The End of an Era?

A cross-sectional observational study comparing individuals with a symptomatic full-thickness rotator cuff tear with age-matched controls

Background

A full-thickness rotator cuff tear (FTRCT) is defined as a complete tear of one of the four rotator cuff muscle tendons (supraspinatus, infraspinatus, subscapularis or teres minor). This condition can lead to pain and reduced function. However, not all FTRCT are symptomatic. A better understanding of the characteristics that lead some individuals with FTRCT to experience pain is fundamental to improve strategies used to manage this condition. This level II descriptive study aimed to explore potential sociodemographic, anatomical, psychosocial, pain sensitivity, biomechanical and neuromuscular variables that may differ between individuals with symptomatic FTRCT and age-matched individuals with asymptomatic shoulders.

Methods

In this cross-sectional observational study, adults aged 50 to 80 years of age, either with symptomatic FTRCT or no shoulder pain, were recruited via convenience sampling. Participants filled out questionnaires on sociodemographic and psychosocial variables. Then, various tests were performed, including pain pressure threshold, shoulder range of motion, shoulder muscle strength, shoulder ultrasound and radiologic examination, and sensorimotor functions testing. Each variable was compared between groups using univariate analyses (independent t-tests, Mann-Whitney U tests, exact probability Fisher tests). Significance was set at 0.05.

Results

FTRCT (n = 30) and Control (n = 30) groups were comparable in terms of sex, age, and number of comorbidities. The symptomatic FTRCT group showed a higher proportion of smokers (P = .026) and more participants indicated consuming alcohol or drugs more than they meant to (P = .010). The FTRCT group had a significantly higher prevalence of glenohumeral osteophytes (48% vs. 17%; P = .012). Participants in the FTRCT group were significantly more stressed (P = .04), anxious (P = .003) and depressed (P = .002). The FTRCT group also showed significantly higher levels of pain catastrophisation (P < .001) and sleep disturbance (P < .001). The FTRCT group showed significantly lower range of motion for flexion (P < .001), and external rotation at 0° (P < .001) and 90° (P < .001) of abduction. Isometric strength in both abduction and external rotation were weaker (P = .005) for the FTRCT group.

Conclusion

Sociodemographic, anatomical, psychosocial and biomechanical variables showed statistically significant differences between the FTRCT and Control groups.

Shoulder Impingement Syndrome

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

No relationship between the acromiohumeral distance and pain in adults with subacromial pain syndrome: a systematic review and meta-analysis

To determine whether subacromial space (i.e. acromiohumeral distance; AHD, and/or occupation ratio percentage) differs between people with subacromial pain syndrome (SAPS) and those without. To investigate whether there is a correlation between subacromial space and pain or disability in adults with SAPS and whether temporal changes in pain or disability are accompanied by changes in subacromial space. Systematic review and meta-analysis. Fifteen studies with a total of 775 participants were included. Twelve studies were of high quality and three studies were of moderate quality using the modified Black and Downs checklist. There was no between group difference in AHD in neutral shoulder position (mean difference [95% CI] 0.28 [−0.13 to 0.69] mm), shoulder abduction at 45° (−0.02 [−0.99 to 0.96] mm) or 60° (−0.20 [−0.61 to 0.20] mm). Compared to the control group, a greater occupation ratio in neutral shoulder position was demonstrated in participants with SAPS (5.14 [1.87 to 8.4] %). There was no consistent pattern regarding the correlation between AHD and pain or disability in participants with SAPS, and no consistent increase in subacromial space with improvement in pain or disability over time. The results suggest that surgical (e.g. sub-acromial decompression) and non-surgical (e.g. manual therapy, taping, stretching and strengthening) management of subacromial pain syndrome should not focus solely on addressing a potential decrease in subacromial space, but also on the importance of other biopsychosocial factors.

Patients with shoulder pain referred to specialist care; treatment, predictors of pain and disability, emotional distress, main symptoms and sick-leave: a cohort study with a six-months follow-up

Objectives

Recommendations for referral of patients with shoulder pain from primary to specialist care are mainly clinical. Several patients are referred without meeting these criteria for referral, whereas some are referred for a second opinion although surgery is not recommended. The aims of this study were to describe a shoulder pain cohort in specialist healthcare according to demographic data, clinical, and psychological factors; evaluate changes in pain and disability, distress and main symptoms from baseline to six-month follow-up; and to assess predictors of pain and disability, changes in the main symptoms and sick-leave at six-months. Results were compared to previous randomised trials conducted at the same clinic in patients with subacromial shoulder pain.

Methods

This prospective study included 167 patients from an outpatient clinic in specialist healthcare with shoulder pain for more than 6 weeks. Clinical (pain duration, intensity, pain sites), sociodemographic (age, gender, educational level, work status) and psychological variables (emotional distress (HSCL-10), fear of pain, screening of “yellow flags”, health-related quality of life) were collected. Shoulder pain and disability (SPADI-score) were assessed and the patients were asked about their outcome expectation and to predict their status of their shoulder problem the next month. They underwent a clinical interview, a clinical assessment of shoulder function and orthopaedic tests for diagnostic purposes. After six months they received a questionnaire with main variables.

Results

Of the 167 patients (55% women), 50% had symptoms for more than 12 months and 37 (22%) were on sick-leave. Characteristics were in general comparable to patients previously included in clinical trials at the same department. The SPADI-score was 46 (23) points. Mean emotional distress was within the normal range (1.7 (SD 0.6)). More than 80% had received treatment before, mainly physiotherapy in addition to the GPs treatment. One hundred and thirty-seven patients (82%) were re-referred to physiotherapy, 74 (44%) in the outpatient clinic specialist healthcare, and 63 (38%) in primary care. One hundred and eighteen (71%) answered the follow-up questionnaire. Mean change in SPADI-score was 10.5 points (95% CI (6.5–14.5)), and 29% of the patients improved more than the smallest detectable difference (SDD). The percentage sick-listed was 19.5%, and mean change in main symptoms (−9 to +9) was 3.4 (SD 3.9). The subgroup of patients receiving physiotherapy in outpatient specialist care did not show any significant change in the main variables. The prediction models suggested that a lower level of education, more fear of pain and a high baseline SPADI-score, predicted a higher SPADI-score at follow-up. A high baseline HSCL-10 score was the only significant predictor for a high HSCL-10 score. At follow-up, less pain at rest predicted more change in main symptoms and more yellow flags (a higher score on the Örebro screening test) predicted sick-leave.

Conclusions

Within the limitations of a cohort study, patients with persistent shoulder pain referred to an outpatient specialist clinic had similar baseline characteristics but shorter treatment duration, inferior clinical results and predictors somewhat different compared with previous clinical trials conducted at the same clinic. The study raises some questions about the effectiveness of the routines in daily clinical practice, the selection of patients, the treatment duration and content.

Subacromial impingement syndrome: a survey of Italian physiotherapists and orthopaedics on diagnostic strategies and management modalities

BACKGROUND AND AIM

The subacromial impingement syndrome (SIS) represents a common cause of disability in approximately 74% of patients with Shoulder Pain (SP). Even if contemporary research suggests that this mechanism is not (always) the dominant driver in SP, SIS is still a source of debate among scholars and clinicians. From a clinical point of view, evidence has suggested that clinicians can use both medical and physiotherapy approaches as effective methods to treat SIS.This survey aims to investigate models of management of patients with SIS in a sample of Italian physiotherapist specialists (Orthopaedic Manipulative Physical Therapists, -OMPTs-) and orthopaedic surgeons.

MATERIALS AND METHODS

An online survey with 29-item questionnaire was administered to assess the knowledge of OMPTs and orthopaedic surgeons about: a) strategies of clinical examination; b) the role of imaging in the diagnostic process; c) the physiotherapy management; and d) the pharmacological and surgical management in patients with SIS.

RESULTS

Six-hundred and twenty-nine respondents completed the survey (511 OMPTs (79.97%) and 128 orthopaedic surgeons (20.03%)). Ninety-two percent (n = 470) of the OMPTs and 80.5% (n = 103) of orthopaedic surgeons stated that in patients with SIS, a combination of diagnostic tests produced better accuracy (p = < 0.001). Twenty point seven % of OMPTs (n = 106) and 4.7% of orthopaedic surgeon (n = 6) stated that the Lift off was the most specific test (p = < 0.001). Four-hundred-and-twenty-four OMPTs (83%) and 40 orthopaedic surgeons (31.3%) answered that the gold standard for diagnosis of a patient with SIS are history and clinical examination (p < 0.001).

CONCLUSION

OMPTs and orthopaedic surgeons approach patients with SIS differently during both the assessment and the treatment. OMPTs appear to be appropriate in planning and managing clinical examination and therapeutic strategies to use with patients with SIS.

Why are assumptions passed off as established knowledge?

In this paper we attempt to explain the problems that can arise when assumptions made by experts in their respective fields of Medicine become widely accepted as established knowledge. Our hypothesis is that these problems are in large part attributable to a failure of the experts to follow the principles of logical argument. Empirical data to evaluate our hypothesis derives from an analysis of the reasoning processes employed in the generation of three syndromes drawn from the clinical discipline of Pain Medicine: myofascial pain, shoulder impingement and central sensitisation. We demonstrate a failure by the proponents of these syndromes to structure their scientific arguments in a logically valid fashion, which lead them to promote assumptions to the status of facts. In each instance those in relevant scientific journals responsible for content review accepted - and thereby promulgated - this fundamental error in reasoning. The wide acceptance of each of these assumptions as established knowledge affirms our hypothesis. Furthermore, we show that such uncritical acceptance has had significant consequences for many patients.

The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice

While advances in assessment and management of musculoskeletal conditions have improved care for many people, there have been other, less beneficial developments in the provision of care for people with musculoskeletal pain conditions, one of which is the worrying tendency to provide too much medicine. Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive. Another concern in musculoskeletal health care is medicalizing normality-when a normal human function or condition is labeled as abnormal. In this Viewpoint, the authors argue that medicalizing normality creates health concerns where none exist, while too much medicine involves provision of care where benefits do not outweigh harms, and wastes precious health care resources. The authors (1) list 2 common examples of too much medicine, and 2 examples of medicalizing normality, relevant to physical therapy practice; (2) outline the drivers of too much medicine and medicalizing normality; and (3) make suggestions for change. J Orthop Sports Phys Ther 2020;50(1):1-4. doi:10.2519/jospt.2020.0601.

The Influence of Glenohumeral Joint Posterior Capsule Tightness and Impingement Symptoms on Shoulder Impairments and Kinematics

BACKGROUND

Posterior capsule tightness (PCT) and shoulder impingement syndrome (SIS) symptoms are both associated with altered shoulder biomechanics and impairments. However, their combined effect on kinematics, pain, range of motion (ROM), strength, and function remain unknown.

OBJECTIVE

The purpose of this study was to determine if the combination of PCT and SIS affects scapular and humeral kinematics, glenohumeral joint ROM, glenohumeral joint external rotation strength, pain, and function differently than does either factor (PCT or SIS) alone.

DESIGN

The design was a cross-sectional group comparison.

METHODS

Participants were placed into 1 of 4 groups based on the presence or absence of SIS and PCT: control group (n = 28), PCT group (n = 27), SIS group (n = 25), and SIS + PCT group (n = 25). Scapular kinematics and humeral translations were quantified with an electromagnetic motion capture system. Shoulder internal rotation and external rotation ROM, external rotation strength, and pain and Shoulder Pain and Disabilities Index scores were compared between groups with ANOVA.

RESULTS

The SIS group had greater scapular internal rotation (mean difference = 5.13°; 95% confidence interval [CI] = 1.53°-8.9°) and less humeral anterior translation (1.71 mm; 95% CI = 0.53-2.9 mm) than the other groups. Groups without PCT had greater internal rotation ROM (16.05°; 95% CI = 5.09°-28.28°). The SIS + PCT group had lower pain thresholds at the levator scapulae muscle (108.02 kPa; 95% CI = 30.15-185.88 kPa) and the highest Shoulder Pain and Disabilities Index score (∼ 44.52; 95% CI = 33.41-55.63).

LIMITATIONS

These results may be limited to individuals with impingement symptoms and cannot be generalized to other shoulder conditions.

CONCLUSIONS

Decreased ROM and lower pain thresholds were found in individuals with both impingement symptoms and PCT. However, the combination of factors did not influence scapular and humeral kinematics.

Towards an integrated clinical framework for patient with shoulder pain

Background

Shoulder pain (SP) represents a common musculoskeletal condition that requires physical therapy care. Along the years, the usual evaluation strategies based on clinical tests and diagnostic imaging has been challenged. Clinical tests appear unable to clearly identify the structures that generated pain and interpretation of diagnostic imaging is still controversial. The current patho-anatomical diagnostic categories have demonstrated poor reliability and seem inadequate for the SP treatment.

Objectives

The present paper aims to (1) describe the different proposals of clinical approach to SP currently available in the literature; to (2) integrate these proposals in a single framework in order to help the management of SP.

Conclusion

The proposed clinical framework, based on a bio-psychosocial vision of health, integrates symptoms characteristics, pain mechanisms and expectations, preferences and psychosocial factors of patients that may guide physiotherapist to make a diagnostic triage and to choose the right treatment for the individual patient.