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Guerra-Rodríguez D, Guerrero-Henriquez J, Basilio D, Mendez-Rebolledo G. Intra- and inter-rater reliability in ultrasonographic measurements of coracohumeral distance. Musculoskelet Sci Pract 2024; 69:102906. [PMID: 38215526 DOI: 10.1016/j.msksp.2024.102906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/29/2023] [Accepted: 01/06/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Ultrasonography (US) is a widely used diagnostic tool in physical therapy. One of the US variables often utilized to quantify the dimensions of the subacromial space and its association with shoulder pathology is the coracohumeral distance (CHD), however, this measurement presents diverse evidence in terms of reliability. OBJECTIVES To assess the intra- and inter-rater reliability of both expert and non-expert raters when measuring CHD through US in asymptomatic subjects. Additionally, we determined the effect of rater experience and measurement conditions on the recording of CHD. METHODS CHD of 15 individuals were recorded from US images of the glenohumeral joint of both upper extremities in three different positions. An expert and a non-expert rater in US usage recorded three CHD measurements, after a randomization procedure. To determine intra- and inter-rater reliability, the interclass correlation coefficient (ICC) and a multivariate variance model for the effects of rater experience, joint position and time of measure were used. Standard Error of Measurement and Minimal Detectable Change was also estimated for CHD measurements. RESULTS Intra-rater reliability ranged 0.970 to 0.998) and Inter-rater reliability ranged 0.48 to 0.876). Joint position (F2;55 = 38.308; p < 0.001; ηp2 = 0.582) and measurement time (F2;55 = 6.019; p = 0.004; ηp2 = 0.180) effect was observed on CHD. CONCLUSION Excellent intra- and poor to moderate inter-rater reliability between expert and non-expert clinicians was determined, the latter being influenced by the position of the glenohumeral joint position at the time of US recording and the time of recording the measurement.
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Affiliation(s)
- Diego Guerra-Rodríguez
- Biomedic Department, Faculty of Health Sciences, University of Antofagasta, Antofagasta, Chile
| | - Juan Guerrero-Henriquez
- Rehabilitation and Human Movement Sciences Department, Faculty of Health Sciences, University of Antofagasta, Antofagasta, Chile; Centro de Investigación en Fisiología y Medicina de Altura, Facultad de Ciencias de la Salud, Universidad de Antofagasta, Chile.
| | - Daniel Basilio
- Kinetic-K Integral Therapy and Training Center, Antofagasta, Chile
| | - Guillermo Mendez-Rebolledo
- Laboratorio de Investigación Somatosensorial y Motora, Escuela de Kinesiología, Facultad de Salud, Universidad Santo Tomás, Chile; Escuela de Kinesiología, Facultad de Salud, Universidad Santo Tomás, Chile
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Siriwanarangsun P, Pakdee W, Pisanuwongse A, Keyurapan E, Lektrakul N. Subscapularis tendon tear detection using axial internal rotation MRI: semiquantitative and quantitative analysis. Quant Imaging Med Surg 2023; 13:8274-8289. [PMID: 38106250 PMCID: PMC10721994 DOI: 10.21037/qims-23-273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 09/13/2023] [Indexed: 12/19/2023]
Abstract
Background Magnetic resonance image (MRI) of the subscapularis tendon plays an important role in preoperative planning. This retrospective study aimed to evaluate the diagnostic value and quantitative measurement of an additional internal rotation sequence in the detection of partial subscapularis tendon tears. Methods The study included 76 patients who underwent arthroscopy and magnetic resonance (MR) shoulder between January 2018 to December 2019. Three different sets of images were evaluated in each case to determine the diagnostic value in the detection of partial subscapularis tendon tears including Set 1: standard axial fat-suppressed proton density (PD/FS) image and sagittal fat-suppressed T2 weight image (T2W/FS) images, Set 2: standard axial PD/FS and internal rotation PD/FS images, and Set 3: standard axial PD/FS, sagittal T2W/FS and axial internal rotation PD/FS images. Subscapularis tendon tear was diagnosed by arthroscopy and patients with or without tears were grouped. The coracohumoral distance (CHD), coracoglenoid angle (CGA), coracohumeral angle (CHA), CHD difference and CHD ratio were evaluated and compared between groups using univariate and multivariate analysis. The interreader agreement was assessed. The cut-off point for the prediction of subscapularis tears was calculated. Results Twenty-nine shoulders revealed partial subscapularis tendon tears (29/76, 38.2%). Imaging Set 3 provided the highest sensitivity and accuracy {79-83% [confidence interval (CI): 0.60-0.95], 75-76% (CI: 0.63-0.85)}, compared to image Set 2 [31-58% (CI: 0.15-0.76), 67-68% (CI: 0.55-0.79)] and Set 1 [17-21% (CI: 0.06-0.40], 61-66% (CI: 0.54-0.76)], and a moderate level of interobserver agreement (Kappa =0.55). Axial CHD [odd ratio (OR) =1.48, P=0.044], internal rotate CHD (OR =0.68, P=0.02), CHD difference (OR =2.58, P<0.001), and CHD ratio (OR =1.34, P<0.001) were associated with subscapularis tears. A CHD difference and CHD ratio of more than 0.04 mm and 1.01 achieved a 90% sensitivity and 72% specificity, both. Conclusions Internal rotation during MRI can increase diagnostic accuracy for subscapularis tendon partial tears. The CHD differences and CHD ratio are useful parameters to indicate subscapularis tears. This technique may improve preoperative management and reduce the consequences of delayed diagnosis and treatment.
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Affiliation(s)
- Palanan Siriwanarangsun
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
| | - Wisitsak Pakdee
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
| | - Arin Pisanuwongse
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
| | - Ekavit Keyurapan
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
| | - Nittaya Lektrakul
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
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Ikebe S, Shimoto T, Higaki H, Banks SA. DRR acceleration using inexpensive GPUs for model-image registration based joint kinematic measurements. J Biomech 2023; 160:111824. [PMID: 37862924 DOI: 10.1016/j.jbiomech.2023.111824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/30/2023] [Accepted: 10/03/2023] [Indexed: 10/22/2023]
Abstract
Model-image registration methods are commonly used in research to measure three-dimensional joint kinematics from single-plane and bi-plane x-ray images. These methods have the potential to be beneficial if used clinically, but current techniques are too slow or expensive to be clinically practical. One technical element of these methods for measuring natural bone motion is the use of digitally reconstructed radiographs (DRRs). DRRs can be very expensive to compute, or require expensive and fast computer hardware. In this technical development, a numerically efficient Siddon-Jacobs algorithm for computing DRRs was implemented on a consumer-grade graphics card using a programming language for parallel architectures. Compared to traditional voxel projection algorithms with a central-processing-unit-only implementation, the parallel computation implementation on the graphics card provided speedups of 650-1546 times faster rendering, while retaining equivalent performance for joint kinematics measurements. The use of consumer grade graphics hardware may contribute to making model-image registration measurements of joint kinematics practical for clinical use.
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Affiliation(s)
- Satoru Ikebe
- National Institute of Technology, Kitakyushu College, Kitakyushu, Fukuoka, Japan; University of Florida, Gainesville, FL, USA.
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Wu H, Zuo Z, Li Y, Song H, Hu W, Chen J, Xie C, Lin L. Anatomic characteristics of shoulder based on MRI accurately predict incomplete rotator cuff injuries in patients: relevance for predictive, preventive, and personalized healthcare strategies. EPMA J 2023; 14:553-570. [PMID: 37605646 PMCID: PMC10439871 DOI: 10.1007/s13167-023-00333-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/03/2023] [Indexed: 08/23/2023]
Abstract
Background and PPPM-related working hypothesis In the diagnosis of incomplete rotator cuff injuries (IRCI), magnetic resonance imaging (MRI) and ultrasound examination often have false-positive and false-negative results, while arthroscopy is expensive, invasive, and complex. From the strategy of predictive, preventive, and personalized medicine (PPPM), shoulder anatomical characteristics based on MRI have been demonstrated to accurately predict IRCI and their clinical applicability for personalized prediction of IRCI. Aims This study aimed to develop and validate a nomogram based on anatomical features of the shoulder on MRI to identify IRCI for PPPM healthcare strategies. Methods The medical information of 257 patients undergoing preoperative MRI examination was retrospectively reviewed and served as the primary cohort. Partial-thickness rotator cuff tears (RCTs) and tendinopathy observed under arthroscopy were considered IRCI. Using logistic regression analyses and least absolute shrinkage and selection operator (LASSO), IRCI was identified among various preoperative factors containing shoulder MRI and clinical features. A nomogram was constructed and subjected to internal and external validations (80 patients). Results The following eight independent risk factors for IRCI were identified:AgeThe left injured sidesThe Goutallier classification of supraspinatus in oblique coronal positionThe Goutallier classification of supraspinatus in the axial positionAcromial thicknessAcromiohumeral distanceCoracohumeral distanceAbnormal acromioclavicular joint signalsThe nomogram accurately predicted IRCI in the development (C-index, 0.932 (95% CI, 0.891, 0.973)) and validation (C-index, 0.955 (95% CI, 0.918, 0.992)) cohorts. The calibration curve was consistent between the predicted IRCI probability and the actual IRCI ratio of the nomogram. The decision curve analysis and clinical impact curves demonstrated that the model had high clinical applicability. Conclusions Eight independent factors that accurately predicted IRCI were determined using MRI anatomical findings. These personalized factors can prevent unnecessary diagnostic interventions (e.g., arthroscopy) and can assist surgeons in implementing individualized clinical decisions in medical practice, thus addressing the goals of PPPM. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-023-00333-5.
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Affiliation(s)
- Hangxing Wu
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
| | - Zhijie Zuo
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
| | - Yucong Li
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
| | - Haoqiang Song
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
| | - Wanyan Hu
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
| | - Jingle Chen
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
| | - Chao Xie
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
| | - Lijun Lin
- Department of Joint and Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong People’s Republic of China
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Reliability of coracohumeral distance and subcoracoid tendons in subacromial pain syndrome. Sci Rep 2023; 13:2383. [PMID: 36765167 PMCID: PMC9918475 DOI: 10.1038/s41598-023-29601-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
This study investigated the intra-rater reliability of a novice ultrasound (US) examiner and the inter-rater reliability of two examiners (novice, expert) in the measures of coracohumeral distance at rest (CHD) and at 60° of elevation without (CHD60) or with weights (CHD60w), tendon thickness of the long head of the biceps (LHB) and subscapularis (SCP). Twenty-one patients with subacromial pain syndrome (SAPS) and 20 asymptomatic participants were included. Intra and inter-rater reliability were tested with intraclass-correlation-coefficient (ICC), differences between raters were analyzed with Bland-Altman plots. Intra-rater reliability for CHD, CHD60 and CHD60w was excellent (ICC = 0.97-0.98) in asymptomatic participants, and good-to-excellent (0.88-0.93) in SAPS, while intra-rater reliability for LHB and SCP was good-to-excellent in asymptomatic participants (0.88-0.97) and in SAPS (0.90-0.92). Inter-rater reliability for CHD, CHD60 and CHD60w was moderate-to-good (0.70-0.90) in asymptomatic participants and good (0.85-0.87) in SAPS, in contrast inter-rater reliability for LHB and SCP was poor in asymptomatic participants (0.10-0.46) and poor-to-moderate (0.49-0.61) in SAPS. Bland-Altman plots revealed systematic and/or proportional bias for tendons' thickness. A novice showed good-to-excellent intra-rater reliability in all US measures, whereas in comparison to an expert a novice can measure reliably CHD, CHD60 and CHD60w, but not LHB and SCP, where more training is recommended.
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Yaka H, Özer M, Kanatlı U. Is lesser tuberosity morphology related to subscapularis tears and anterior shoulder instability? Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04790-5. [PMID: 36729218 DOI: 10.1007/s00402-023-04790-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 01/22/2023] [Indexed: 02/03/2023]
Abstract
PURPOSE Although the morphological relationship of the scapula and the humeral head has been claimed to be related to shoulder pathologies, few studies examined the relationship between subscapularis (Ssc) tears and lesser tuberosity (LT)-humeral head (HH) and between Ssc tears and HH-glenoid. This study aims to evaluate the relationship of LT with HH and glenoid in patients with Ssc tears and anterior shoulder instability (ASI). We hypothesized that the glenoid, HH, and their combined relationship with LT may impact Ssc tears and ASI. MATERIAL AND METHODS The study included 34 patients with ASI, 28 patients with isolated Ssc tears, and 40 patients as the control group. The radius of HH (Hr), the distance between the center of HH and LT (LTr), and the glenoid radius (Gr) were measured in shoulder magnetic resonance (MR) images. The LTr to Hr (LTr/Hr) ratio was defined as the lesser tuberosity-humeral head index (LTHHI), whereas the LTr to Gr (LTr/Gr) ratio was defined as the lesser tuberosity-glenoid index (LTGI). The three groups were compared regarding LTHHI, LTGI, LTr, Hr, and Gr. RESULTS There was a significant difference between each group concerning LTGI (p < 0.001). LTGI values below 1.99 showed 93.1% sensitivity and 93.3% specificity for Ssc tears, while values above 2.24 showed 86.7% sensitivity and 86.2% specificity for ASI. Also, there was a significant difference when the groups were compared for LTHHI (p < 0.001). This rate was lowest for Ssc tears, and LTHHI values below 1.17 showed 82.8% sensitivity and 80.1% specificity. CONCLUSION LTGI may be a new predictive factor showing 93.1% sensitivity and 93.3% specificity for Ssc tears and 86.7% sensitivity and 86.2% specificity for ASI. In addition, LTHHI may be a new predictive factor showing 82.8% sensitivity and 80.1% specificity for Ssc tears. LEVEL OF EVIDENCE III retrospective comparative study.
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Affiliation(s)
- Haluk Yaka
- Department of Orthopaedics and Traumatology, Konya City Hospital, 42020, Karatay, Konya, Turkey.
| | - Mustafa Özer
- Department of Orthopaedics and Traumatology, Necmettin Erbakan University School of Medicine, Konya, Turkey
| | - Ulunay Kanatlı
- Department of Orthopaedics and Traumatology, Gazi University School of Medicine, Ankara, Turkey
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Ting DS, Yang JL, Lin KH, Wang TG, Lin JJ. Alteration in coracohumeral ligament and distance in people with symptoms of subcoracoid impingement. BMC Musculoskelet Disord 2023; 24:58. [PMID: 36683027 PMCID: PMC9869551 DOI: 10.1186/s12891-023-06152-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/09/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Differentiation between subacromial impingement versus subcoracoid impingement are important for the treatment target. We evaluated the correlations between coracohumeral ligament (CHL) thickness and distance (CHD) and characterized the CHL and subscapularis (SSC) in subcoracoid impingement subjects. METHODS An observational, cross-sectional study was carried out. Twenty subcoracoid impingement subjects and age/gender matched controls were assessed in 4 different shoulder positions by ultrasonography. RESULTS Moderate correlations between CHL thickness with CHD (r = 0.455 in neutral rotation, p = 0.044; r = 0.483 in interior rotation, p = 0.031) were found in subacromial subjects. Subcoracoid impingement subjects had greater CHL thickness (difference = 0.3 mm, effect size = 0.85, p = 0.006), SSC tendon thickness (difference = 0.7 mm, effect size = 0.92, p = 0.01) and SSC/CHD occupation ratio (difference = 8%, effect size = 0.95, p = 0.005) compared with the control. CONCLUSIONS Coracohumeral distance is related to ligament thickness, especially in subacromial impingement subjects. Increased coracohumeral ligament and subscapularis thickness as well as decreased subscapularis/coracohumeral distance occupation ratio are characterized in subcoracoid impingement subjects. These quantitative measurements can be useful in identifying patients at risk of subcoracoid impingement from subacromial impingement.
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Affiliation(s)
- Deng Siang Ting
- grid.19188.390000 0004 0546 0241School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Jing-lan Yang
- grid.412094.a0000 0004 0572 7815Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei City, Taiwan
| | - Kwan-Hwa Lin
- grid.19188.390000 0004 0546 0241School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Tyng-Guey Wang
- grid.412094.a0000 0004 0572 7815Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei City, Taiwan
| | - Jiu-Jenq Lin
- grid.19188.390000 0004 0546 0241School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei City, Taiwan ,grid.412094.a0000 0004 0572 7815Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei City, Taiwan
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Heilmann LF, Sussiek J, Raschke MJ, Langer MF, Frank A, Wermers J, Michel PA, Dyrna F, Schliemann B, Katthagen JC. Biomechanical Analysis of Coracoid Stability After Coracoplasty: How Low Can You Go? Orthop J Sports Med 2022; 10:23259671221077947. [PMID: 35340899 PMCID: PMC8951046 DOI: 10.1177/23259671221077947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Arthroscopic coracoplasty is a procedure for patients affected by subcoracoid
impingement. To date, there is no consensus on how much of the coracoid can
be resected with an arthroscopic burr without compromising its
stability. Purpose: To determine the maximum amount of the coracoid that can be resected during
arthroscopic coracoplasty without leading to coracoid fracture or avulsion
of the conjoint tendon during simulated activities of daily living
(ADLs). Study Design: Controlled laboratory study. Methods: A biomechanical cadaveric study was performed with 24 shoulders (15 male, 9
female; mean age, 81 ± 7.9 years). Specimens were randomized into 3
treatment groups: group A (native coracoid), group B (3-mm coracoplasty),
and group C (5-mm coracoplasty). Coracoid anatomic measurements were
documented before and after coracoplasty. The scapula was potted, and a
traction force was applied through the conjoint tendon. The stiffness and
load to failure (LTF) were determined for each specimen. Results: The mean coracoid thicknesses in groups A through C were 7.2, 7.7, and 7.8
mm, respectively, and the mean LTFs were 428 ± 127, 284 ± 77, and 159 ± 87
N, respectively. Compared with specimens in group A, a significantly lower
LTF was seen in specimens in group B (P = .022) and group C
(P < .001). Postoperatively, coracoids with a
thickness ≥4 mm were able to withstand ADLs. Conclusion: While even a 3-mm coracoplasty caused significant weakening of the coracoid,
the individual failure loads were higher than those of the predicted ADLs. A
critical value of 4 mm of coracoid thickness should be preserved to ensure
the stability of the coracoid process. Clinical Relevance: In correspondence with the findings of this study, careful preoperative
planning should be used to measure the maximum reasonable amount of
coracoplasty to be performed. A postoperative coracoid thickness of 4 mm
should remain.
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Affiliation(s)
| | - Julia Sussiek
- University Hospital Muenster (WWU), Muenster, Germany
| | | | | | - Andre Frank
- University Hospital Muenster (WWU), Muenster, Germany
| | - Jens Wermers
- University Hospital Muenster (WWU), Muenster, Germany
| | | | - Felix Dyrna
- University Hospital Muenster (WWU), Muenster, Germany
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Anatomy of the coracoid process in thais: Cadaveric study and clinical implications. TRANSLATIONAL RESEARCH IN ANATOMY 2022. [DOI: 10.1016/j.tria.2022.100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Kucukciloglu Y, Aydın D. Relationship between Radiological Measurement of Subcoracoid Impingement and Subscapularis Tendon Lesions. Clin Orthop Surg 2022; 14:441-449. [PMID: 36061841 PMCID: PMC9393267 DOI: 10.4055/cios21261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/10/2022] [Accepted: 02/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background The value of radiological measurements of subcoracoid impingement such as the coracohumeral interval in predicting subscapularis tendon injuries is controversial. We aimed to assess the relationship between radiological measurements of subcoracoid impingement and subscapularis tendon lesions in young and middle-aged adults. Methods This study was designed as a retrospective cohort study. Patients between the ages of 18–55 years without a history of shoulder surgery or major trauma were included and patients with arthritis, instability, or retracted rotator cuff tears were excluded from the study. Magnetic resonance images were evaluated and patients were grouped into two according to the subscapularis tendon condition: normal or pathologic. Glenoid version, axial coracohumeral distance, coracoglenoid angle, coracoid index, sagittal coracoid-glenoid tubercule distance, and axial coracoacromial inclination-glenoid version difference were measured for all patients. Measurement findings were compared between the groups. Correlation analysis was performed for age and radiologic measurements. A p < 0.05 was considered statistically significant for all tests. Results A total of 298 patients, 107 women (35.1%) and 191 men (64.9%), with a mean age of 34.46 ± 10.10 years (range, 18–55 years) were examined in the study. Subscapularis tendon pathology was noted in 85 patients (28.5%). The diagnosed pathologies were tendinosis in 48 patients (56.5%), partial tears in 28 (32.9%), and full thickness tears in 9 (10.6%). A significant relationship was observed between increasing age and subscapularis tendon lesions (p = 0.001). There was no statistically significant relationship between subscapularis pathology and calculated measurements. Axial coracohumeral distance and coracoglenoid angle measurements showed a statistically significantly negative correlation with age. A positive correlation was found between axial coracohumeral distance and coracoglenoid angle measurements (p < 0.001) and also between glenoid version and coracoid index measurements (p = 0.004). Axial coracohumeral distance and coracoglenoid angle measurements showed a negative correlation with glenoid version and coracoid index measurements (p < 0.05). Conclusions In this study, the coracohumeral distance and coracoglenoid angle decreased and the incidence of subscapularis tendon lesions increased as the age progressed. However, no relationship was found between radiological measurements and subscapularis tendon lesions.
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Affiliation(s)
- Yasemin Kucukciloglu
- Department of Orthopedics and Traumatology, Near East University Medical Faculty, Nicosia, Cyprus
| | - Deniz Aydın
- Department of Orthopedics and Traumatology, Near East University Medical Faculty, Nicosia, Cyprus
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Charry FB, Martínez MJL, Rozo L, Jurgensen F, Guerrero-Henriquez J. In vivo effects of two shoulder girdle motor control exercises on acromiohumeral and coracohumeral distances in healthy men. J Man Manip Ther 2021; 29:367-375. [PMID: 34260343 PMCID: PMC8725678 DOI: 10.1080/10669817.2021.1950300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Altered motor control and proprioceptive deficits are associated with kinematics dysfunctions and may cause alterations in subacromial space (SAS) that could lead to shoulder pathologies. Dimensions of the subacromial space, as well as interventions aimed at its normal restitution, can be explored by ultrasound (US). OBJECTIVE To describe the effect of two shoulder girdle motor control exercises with cognitive training strategies on SAS dimensions, measured with US. METHODS Cognitive movement control strategies, with visual and haptic feedback were applied on 21 healthy participants. SAS dimensions were measured through in vivo variations of acromiohumeral (AHD) and coracohumeral distances (CHD) using US. RESULTS Our results show that as exercise repetitions are performed, an increasing trend in both measures can be observed, being wider for AHD (i.e. humeral head descent exercise) than CHD (i.e. scapular retraction exercise). CONCLUSION Specific cognitive and motor control exercises improve congruence joint and centering of the humeral head.
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Affiliation(s)
- Fernanda B Charry
- Manual Therapy Master's Degree, Faculty of Rehabilitation Sciences, Andrés Bello University, Santiago, Chile
| | - María Jesús L Martínez
- Manual Therapy Master's Degree, Faculty of Rehabilitation Sciences, Andrés Bello University, Santiago, Chile
| | - Liliana Rozo
- Postgraduate Department of Manual Therapy, Faculty of Rehabilitation Sciences, Andres Bello University, Santiago, Chile
| | - Fernando Jurgensen
- Clinical Applicationist of Ultrasound for General Electric Company, Hoser Ingenieria, Santiago, Chile
| | - Juan Guerrero-Henriquez
- Rehabilitation and Human Movement Sciences Department, Faculty of Health Sciences, University of Antofagasta, Antofagasta, Chile
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Reichel T, Herz S, Tabbakh ME, Bley TA, Plumhoff P, Rueckl K. Less than 9.5-mm coracohumeral distance on axial magnetic resonance imaging scans predicts for subscapularis tear. JSES Int 2021; 5:424-429. [PMID: 34136849 PMCID: PMC8178628 DOI: 10.1016/j.jseint.2021.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Diagnosis of subscapularis (SSC) tendon lesions on magnetic resonance imaging (MRI) can be challenging. A small coracohumeral distance (CHD) has been associated with SSC tears. This study was designed to define a specific threshold value for CHD to predict SSC tears on axial MRI scans. Methods This retrospective study included 172 shoulders of 168 patients who underwent arthroscopic surgery for rotator cuff tear or glenohumeral instability. Diagnostic arthroscopy confirmed an SSC tear in 62 cases (36.0%, test group a), rotator cuff tear tears other than SSC in 71 cases (41.3%, control group b) and glenohumeral instability without any rotator cuff tear in 39 cases (22.7%, zero-sample group c). All patients had a preoperative MRI of the shoulder (1.5T or 3T). Minimum CHD was measured on axial fat-suppressed proton density-, T2-, or T1-weigthed sequences. Receiver operating characteristics analysis was used to determine the threshold value for CHD, and sensitivity and specificity were calculated. Results CHD measurement had a good interobserver reliability (Intraclass correlation coefficient 0.799). Mean CHD was highly significantly (P < .001) less for test group a (mean 7.3 mm, standard deviation ± 2.2) compared with control group b (mean 11.1 mm, standard deviation ± 2.3) or zero-sample group c (mean 13.6 mm, standard deviation ± 2.9). A threshold value of CHD <9.5 mm had a sensitivity of 83.6% and a specificity of 83.9% to predict SSC tears. Conclusion A CHD <9.5 mm on MRI is predictive of SSC lesions and a valuable tool to diagnose SSC tears.
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Affiliation(s)
- Thomas Reichel
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
| | - Stefan Herz
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Würzburg, Germany
| | - Mohammed El Tabbakh
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
| | - Thorsten Alexander Bley
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Würzburg, Germany
| | - Piet Plumhoff
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
| | - Kilian Rueckl
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
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Hodax JD, Shah KN, Campbell SE, Cameron KL, Owens BD. Measurement of the coracohumeral distance on magnetic resonance imaging in a large patient cohort. J Shoulder Elbow Surg 2021; 30:408-412. [PMID: 32561480 DOI: 10.1016/j.jse.2020.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Coracoid impingement syndrome is an increasingly recognized etiology of anterior shoulder pain. Numerus studies have documented the coracohumeral distance (CHD) as a primary or secondary measurement in symptomatic individuals, but there lacks an evaluation of CHD in a large cohort of asymptomatic individuals. The purpose of this study was to quantify a normative distribution of the CHD in a large cohort of healthy, asymptomatic subjects with no history of impingement or shoulder instability. METHODS Incoming first-year students in the United States Military Academy were offered enrollment in this study as part of a prospective cohort to assess the normal anatomic relationships of the shoulder girdle. Magnetic resonance images were obtained, and a board-certified, fellowship-trained musculoskeletal radiologist performed measurements of the smallest distance from the coracoid to the humeral head on axial images. RESULTS Magnetic resonance images of 714 subjects were available for analysis, including 630 males and 84 females, with a total of 1120 individual shoulders with images of adequate quality. The mean CHD for all shoulders imaged was 13.7 mm. The mean CHD in male shoulders was 13.8 mm, and in female subjects the average was 12.4 mm. CONCLUSIONS This study is the largest of its kind to evaluate the CHD in asymptomatic, healthy shoulders to date and demonstrates a mean CHD of 13.7 mm for all subjects. This information can help to standardize "normal" ranges and act as a comparison for future work, when taken in the context of age and imaging in neutral rotation.
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Affiliation(s)
- Jonathan D Hodax
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - Kalpit N Shah
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA.
| | | | | | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
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Diagnosis and Management of Subcoracoid Impingement. J Am Acad Orthop Surg 2021; 29:100-107. [PMID: 33323679 DOI: 10.5435/jaaos-d-20-00008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 10/05/2020] [Indexed: 02/01/2023] Open
Abstract
Impingement of the subcoracoid space is a poorly understood pathologic cause of anterior shoulder pain. Because of its relative rarity in isolation and nonspecific presentation, diagnosis and management are often challenging for orthopaedic surgeons and their patients. Stenosis of the subcoracoid space between the lesser tuberosity and the coracoid process <6 mm can lead to anterior shoulder pain and associated rotator cuff and biceps pathology. Multiple imaging modalities are available to assess narrowing of the coracohumeral interval, each with its strengths and limitations. If the patient can be accurately diagnosed with subcoracoid impingement, both conservative and surgical management options are available. Despite earlier case series demonstrating promising results with arthroscopic treatment, comparative studies have yet to support these initial claims.
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Sundararajan SR, Joseph JB, Ramakanth R, Jha AK, Rajasekaran S. Do coracohumeral interval and glenoid version play a role in subscapularis tears? JSES Int 2020; 4:888-892. [PMID: 33345230 PMCID: PMC7738594 DOI: 10.1016/j.jseint.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Purpose To study the effect of the coracohumeral interval and orientation of the glenoid for causation of subscapularis tears and literature review for the need of coracoplasty. Methods This is a retrospective cohort study of patients who underwent arthroscopic shoulder surgery from January 2013 to December 2017. The coracohumeral interval and orientation of the glenoid in patients with arthroscopically diagnosed subscapularis tears (group A, n = 40) were compared with 2 control groups (group B, n = 38 [intact subscapularis with supraspinatus and infraspinatus cuff tears] and group C, n = 39 [intact rotator cuff]). Group A1 (n = 23) consisted of the isolated subscapularis and combined subscapularis + supraspinatus tears, and group A2 (n = 17) all the 3 rotator cuff tears. The measurements were made on preoperative axial magnetic resonance imaging. Statistical analysis was performed to compare the groups. Results The mean coracohumeral interval was 8.81 ± 2.69 mm in group A and 10.62 ± 2.21 and 10.39 ± 2.59 mm in control groups B and C, respectively; this difference was statistically significant (P = .002 and .01, respectively). The mean glenoid version in patients with subscapularis tears was -3.7°, whereas the mean version in patients with intact cuff was -3.4°, and this difference was not statistically significant (P = .74). The mean glenoid version was -4.69° ± 4.22° in group A1 and -3.28° ± 4.04° in group B, with no statistically significant difference (P = .07). Conclusion The coracohumeral interval was significantly decreased in patients with subscapularis tears. The glenoid was retroverted in the subscapularis group but was not statistically significant.
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Affiliation(s)
| | - Joseph Babu Joseph
- Department of Arthroscopy and Sports Medicine, Ganga Medical Centre & Hospitals, Coimbatore, India
| | | | - Amit Kumar Jha
- Department of Arthroscopy and Sports Medicine, Ganga Medical Centre & Hospitals, Coimbatore, India
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Watson AC, Jamieson RP, Mattin AC, Page RS. Magnetic resonance imaging based coracoid morphology and its associations with subscapularis tears: a new index. Shoulder Elbow 2019; 11:52-58. [PMID: 31019563 PMCID: PMC6463382 DOI: 10.1177/1758573217744170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 10/15/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to assess the validity of magnetic resonance imaging (MRI) in assessing the subcorocoid space and determine the validity of novel sagittal plane subcorocoid space measurements. METHODS We assessed 33 arthroscopically proven subscapularis tears with MRIs compared to 33 (instability) controls with normal subscapularis tendons. Three examiners analyzed MRIs for seven static indices of corocoid morphology, in axial and sagittal planes. We explored reviewer variation using intraclass correlation coefficients (ICC) and differences between the two groups was explored using t-tests. RESULTS Groups were similar in characteristics but different in age (cases = 53, controls = 23). ICC showed good (2/7) or excellent (5/7) reliability. Small differences(<1.6 mm) were identified between subscapularis tears and controls in coraco-humeral distance, in axial (p = 0.092) and sagittal planes (p = 0.045). There were statistically significant differences between groups when analyzing the angular projection of the coracoid from the glenoid, in both sagittal (p < 0.0001) and axial planes (p = 0.045). CONCLUSIONS Acute inferior angulation of the corocoid in the sagittal plane may be associated with subscapularis tears. Static indices are measured within the scapula and not affected by arm position. MRI reliably provided a platform to assess the coracoid. Based on this, we currently consider corocoplasty in patients with subscapularis tears and a sagittal coroco-glenoid angle <60o to reduce potential impingement.
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Affiliation(s)
- Adam C. Watson
- Adam C. Watson, University Hospital Geelong, Ryrie St, Geelong, Victoria 3220. Australia.
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Asal N, Şahan MH. Radiological Variabilities in Subcoracoid Impingement: Coracoid Morphology, Coracohumeral Distance, Coracoglenoid Angle, and Coracohumeral Angle. Med Sci Monit 2018; 24:8678-8684. [PMID: 30500807 PMCID: PMC6284362 DOI: 10.12659/msm.911470] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/01/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the effects of coracoid morphology, coracohumeral distance, coracoglenoid angle, and coracohumeral angle variabilities on subcoracoid impingement development using magnetic resonance imaging (MRI). MATERIAL AND METHODS A total of 200 patients (87 males with mean age of 51.1±15.2 years and 113 females with mean age of 52.6±10.7 years) undergoing shoulder MRI were included in this retrospective study. All MRI studies were performed with standard positioning. Coracoid morphology and subscapularis tendon were evaluated. Coracohumeral distance, coracoglenoid angle and coracohumeral angle were measured in all subjects. One-way ANOVA was used to assess the difference between the groups. For binary comparisons, Tukey post hoc analysis was done. Pearson correlation analysis was performed between variables. RESULTS Type C coracoid was more frequent in the tendinosis and tendon tear groups. There was a significant difference between type C coracoid and the other coracoid types for coracohumeral distance values (P=0.016). There was a statistically significant decrease in coracoglenoid angle values and coracohumeral distance in patients with subscapularis tendon pathologies (P=0.000). A statistically insignificant increase in coracohumeral angle values was found in the subscapularis tendon pathologies. There was a positive correlation between coracohumeral distance and coracoglenoid angle (R=0.749 P=0.000). There was a negative correlation between coracohumeral distance and coracohumeral angle (R=-0.668 P=0.000) and between coracoglenoid angle and coracohumeral angle (R=-0.605 P=0.000). CONCLUSIONS In subscapularis tendon pathologies, decrease in coracohumeral distance and coracoglenoid angle was observed. A new approach uses coracohumeral angle to evaluate subcoracoid impingement. A statistically insignificant increase in coracohumeral angle was noted.
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Altintas B, Buckley PS, Millett PJ. Editorial Commentary: Arthroscopic Subscapularis Repair: Bridging Successful Tendon Healing and Improved Patient Outcomes. Arthroscopy 2018; 34:2549-2551. [PMID: 30173795 DOI: 10.1016/j.arthro.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 02/02/2023]
Abstract
Open repair has been regarded as the gold standard for the treatment of subscapularis tendon tears. However, recent studies on newer arthroscopic techniques and published results of arthroscopic repair have shown promising results. As such, there exists a growing interest in understanding the best fixation technique to obtain successful functional and patient-reported clinical outcomes. While the literature shows superior outcomes after double-row repair for posterosuperior rotator cuff tears compared with single-row repair, the evidence is inconclusive for subscapularis tears. We believe that arthroscopic double-row transosseous equivalent repair of full-thickness subscapularis tears leads to superior clinical outcomes with higher healing rates and will become the standard of care in the future.
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Dugarte AJ, Davis RJ, Lynch TS, Schickendantz MS, Farrow LD. Anatomic Study of Subcoracoid Morphology in 418 Shoulders: Potential Implications for Subcoracoid Impingement. Orthop J Sports Med 2017; 5:2325967117731996. [PMID: 29085845 PMCID: PMC5648098 DOI: 10.1177/2325967117731996] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Subcoracoid impingement has been implicated as a cause of anterior shoulder pain and subscapularis tendon tears. Purpose/Hypothesis: The purpose of this study was to evaluate the bony anatomy of the coracoid process and the subcoracoid space. We hypothesized that age-related changes that may contribute to subcoracoid impingement occur in the subcoracoid space. Study Design: Descriptive laboratory study. Methods: In total, 418 skeletal shoulder specimens were included in this study. We utilized 214 shoulders from a young cohort (25-35 years of age) and 204 shoulders from an older cohort (>55 years of age) for comparison. We evaluated several morphological characteristics of the coracoid process and the subcoracoid space: coracoid width, coracoid shape, coracoid thickness, and subcoracoid distance. Each coracoid was observed for the presence of spurring or other morphological changes. Results: The mean anteroposterior (AP) thickness of the coracoid tip was 7.9 and 9.4 mm in our young female and male cohorts, respectively, while the mean AP thickness was 8.1 and 9.7 mm in our older female and male cohorts, respectively. The coracoid tip was hooked in 31 of 108 young female shoulders compared with 55 of 102 older female shoulders, and the coracoid tip was hooked in 25 of 106 young male shoulders compared with 45 of 102 older male shoulders. The mean subcoracoid distance in neutral rotation was 14.8 and 12.5 mm in young and older female shoulders, respectively, while the mean subcoracoid distance in internal rotation in these same cohorts was 8.7 and 7.0 mm, respectively. The mean subcoracoid distance in neutral rotation was 14.8 and 13.3 mm in young and older male shoulders, respectively, while the mean subcoracoid distance in internal rotation was 8.6 and 8.1 mm in young and older male shoulders, respectively. Conclusion: The principal findings of our study demonstrate that anatomic changes implicated in subcoracoid impingement may be developmental and worsen with age. The subcoracoid space was narrower in our older cohort of shoulders. Additionally, these older shoulders also had a greater AP width and a more hooked coracoid compared with young shoulders. Clinical Relevance: Narrowing of the subcoracoid space has been shown to be implicated as a cause of anterior shoulder pain and subscapularis tendon tears. This is the first study to show that the morphological changes implicated in subcoracoid impingement become more prevalent with age. This may help to explain the increasing prevalence of subscapularis tendon tears in older patients. Furthermore, subcoracoid decompression may be seen as an option for older patients with anterior shoulder pain and subscapularis tendon tears.
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Affiliation(s)
| | | | - T Sean Lynch
- Columbia University Medical Center, New York, New York, USA
| | | | - Lutul D Farrow
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Navarro-Ledesma S, Struyf F, Labajos-Manzanares MT, Fernandez-Sanchez M, Luque-Suarez A. Is coracohumeral distance associated with pain-function, and shoulder range of movement, in chronic anterior shoulder pain? BMC Musculoskelet Disord 2017; 18:136. [PMID: 28376749 PMCID: PMC5379620 DOI: 10.1186/s12891-017-1498-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was twofold: (i) to assess the intrarater reliability of coracohumeral distance; (ii) to investigate the level of association between coracohumeral distance measured by ultrasonography, and pain-disability and shoulder range of movement, in patients suffering from chronic anterior shoulder pain. METHODS An observational, cross sectional study was carried out. A convenience sample comprised of 87 patients with chronic anterior shoulder pain was assessed from 3 primary care centres. Main outcomes as pain and function were measured through the shoulder pain and disability index. Furthermore, shoulder range of movement-free of pain in shoulder elevation, as well as coracohumeral distance at both 0 and 60 degrees, were collected. RESULTS Absence of any correlation was found between coracohumeral distance and shoulder pain and disability index at both 0 and 60 degrees of shoulder elevation. Furthermore, absence of any correlation was found between coracohumeral distance measurements and active shoulder range of movement -free of pain. CONCLUSIONS There was poor association between coracohumeral distance and shoulder pain and function, as well as with shoulder range of movement, in patients with chronic anterior shoulder pain. Hence, clinicians should consider, not only increasing this space, but also other possibilities in their therapies, when patients with anterior shoulder pain are treated. TRIAL REGISTRATION ACTRN12614000144617 . Registered: 1st March 2014.
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Affiliation(s)
- S Navarro-Ledesma
- Department of Physiotherapy, University of Malaga, Malaga, Spain.,Departament of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerpen, Belgium
| | - F Struyf
- Departament of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerpen, Belgium
| | | | - M Fernandez-Sanchez
- Department of Nursing, Physiotherapy and Medicine, University of Almeria, Almeria, Spain
| | - A Luque-Suarez
- Department of Physiotherapy, University of Malaga, Malaga, Spain.
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