reduce in prevalence around retirement age. Associations between shoulder pain and work-place exposures, physical activity, or mental health status are unclear and may change with age. This study aimed to determine the prevalence of self-reported shoulder pain in Australian adults across two generations and test the association with occupational factors, physical activity, and mental health.

METHODS

In this cross-sectional study we used data from a longitudinal Australian pregnancy cohort (the Raine Study). We analysed data from the children (Gen2) at the 22-year follow-up (N = 1128) and parents (Gen1) at the 26-year follow-up (N = 1098). Data were collected on self-reported shoulder pain, occupational factors (employment status and work description), physical activity, and mental health at the respective follow-ups. Prevalence rates were provided as percentages with 95% confidence intervals. Univariate analysis for group comparisons included chi squared for categorical comparisons. The association of predictor variables and shoulder pain was assessed using logistical regression.

RESULTS

In Gen1 31.4% of adults aged 40-80 reported the presence of shoulder pain in the last month, with no significant difference between females and males. Gen1 participants younger than 65 reported more shoulder pain (OR[95%CI] = 1.80 [1.04-3.09]). Gen2 females (14.7%) reported shoulder pain in either shoulder more frequently than males (7.7%) and bilateral shoulder pain (8.0%) more frequently than males (1.9%). Gen1 had increased odds of reporting shoulder pain if their work was "physical or heavy manual" compared to "sedentary" (OR [95% CI] = 1.659 [1.185-2.323]) and when categorised with depression (OR [95% CI] = 1.940 [1.386-2.715]) or anxiety (OR [95% CI] = 1.977 [1.368-2.857]). Gen2 participants with depression (OR [95% CI] = 2.356 [1.620-3.427]) or anxiety (OR [95% CI] = 2.003 [1.359-2.952]) reported more shoulder pain.

CONCLUSION

Overall, shoulder pain was more prevalent in young females than males and was more prevalent in those under the age of 65. Cross-sectional associations were established between some occupational factors in older adults and depression in all adults, and shoulder pain.

Cervical sensitivity, range of motion and strength in individuals with shoulder pain: A cross-sectional case control study

OBJECTIVES

To assess whether cervical sensitivity, range of motion (ROM) and strength are impaired in individuals with shoulder pain and how they interact with sociodemographic and clinical data.

METHODS

Forty-eight individuals with shoulder pain and 48 asymptomatic matched ones were included. Pressure pain thresholds (PPTs) in cervical region and tibialis anterior muscles, ROM of cervical flexion, extension, lateral flexions and rotations and cervical muscle strength of flexion, extension and lateral flexions were assessed. Between-groups comparisons and a logistic multiple regression model were performed.

RESULTS

The symptomatic group showed lower and not meaningful PPTs in trapezius of the unaffected/unmatched side, both sternocleidomastoid muscles, and tibialis anterior and reduced ROM in cervical extension (MD = -9.00°) when compared to the asymptomatic group. No differences were identified in muscle strength. Reduced PPT of the trapezius and reduced cervical extension ROM together accounted for 40.2% of the variance of the chance of presenting shoulder pain.

CONCLUSION

Individuals with shoulder pain have more, but not clinically relevant, cervical sensitivity and lower cervical extension than asymptomatic individuals. The lower the PPT of the upper trapezius and the cervical extension ROM, the higher was the chance to present shoulder pain. Regional interdependence between cervical spine and shoulder may explain cervical physical function alterations in shoulder pain.

Specific versus general exercise programme in adults with subacromial impingement syndrome: a randomised controlled trial

Objectives

Current evidence on the clinical effectiveness about the different types of exercises in the subacromial impingement syndrome (SIS) remains controversial. This study aims to compare the short-term (at 5 weeks) effects of a specific exercise programme with a general exercise programme on shoulder function in adults with SIS.

Methods

In total, 52 adults with SIS were randomly allocated to 5 weeks to perform specific exercises (experimental group, n=26) or general exercises (control group, n=26). The primary outcome was change in shoulder function, it was assessed using the Shoulder Pain and Disability Index (SPADI) from baseline to 5 weeks. Secondary end points included changes in upper limb function (Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire), pain intensity (Visual Analog Scale (VAS)) and kinesiophobia (Tampa Scale of Kinesiophobia (TSK)).

Results

All participants completed the trial. The between-group differences at 5 weeks were: SPADI, 13.5 points (95% CI: 4.3 to 15.6; ƞ2=0.22; p=0.001); DASH, 10.1 points (95% CI: 5.6 to 15.2; ƞ2=0.27; p<0.001); VAS at rest, 0.2 cm (95% CI: 0.1 to 0.3; ƞ2=0.07; p=0.553); VAS on movement, 1.7 cm (95% CI: 0.9 to 2.2; ƞ2=0.24; p<0.001); and TSK, 16.3 points (95% CI: 13.2 to 15.3; ƞ2=0.33; p<0.001). All differences favoured the experimental group and effect sizes were medium to large for most outcomes. Mediation analyses showed that the effect of the specific exercises on shoulder function was mediated by kinesiophobia (β=2.800; 95% CI: 1.063 to 4.907) and pain on movement (β= -0.690; 95% CI: -1.176 to -0.271).

Conclusion

In adults with SIS, specific exercises may have a larger effect than general exercises. However, most differences did not reach the minimum threshold to be considered clinically important and the evidence to support exercise as standard treatment warrant further study.

Trial registration number

Brazilian Registry of Clinical Trials UTN number U111-1245-7878. Registered on 17 January 2020 (https://ensaiosclinicos.gov.br/rg/RBR-4d5zcg).

Subacromial Platelet-Rich Plasma Injections Produce Significantly Worse Improvement in Functional Outcomes in Patients With Partial Supraspinatus Tears Than in Patients With Isolated Tendinopathy

PURPOSE

To compare the effect of subacromial leukocyte-rich platelet-rich plasma (PRP) injections in patients with isolated rotator cuff tendinopathy (RCT) and those with partial-thickness rotator cuff tears (PTRCTs) based on functional outcomes, pain improvement, sleep disturbances, and return to sports.

METHODS

Between November 2019 and March 2021, 150 patients underwent PRP injections at our institution for refractory rotator cuff tendinopathy and partial rotator cuff tears (105 RCTs and 45 PTRCTs). The American Shoulder and Elbow Surgeons (ASES) score, the visual analog scale (VAS) for pain, the Single Assessment Numeric Evaluation (SANE) and The Pittsburgh Sleep Quality Index were evaluated at 2-, 6-, and 12-month follow-up. Return to sports was also evaluated. An ultrasound examination was performed to evaluate structural outcomes 12 months after the injection.

RESULTS

The mean age was 36.6 years (±9.08). Overall, the ASES, VAS, SANE, and Pittsburgh scores showed statistical improvement after the injection (P < .01). Specifically, the improvement in the ASES score, which was the primary outcome measure was significantly greater in the group without tears than in the group with PTRCTs at all follow-up times. Moreover, 94% of the patients in the isolated RCT group and 49% in the PTRCTs group achieved a substantial clinical benefit at 12 months follow-up. Ten out of the 50 patients (20%) who received PRP injections due to a partial RC tear underwent surgery due to the lack of clinical improvement.

CONCLUSIONS

Subacromial PRP injections produced a significant improvement in shoulder function, pain, and sleep disturbances in most patients with RCT refractory to conservative treatment that was maintained at the 12-month follow-up. Moreover, most patients returned to sports at the same level prior to injury. However, improvement in symptoms and functional outcomes was significantly worse in patients who had a PTRCT compared with patients who had an isolated tendinopathy.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Suprascapular nerve blockage for painful shoulder pathology - a systematic review and meta-analysis of treatment techniques

BACKGROUND

Suprascapular nerve blockade (SSNB) through injection (SSNBi) and/or pulsed radiofrequency (PRF) provide options for the management of painful shoulder pathology. Multiple techniques for delivery of SSNB are described but no consensus on optimal symptom control is available. This systematic review and meta-analysis aims to assess patient-focussed outcomes in SSNB and explore the impact of variation in the technical application of this treatment modality.

METHODS

MEDLINE, Embase and CINAHL were searched for case series, cohort studies and randomised control trials published from database inception until 28 January 2021. Articles reporting use of SSNBi or PRF for treatment of shoulder pain with a minimum 3 months follow-up were included. Patient-reported outcome measures (PROMs) were extracted and the pooled standardised mean difference (SMD), weighted by study size, was reported. Quality of methodology was assessed using Wylde's nonsummative four-point system.

FINDINGS

Of 758 references, 18 studies were included, totalling 704 SSNB. Average pain improvement at 3 months was 52.3%, with meta-analysis demonstrating a SMD of 2.37. Whereas SSNBi combined with PRF shows the greatest SMD of 2.75, this did not differ significantly from SSNBi or PRF when used as monotherapy. Location of treatment and the guidance technique used did not influence outcome.

CONCLUSION

SSNBi and PRF provide safe and effective treatment for shoulder pain, as judged by PROMs. This may be of particular value in aging or comorbid patients and with surgical restrictions during the COVID-19 pandemic. Regardless of technique, patients experience a marked improvement in pain that is maintained beyond 3 months.

Level of pain catastrophising determines if patients with long-standing subacromial impingement benefit from more resistance exercise: predefined secondary analyses from a pragmatic randomised controlled trial (the SExSI Trial)

OBJECTIVE

The primary aim was to investigate the effectiveness of adding more resistance exercise to usual care on pain mechanisms (including temporal summation, conditioned pain modulation (CPM) and local pain sensitivity) and pain catastrophising in people with subacromial impingement at 16 weeks follow-up. Second, to investigate the modifying effect of pain mechanisms and pain catastrophising on the interventions' effectiveness in improving shoulder strength and disability METHODS: 200 consecutive patients were randomly allocated to usual exercise-based care or the same plus additional elastic band exercise to increase total exercise dose. Completed add-on exercise dose was captured using an elastic band sensor. Outcome measures recorded at baseline, 5 weeks, 10 weeks and 16 (primary end point) weeks included temporal summation of pain (TSP) and CPM assessed at the lower leg, pressure pain threshold at the deltoid muscle (PPT-deltoid), pain catastrophising and the Shoulder Pain and Disability Index.

RESULTS

Additional elastic band exercise was not superior to usual exercise-based care in improving pain mechanisms (TSP, CPM and PPT-deltoid) or pain catastrophising after 16 weeks. Interaction analyses showed that pain catastrophising (median split) modified the effectiveness of additional exercises (effect size 14 points, 95% CI 2 to 25), with superior results in the additional exercise group compared with the usual care group in patients with less pain catastrophising.

CONCLUSION

Additional resistance exercise added to usual care was not superior to usual care alone in improving pain mechanisms or pain catastrophising. Additional exercise was, however, superior in improving self-reported disability in patients with lower levels of pain catastrophising at baseline.

TRIAL REGISTRATION NUMBER

NCT02747251.

Exercise for rotator cuff tendinopathy: Proposed mechanisms of recovery

Rotator cuff (RC) tendinopathy is a common recurrent cause of shoulder pain, and resistance exercise is the first-line recommended intervention. Proposed causal mechanisms of resistance exercise for patients with RC tendinopathy consist of four domains: tendon structure, neuromuscular factors, pain and sensorimotor processing, and psychosocial factors. Tendon structure plays a role in RC tendinopathy, with decreased stiffness, increased thickness, and collagen disorganization. Neuromuscular performance deficits of altered kinematics, muscle activation, and force are present in RC tendinopathy, but advanced methods of assessing muscle performance are needed to fully assess these factors. Psychological factors of depression, anxiety, pain catastrophizing, treatment expectations, and self-efficacy are present and predict patient-reported outcomes. Central nervous system dysfunctions also exist, specifically altered pain and sensorimotor processing. Resisted exercise may normalize these factors, but limited evidence exists to explain the relationship of the four proposed domains to trajectory of recovery and defining persistent deficits limiting outcomes. Clinicians and researchers can use this model to understand how exercise mediates change in patient outcomes, develop subgroups to deliver patient-specific approach for treatment and define metrics to track recovery over time. Supporting evidence is limited, indicating the need for future studies characterizing mechanisms of recovery with exercise for RC tendinopathy.

The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs

INTRODUCTION

The purpose of this study was to evaluate rates of rotator cuff tears (RCTs), repairs (RCRs), and revision RCR in patients who were prescribed testosterone replacement therapy (TRT) and compare these patients with a control group.

METHODS

The PearlDiver database was queried for patients who were prescribed testosterone for at least 90 days between 2011 and 2018 to evaluate the incidence of RCTs in this population. A second analysis evaluated patients who sustained RCTs using International Classification of Diseases, 9th/10th codes to evaluate these patients for rates of RCR and revision RCR. Chi square analysis and multivariate regression analyses were used to compare rates of RCTs, RCR, and subsequent or revision RCR between the testosterone and control groups, with a P -value of 0.05 representing statistical significance.

RESULTS

A total of 673,862 patients with RCT were included for analysis, and 9,168 of these patients were prescribed testosterone for at least 90 days before their RCT. The TRT group had a 3.6 times greater risk of sustaining an RCT (1.14% versus 0.19%; adjusted odds ratio (OR) 3.57; 95% confidence interval (CI) 3.57 to 3.96). A 1.6 times greater rate of RCR was observed in the TRT cohort (TRT, 46.4% RCR rate and control, 34.0% RCR rate; adjusted OR 1.60; 95% CI 1.54 to 1.67). The TRT cohort had a 26.7 times greater risk of undergoing a subsequent RCR, irrespective of laterality, within 1 year of undergoing a primary RCR when compared with the control group (TRT, 47.1% and control, 4.0%; adjusted OR 26.4; 95% CI 25.0 to 27.9, P < 0.001).

CONCLUSIONS

There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. This finding may represent a musculoskeletal consequence of TRT and is important for patients and clinicians to understand. Additional research into the science of tendon injury in the setting of exogenous anabolic steroids remains of interest.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective cohort study.

Incidence of shoulder disorders in a cohort of healthcare workers from 2009 to 2020

PURPOSE

To estimate the incidence of shoulder disorders in a cohort of Health Care Workers (HCWs).

METHODS

4406 workers employed from 2009 to 2020, were included in the study. Occupational risk factors and jobs were assessed according to working history. Incident cases were defined in case of shoulder pain associated with functional limitations during the medical examination. The Cox regression model was used to calculate the Hazard Ratio (HR) for different work activities, adjusted for age, sex, body mass index, and previous musculoskeletal injuries, using clerks as the reference category.

RESULTS

The incidence rates of shoulder musculoskeletal disorder for men and women were 13.1 for 1000 person-years (CI 95% 10.6-16.3) and 20.1 for 1000 person-years (CI 95% 17.8-22.6) respectively. The adjusted HR was significantly increased with age (1.06, CI 95% 1.05-1.07), outpatient health activities (2.82, CI 95% 1.89-4.219), and wards health activity (2.37, CI 95% 1.68-3.33).

CONCLUSION

HCWs with high biomechanical risk such as nurses and healthcare assistants had a higher incidence of shoulder disorders. Actions are needed for better prevention in health care assistance.

How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment

OBJECTIVES

To explore how people perceive different advice for rotator cuff disease in terms of words/feelings evoked by the advice and treatment needs.

SETTING

We performed a content analysis of qualitative data collected in a randomised experiment.

PARTICIPANTS

2028 people with shoulder pain read a vignette describing someone with rotator cuff disease and were randomised to: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation emphasised that treatment is needed for recovery.

PRIMARY AND SECONDARY OUTCOMES

Participants answered questions about: (1) words/feelings evoked by the advice; (2) treatments they feel are needed. Two researchers developed coding frameworks to analyse responses.

RESULTS

1981 (97% of 2039 randomised) responses for each question were analysed. Guideline-based advice (vs treatment recommendation) more often elicited words/feelings of reassurance, having a minor issue, trust in expertise and feeling dismissed, and treatment needs of rest, activity modification, medication, wait and see, exercise and normal movements. Treatment recommendation (vs guideline-based advice) more often elicited words/feelings of needing treatment/investigation, psychological distress and having a serious issue, and treatment needs of injections, surgery, investigations, and to see a doctor.

CONCLUSIONS

Words/feelings evoked by advice for rotator cuff disease and perceived treatment needs may explain why guideline-based advice reduces perceived need for unnecessary care compared to a treatment recommendation.

Comparison of acromiohumeral distance and glenohumeral internal rotation angle between the empty can test and modified empty can test: "thumb pointing down" versus "elbow pointing laterally"

BACKGROUND

During the empty can test, the direction of the thumb (downward) has been widely used as an instruction for producing glenohumeral internal rotation. However, the combination of forearm pronation and thumb motion as a compensatory movement could contribute to the lack of glenohumeral internal rotation during the empty can test. This study aimed to compare the glenohumeral internal rotation angle between the conventional empty can (with thumb direction) and modified empty can tests (with elbow direction), as well as the acromiohumeral distance between the full can, conventional empty can, and modified empty can tests.

METHODS

In this laboratory study, we measured the glenohumeral internal rotation angle using a motion sensor and the acromiohumeral distance using ultrasonography during the following tests: full can test (thumb pointing up), conventional empty can test (thumb pointing down), and modified empty can test (elbow pointing laterally) in 20 healthy subjects.

RESULTS

Compared with the conventional empty can test, the glenohumeral internal rotation angle was significantly greater during the modified empty can test (p < 0.05). Furthermore, the acromiohumeral distance measured in the modified empty can test was significantly less than that in the full can test (p < 0.001) and conventional empty can test (p < 0.001). However, there was no difference in the acromiohumeral distance between the full can test and the conventional empty can test (p > 0.017).

CONCLUSIONS

During the empty can test, the instructions should be given to patients based on the elbow direction (elbow pointing laterally). The modified empty can test can produce full glenohumeral internal rotation, compared with instructions based on the thumb direction (thumb pointing down). Consequently, the modified empty can test can produce a more decreased subacromial space.

Self-reported bio-psycho-social factors partially distinguish rotator cuff tendinopathy from other shoulder problems and explain shoulder severity: A case-control study

OBJECTIVE

Examine how rotator cuff (RC) tendinopathy differed from other shoulder problems (OSP) by measuring a variety of self-reported bio-psycho-social factors, and establish which explain severity.

METHODS

A validated online survey battery was used to collect self-reported biopsychosocial variables in an international population. Diagnostic group and severity were the dependent variables. Multiple logistic and linear regression analyses were utilised to generate explanatory models for group differences and severity after group comparison and univariate regression analysis.

RESULTS

82 people with RC tendinopathy (50 female, 42.8 ± 13.9 years) and 54 with OSP (33 female, 40.2 ± 14.1 years) were recruited. Both groups had comparable severity results (Shoulder Pain and Disability Index = 37.3 ± 24.5 vs. 33.7 ± 22.5). Seven factors individually differentiated RC tendinopathy from OSP. The multivariable model included 4 factors: activity effect on pain (OR(95%CI) = 2.24(1.02-4.90)), previous injury in the shoulder (OR(95% CI) = 0.30(0.13-0.69)), activity level (moderate OR(95% CI) = 3.97(1.29-12.18), high OR(95% CI) = 3.66(1.41-9.48)) and self-efficacy (OR(95%CI) = 1.12(1.02-1.22)) demonstrating acceptable accuracy. The second multivariable model for RC tendinopathy severity included one demographic, three psychological and two biomedical variables (β(range) = 0.19-0.38) and explained 68% of the variance.

CONCLUSION

Self-reported bio-psycho-social variables may be beneficial for further detailed clinical assessment as they partially distinguish RC tendinopathy from OSP, even when the groups have comparable overall pain and functional problems. Moreover, these variables were shown to be substantially associated with RC tendinopathy severity variance, implying that the clinical evaluation might be improved, perhaps by pre-consultation online data collection. The models should be validated in the future and considered alongside data from physical and imaging examinations.

Terminology and diagnostic criteria used in studies investigating patients with subacromial pain syndrome from 1972 to 2019: a scoping review

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.

Platelet-Rich Plasma Injection Can Be a Viable Alternative to Corticosteroid Injection for Conservative Treatment of Rotator Cuff Disease: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To explore whether platelet-rich plasma (PRP) injection can be a viable alternative to corticosteroid (CS) injection for conservative treatment of rotator cuff disease.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, The Cochrane Library, and Web of Science were searched from January 1, 1990, to March 20, 2022, for English-language randomized controlled trials that compared PRP and CS injections for patients with rotator cuff disease. Two evaluators independently screened the literature, extracted data, and assessed the level of evidence and methodologic quality of the enrolled studies. The meta-analysis was conducted using RevMan software (version 5.3.3).

RESULTS

Thirteen nonsurgical randomized controlled trials with 725 patients were included. Compared with CS, PRP provided statistically worse short-term (<2 months) changes in American Shoulder and Elbow Surgeons (ASES) assessment scores, Simple Shoulder Test scores, and Disabilities of the Arm, Shoulder and Hand questionnaire scores but provided better medium-term (2-6 months) changes in Disabilities of the Arm, Shoulder and Hand scores, as well as long-term (≥6 months) changes in Constant-Murley scores, ASES scores, and Simple Shoulder Test scores. No statistically significant differences regarding pain reduction were found between the 2 groups. PRP injections led to worse short-term changes in forward flexion and internal rotation but better medium-term changes in forward flexion and external rotation. PRP showed significantly lower rates of post-injection failure (requests for subsequent injections or surgical intervention prior to 12 months) than CS. No outcome reached the minimal clinically important difference. After sensitivity analyses excluding studies with substantial clinical and/or methodologic heterogeneity, PRP showed better medium-term changes in ASES scores and visual analog scale scores and long-term changes in visual analog scale scores that reached the minimal clinically important difference.

CONCLUSIONS

Without the drawbacks of CS injection, PRP injection is not worse than CS injection in terms of pain relief and function recovery at any time point during follow-up. PRP injection may reduce rates of subsequent injection or surgery, and it might provide better improvements in pain and function in the medium to long term. PRP injection can be a viable alternative to CS injection for conservative treatment of rotator cuff disease.

LEVEL OF EVIDENCE

Meta-analysis of Level I and II studies.

Subacromial impingement syndrome: association of multiple magnetic resonance imaging parameters with shoulder function and pain

INTRODUCTION

Shoulder pain is one of the most common complaints in orthopaedics. This study focusses on the relationship between shoulder function in subacromial impingement syndrome and imaging criteria in magnetic resonance imaging (MRI).

MATERIALS AND METHODS

This prospective clinical trial included 69 patients treated for subacromial impingement syndrome. Shoulder function (Constant Score, range of abduction, abduction force) and pain were correlated with the following MRI parameters: tendinosis of the rotator cuff, "halo-sign" around the biceps tendon, subacromial distance, critical shoulder angle, size of subacromial osteophytic spurs and maximum width of subacromial and subdeltoid bursa. Statistical analyses included Pearson's and Spearman's coefficients of correlation, multiple regression analysis and Student's t-test.

RESULTS

The Constant Score was correlated positively with the critical shoulder angle (r = 0.313; p = 0.009) and inversely with a "halo-sign" around the biceps tendon (rho =  -0.384; p = 0.001). There was no significant correlation between spur size and shoulder function, but the size of the subacromial and subdeltoid bursae was positively correlated with the subacromial spur's size (subacromial bursa: coronal plane: r = 0.327; p = 0.006; sagittal view: r = 0.305; p = 0.011; subdeltoid bursa coronal view: r = 0.333 p = 0.005). The width of the subdeltoid bursa in coronal plane was positively correlated with shoulder pain (r = 0.248; p = 0.004) and negatively with the range of abduction (r =  -0.270; p = 0.025), as well as the mean (r =  -0.332; p = 0.005) and maximum (r =  -0.334; p = 0.005) abduction force.

CONCLUSIONS

Shoulder function and pain in subacromial impingement are best predicted by the width of the subdeltoid bursa measured in the coronal MRI plane as an indicator of bursitis as well as the presence of a "halo-sign" around the biceps tendon indicating glenohumeral joint effusion. Presence of a subacromial spur could lead to subacromial and subdeltoid bursitis, which impairs shoulder function. Shoulder function seems not to be compromised by the presence of a subacromial spur in absence of bursitis. This study was registered at the German Clinical Trials Register on 08 February 2013 (ID: DRKS00011548).

Image quality improvement and motion degradation reduction in shoulder MR imaging: comparison of BLADE and rectilinear techniques at 3-Tesla scanning

OBJECTIVE

MR imaging of joints, particularly shoulder, requires a high degree of spatial resolution to ascertain anatomy and pathology. Unfortunately, motion artifacts can reduce the clinical quality of the examinations. BLADE sequence reduces motion degradation improving overall diagnostic imaging quality. The objective was to compare standard, rectilinear k-space coverage turbo spin echo (TSE), and BLADE sequences.

MATERIAL AND METHODS

Over a 4-month period, fifty-seven consecutive patients (22 males, 35 females; mean age: 48.5 years, range: 23-64 years) were scanned using traditional intermediate-weighted spin echo and BLADE sequences. Qualitative evaluation was performed by three musculoskeletal fellowship trained radiologists, each with more than 5 years of experience. Image sequences were evaluated using a Likert scale for each of the following five categories: motion degradation, ghosting/phase misregistration artifacts, star/radial encoding artifacts, fat suppression quality, and overall diagnostic quality. Additionally, image sequences were evaluated for signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) using manually drawn regions of interest (ROI) analysis.

RESULTS

Ghosting and phase artifacts were lower within BLADE sequence while streak artifacts were higher (p < 0.001). Image fat suppression, tendon and labral appearances, and the overall SNR and CNR were comparable on both sequences (p > 0.05).

CONCLUSION

Addition of BLADE reduces motion degradation and improves overall diagnostic imaging quality. Application of BLADE in patient scans suspected of motion artifacts can reduce the frequency of repeat imaging in patients with claustrophobia or those where motion is a concern. By reducing overall imaging time and call backs, it could reduce the cost burden to patients and healthcare system.

The internal structure of the infraspinatus muscle: a magnetic resonance study

Purpose

This study aimed to describe the internal structure of the infraspinatus muscle. A secondary aim was to explore differences in internal structure between genders, sides, and correlations to demographic data.

Methods

In total, 106 shoulder MRI examinations of patients between 18 and 30 years of age seeking care in 2012–2020 at The Sahlgrenska University Hospital in Gothenburg, Sweden were re-reviewed.

Results

The number of intramuscular tendons centrally in the infraspinatus muscle varied between 3 and 8 (median = 5). Laterally, the number of intramuscular tendons varied between 1 and 5 (median = 2). There was no difference in the median between the genders or sides. No correlations between the number of intramuscular tendons and demographic data were found. The muscle volume varied between 63 and 249 ml with a median of 188 ml for males and 122 ml for females. There was no significant difference in volume between the sides. The muscle volume correlated with body weight (Pearson’s correlation coefficient, r = 0.72, p < 0.001) and height (r = 0.61, p < 0.001).

Conclusion

The anatomical variations of the infraspinatus muscle are widespread. In the medial part of the muscle belly, the number of intramuscular tendons varied between 3 and 8, while the number of intramuscular tendons laterally varied between 1 and 5. Results of our study may help to understand the internal structure of the infraspinatus muscle and its function in shoulder stabilization.

In Vivo Anatomical Research by 3D CT Reconstruction Determines Minimum Acromiohumeral, Coracohumeral, and Glenohumeral Distances in the Human Shoulder: Evaluation of Age and Sex Association in a Sample of the Chinese Population

Accurate measurement of the minimum distance between bony structures of the humeral head and the acromion or coracoid helps advance a better understanding of the shoulder anatomical features. Our goal was to precisely determine the minimum acromiohumeral distance (AHD), coracohumeral distance (CHD), and glenohumeral distance (GHD) in a sample of the Chinese population as an in vivo anatomical analysis. We retrospectively included 146 patients who underwent supine computed tomography (CT) examination of the shoulder joint. The minimum AHD, CHD, and GHD values were quantitatively measured using three-dimensional (3D) CT reconstruction techniques. The correlation between minimum AHD, CHD, and GHD value and age with different sexes was evaluated using Pearson Correlation Coefficient. The mean value of minimum AHD in males was greater than that in females (male 7.62 ± 0.98 mm versus female 7.27 ± 0.86 mm, p = 0.046). The CHD among different sexes differed significantly (male 10.75 ± 2.40 mm versus female 8.76 ± 1.38 mm, p < 0.001). However, we found no statistical differences in GHD with different sexes (male 2.00 ± 0.31 mm versus female 1.96 ± 0.36 mm, p > 0.05). In terms of age correlation, a negative curve correlation existed between age and AHD among the different sexes (male R2 = 0.124, p = 0.030, female R2 = 0.112, p = 0.005). A negative linear correlation was found in CHD among the different sexes (male R2 = 0.164, p < 0.001, female R2 = 0.122, p = 0.005). There were no differences between age and minimum GHD in both sexes. The 3D CT reconstruction model can accurately measure the minimum AHD, CHD, and GHD value in vivo and is worthy of further investigation for standard clinical anatomical assessment. Aging may correlate with AHD and CHD narrowing for both sexes.

Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment

QUESTION

What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease?

DESIGN

2×2 factorial online randomised experiment.

PARTICIPANTS

People with shoulder pain.

INTERVENTION

Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery.

OUTCOME MEASURES

Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work.

RESULTS

A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect -0.5 on a 0-to-10 scale, 98.3% CI -0.7 to -0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect -1.0, 98.3% CI -1.3 to -0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome.

CONCLUSION

Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition).

TRIAL REGISTRATION

ACTRN12621001370897.

Evaluating the role of subacromial impingement in rotator cuff tendinopathy: development and analysis of a novel rat model

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. Because 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 4 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 with control tendons. Semiquantitative 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, Pparg2, and Klf15).

CONCLUSION

This new 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.

Efficacy of Single Injection of Platelet-Rich Plasma in Shoulder Impingement Syndrome

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.

Anti-inflammatory and Tendon-Protective Effects of Adipose Stem Cell-Derived Exosomes with Concomitant Use of Glucocorticoids

Glucocorticoid (GC) injections are commonly used in clinical practice to relieve pain and improve function in patients with multiple shoulder disabilities but cause detrimental effects on rotator cuff tendons. Adipose stem cell-derived exosomes (ASC-Exos) reportedly recover impaired tendon matrix metabolism by maintaining tissue homeostasis. However, it is unclear whether additional treatment with ASC-Exos overrides the detrimental effects of GCs without interfering with their anti-inflammatory effects. Thus, we aimed to investigate the anti-inflammatory effect of ASC-Exos with GCs and protective effect of ASC-Exos against GC-induced detriments. The present study comprised in vitro and in vivo studies. In vitro inflammatory analysis revealed that ASC-Exos exerted a synergic anti-inflammatory effect with GCs by significantly decreasing secretion of proinflammatory cytokines by RAW cells and increasing secretion of anti-inflammatory cytokines. In vitro cytoprotective analysis showed that ASC-Exos overrode GC-induced detrimental effects on tenocytes by significantly improving GC-suppressed cellular proliferation, migration, and transcription of tenocytic matrix molecules and degradative enzyme inhibitors and significantly decreasing GC-induced cell senescence, apoptosis, and transcription of ROS and tenocytic degradative enzymes. In vivo studies revealed that additional ASC-Exo injection restored impairments in histological and biomechanical properties owing to GC administration. Collectively, these results suggest that ASC-Exos exert a stronger anti-inflammatory effect in combination with GCs, overriding their detrimental effects on rotator cuff tendons.

Thoracic manual therapy improves pain and disability in individuals with shoulder impingement syndrome compared to placebo: a randomised controlled trial with one year follow-up

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.

Publication Trends and Hot Spots in Subacromial Impingement Syndrome Research: A Bibliometric Analysis of the Web of Science Core Collection

Background

In recent years, the research on subacromial impingement syndrome (SIS) has gradually increased. Although the research directions are diverse, the overall research status and trend are not clear.

Objective

The aim of our study was to use bibliometric analysis to identify the trends in SIS-related research and to analyze the most highly cited scientific publications on SIS.

Methods

All data were retrieved from the Web of Science Core Collection database, and the year of publications, countries, journals, institutions and total number of citations were extracted and analyzed. The results related to countries, institutions and keywords were then analyzed using VOSviewer software and bibliometrics online analysis platform. And, we also identified the 100 most cited articles on SIS.

Results

A total of 548 articles related to AIS were identified. The frequency of publication on SIS has increased substantially over time. Among all countries, Turkey has contributed the most publications on SIS (n=118). The institution with the most articles was Istanbul University (n=17). Journal of Shoulder and Elbow Surgery topped the list of journals and has published 19 SIS-related publications. The hotspot of research changed from the former arthroscopic surgery to physical therapy and rehabilitation.

Conclusion

The scientific research on SIS has rapidly expanded in recent years. This study represents the first bibliometric analysis of SIS, gives us a systematic and comprehensive summary into the development of SIS.

Osteoid Osteoma in an Adult Wheelchair Basketball Player Mimicking Musculoskeletal Shoulder Pain: Red Flag or a Red Herring?

Osteoid osteoma (OO) is a relatively common, benign bone-forming tumour, which mainly occurs on the long tubular bones of the limbs in adolescents. Usually, the OO is classified based on its localisation. Night-time pain is the major symptom of OO, which is commonly relieved using non-steroidal anti-inflammatory drugs, while surgery is required only for those patients with severe pain or in case of failure of previous conservative treatments. Our case report describes a 56-year-old male basketball player who self-referred to our outpatient physical therapy with a shoulder pain complaint. Considering the anamnesis and the physical examination, the physical therapist referred the patient to an orthopaedic surgeon, who suggested a detailed imaging investigation. The peculiarity of this clinical case is the overlapping of two clinical presentations: the symptomatology of the OO and the concurrent mechanical disorder due to a rotator cuff tendinopathy.

The Role of Indian Hedgehog Signaling in Tendon Response to Subacromial Impingement: Evaluation Using a Mouse Model

BACKGROUND

The underlying cellular and molecular mechanisms involved in the development of tendinopathy due to subacromial supraspinatus tendon (SST) impingement and the response to subsequent removal of impingement remain unknown.

PURPOSE

To investigate the involvement of Indian hedgehog (IHH) signaling in the development of SST tendinopathy and the subsequent healing process after the relief of subacromial impingement in a novel mouse shoulder impingement model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 48 male wild-type C57BL/6 mice were used in this study. Supraspinatus tendinopathy was induced by inserting a microsurgical clip into the subacromial space bilaterally. Eleven mice were sacrificed at 4 weeks after surgery to establish impingement baseline; 24 mice underwent clip removal at 4 weeks after surgery and then were euthanized at 2 or 4 weeks after clip removal. Thirteen mice without surgical intervention were utilized as the control group. All SSTs were evaluated with biomechanical testing; quantitative histomorphometry after staining with hematoxylin and eosin, Alcian blue, and picrosirius red; and immunohistochemical staining (factor VIII, IHH, Patched1 [PTCH1], and glioma-associated oncogene homolog 1 [GLI1]).

RESULTS

The mean failure force and stiffness in the 4-week impingement group decreased significantly compared with the control group (P < .001) and gradually increased at 2 and 4 weeks after clip removal. Histological analysis demonstrated increased cellularity and disorganized collagen fibers in the SST, with higher modified Bonar scores at 4 weeks, followed by gradual improvement after clip removal. The IHH-positive area and PTCH1- and GLI1-positive cell percentages significantly increased after 4 weeks of clip impingement (20.64% vs 2.06%, P < .001; 53.9% vs 28.03%, P = .016; and 30% vs 12.19%, P = .036, respectively) and continuously increased after clip removal.

CONCLUSION

The authors' findings suggest that the hedgehog signaling pathway and its downstream signaling mediator and target GLI1 may play a role in the development and healing process of rotator cuff tendinopathy due to extrinsic rotator cuff impingement.

CLINICAL RELEVANCE

This study suggests the potential for the hedgehog pathway, together with its downstream targets, as candidates for further study as potential therapeutic targets in the treatment of supraspinatus tendinopathy.

Clinical Characteristics of 100 Patients with Hypermobility Spectrum Disorders and Shoulder Complaints With or Without Mechanical Symptoms: A Cross-Sectional Study

OBJECTIVE

The aims were to describe the clinical characteristics of patients with hypermobility spectrum disorders (HSD) and shoulder complaints with or without mechanical symptoms, and to compare characteristics between these groups.

DESIGN

Descriptive study.

SETTING

Primary care PARTICIPANTS: One-hundred patients with HSD and shoulder complaints for at least three months were included from primary care.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Medical history, self-reported (shoulder pain and function, discomfort due to other symptoms, fatigue, fear of movement, quality of life) and objective (strength, range of motion, proprioception) characteristics were collected by physiotherapists. Mechanical symptoms (Yes/No) were defined as self-reported shoulder instability, subluxation, and/or laxity.

RESULTS

Sixty-seven reported mechanical symptoms. Patients in both groups reported impairments related to shoulder pain, function, fatigue, fear of movement, and quality of life. Patients with mechanical symptoms were younger (mean (95% CI): 35.1 (32.3; 37.9) vs. 43.3 (38.4; 48.1) years), had longer symptom duration (median: 46 (36; 66) vs. 24 (9; 56) months), reported a previous shoulder dislocation (25% (16; 37) vs. 3% (0; 16)), experienced that their shoulder was loose (64% (52; 76) vs. 15% (5; 32)), and reported discomfort due to other symptoms (OR 1.48 (1.17; 1.87)). Furthermore, a larger proportion had received supplemental treatment (analgesic medication, steroid injection/surgery).

CONCLUSION(S)

Both groups with HSD and shoulder complaints presented with substantial shoulder-related impairments. Two-thirds reported mechanical symptoms, were younger, and more severely impaired than those without mechanical symptoms. These findings highlight the importance of managing mechanical shoulder symptoms to fully address the patients' impairments.

How do people perceive different labels for rotator cuff disease? A content analysis of data collected in a randomised controlled experiment

OBJECTIVES

Explore how people perceive different labels for rotator cuff disease in terms of words or feelings evoked by the label and treatments they feel are needed.

SETTING

We performed a content analysis of qualitative data collected in a six-arm, online randomised controlled experiment.

PARTICIPANTS

1308 people with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomised to one of six labels: subacromial impingement syndrome, rotator cuff tear, bursitis, rotator-cuff-related shoulder pain, shoulder sprain and episode of shoulder pain.

PRIMARY AND SECONDARY OUTCOMES

Participants answered two questions (free-text response) about: (1) words or feelings evoked by the label; (2) what treatments they feel are needed. Two researchers iteratively developed coding frameworks to analyse responses.Results1308/1626 (80%) complete responses for each question were analysed. Psychological distress (21%), uncertainty (22%), serious condition (15%) and poor prognosis (9%) were most often expressed by those labelled with subacromial impingement syndrome. For those labelled with a rotator cuff tear, psychological distress (13%), serious condition (9%) and poor prognosis (8%) were relatively common, while minor issue was expressed least often compared with the other labels (5%). Treatment/investigation and surgery were common among those labelled with a rotator cuff tear (11% and 19%, respectively) and subacromial impingement syndrome (9% and 10%) compared with bursitis (7% and 5%).

CONCLUSIONS

Words or feelings evoked by certain labels for rotator cuff disease and perceived treatment needs may explain why some labels drive management preferences towards surgery and imaging more than others.

Correlation Between Clinical Diagnosis, MRI, and Arthroscopy in Diagnosing Shoulder Pathology

Introduction

Shoulder disorders are frequently encountered by clinicians and are a common cause of musculoskeletal pain in the general population. Clinical tests specific to each shoulder pathology, MRI, and arthroscopy are the most relied upon modalities of diagnosis used by many clinicians. The aim of this study was to correlate clinical tests and MRI with arthroscopy as the gold standard and whether a negative MRI with a positive clinical test could justify an arthroscopy.

Materials and methods

A total of 120 consecutive patients who had a history of shoulder pain or instability were evaluated by clinical tests and MRI, and underwent arthroscopy. Based on the confirmatory findings of arthroscopy, they were classified as True Positive (TP), True Negative (TN), False Positive (FP) and False Negative (FN) for each modality i.e., clinical tests and MRI.

Results

Clinical assessment of rotator cuff tears in comparison to arthroscopy yielded a sensitivity of 96.88%, specificity of 92.86% and diagnostic accuracy of 95%, whilst MRI had a sensitivity of 90.62%, specificity of 92.86% and diagnostic accuracy of 91.67%. In anterior labral lesions, clinical assessment had a sensitivity of 94.44%, specificity of 97.62 % and diagnostic accuracy of 96.67%, whilst MRI had a sensitivity of 83.33%, specificity of 92.86%, with diagnostic accuracy of 90%. Interestingly, in the clinical assessment of superior labral tear from anterior to posterior (SLAP) lesions, a sensitivity of 90%, specificity of 95%, and diagnostic accuracy of 93.33% were observed while MRI had a sensitivity of 60%, specificity of 92.50%, and diagnostic accuracy of 81.67%.

Conclusion

On the basis of these results, clinical assessment appears to be an effective tool in diagnosing shoulder pathologies, whereas MRI, though reliable in the identification of rotator cuff tears and instability, does not identify patients with SLAP lesions effectively. This study reinforces the importance of a good clinical examination of the shoulder, especially in chronic pain and an uncertain MRI, therefore improving patient management.

National Trends Show Declining Use of Arthroscopic Subacromial Decompression Without Rotator Cuff Repair

PURPOSE

The goal of this study was to investigate trends in the United States for arthroscopic subacromial decompression (aSAD) and open SAD (oSAD) with and without rotator cuff repair (RCR) between 2010 and 2018.

METHODS

The PearlDiver Mariner claims database was queried using CPT codes for open and arthroscopic subacromial decompression and rotator cuff repair. Patient cohorts were developed for those undergoing aSAD or oSAD between 2010 and 2018, then segmented by whether RCR was performed simultaneously. Annual incidence was analyzed, as were associated diagnosis codes, and concomitant shoulder-associated procedures performed on the same day.

RESULTS

The PearlDiver Mariner dataset from 2010 to 2018 included 186,932 patients that underwent aSAD, while 9,263 patients underwent oSAD. The total incidence of aSAD declined from 118.0 to 71.3 per 100,000 (39.6% decrease) (P < .001). This change was due primarily to a decreasing incidence of aSAD performed without RCR, which declined from 66.3 to 25.5 per 100,000 (61.5% decrease) (P < .001). During the same period, the incidence of aSAD combined with RCR remained relatively stable, from 51.7 to 45.8 per 100,000 (11.5% decrease) (P = .27). The overall incidence of oSAD declined from 7.1 to 2.2 per 100,000 (68.1% decrease) (P < .001).

CONCLUSIONS

The overall rate of aSAD has declined in recent years, primarily due to a large decrease in the incidence of aSAD without RCR as an isolated treatment for rotator cuff disorders.

CLINICAL RELEVANCE

Prior studies have demonstrated a rising incidence of SAD; however, high-level clinical evidence and clinical practice guidelines have challenged its efficacy. It is important for orthopaedic surgeons to understand evolving national trends in management among their peers.