Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment?

Efficacy of hypertonic dextrose proliferation therapy in the treatment of rotator cuff lesions: a meta-analysis

BACKGROUND

One of the most prevalent illnesses of the shoulder is rotator cuff tendinosis, which is also a major contributor to shoulder discomfort and shoulder joint dysfunction. According to statistics, rotator cuff tendinosis occurs in 0.3-5.5% of cases and affects 0.5-7.4% of people annually. It will be necessary to conduct a meta-analysis to evaluate the efficacy of hypertonic glucose proliferation therapy in the treatment of rotator cuff problems.

METHODS

The databases Cochrane PubMed, Library, Web of Science and EMbase, are retrieved by the computer. Individuals with rotator cuff lesions in the intervention group were treated with hypertonic dextrose proliferation therapy, whereas individuals in the control condition were treated with a placebo. Outcome markers for rotator cuff lesions patients; Pursuant to studies, the visual analogue scale (VAS) score, the shoulder pain & disability index (SPADI), & other metrics are used to evaluate the effects of hypertonic dextrose proliferation treatment on individuals with rotator cuff diseases. After carefully evaluating the calibre of the literature, data analysis was performed utilising the RevMan 5.3 programme.

RESULTS

Meta-analysis finally contained 6 papers. In six investigations, the test & control group's VAS scores improved, with the test team's score considerably outperforming the control team [standardized mean difference (SMD): 1.10; 95% Cl: 0.37,1.83; P < 0.01], shoulder pain and disability index (SPADI) score (SMD:8.13; 95% Cl: 5.34,10.91; P < 0.01), Flexion (SMD:5.73; 95% Cl: 0.99,10.47; P < 0.05), Abduction (SMD:6.49; 95% Cl: 0.66,12.31; P < 0.05), Internal rotation (SMD:-1.74; 95% Cl: -4.25,0.78; P = 0.176) and External rotation (SMD:2.78; 95% Cl: -0.13,5.69; P = 0.062).

CONCLUSION

The findings of this study suggest that individuals with rotator cuff injuries may benefit from hypertonic dextrose proliferation treatment based on the visual analogue scale (VAS) score, the Shoulder Pain and Disability Index (SPADI) score, Flexion, & Abduction. These results must, nevertheless, be supported by high-caliber follow-up research.

To allow or avoid pain during shoulder rehabilitation exercises for patients with chronic rotator cuff tendinopathy-Study protocol for a randomized controlled trial (the PASE trial)

BACKGROUND

Rotator cuff (RC) tendinopathy is the most reported shoulder disorder in the general population with highest prevalence in overhead athletes and adult working-age population. A growing body of evidence support exercise therapy as an effective intervention, but to date there are no prospective randomized controlled trials addressing pain as an intervention variable.

METHODS

A single-site, prospective, pragmatic, assessor-blinded randomized controlled superiority trial. Eighty-four patients aged 18-55 years with chronic (symptom duration over 3 months) RC tendinopathy are randomized 1:1 to receive shoulder exercise during which pain is either allowed or avoided. The intervention period lasts 26 weeks. During that period, participants in both groups are offered 8 individual on-site sessions with an assigned sports physiotherapist. Participants perform home exercises and are provided with a pain and exercise logbook and asked to report completed home-based exercise sessions and reasons for not completing sessions (pain or other reasons). Patients are also asked to report load and the number of sets and repetitions per sets for each exercise session. The logbooks are collected continuously throughout the intervention period. The primary and secondary outcomes are obtained at baseline, 6 weeks, 26 weeks, and 1 year after baseline. The primary outcome is patient-reported pain and disability using the Shoulder PAin and Disability Index (SPADI). Secondary outcomes are patient-reported pain and disability using Disability Arm Shoulder and Hand short-form (Quick DASH), and shoulder pain using Numeric Pain Rating Scale. Objective outcomes are shoulder range of motion, isometric shoulder muscle strength, pain sensitivity, working ability, and structural changes in the supraspinatus tendon and muscle using ultrasound.

DISCUSSION

The results of this study will contribute knowledge about the treatment strategies for patients with RC tendinopathy and help physiotherapists in clinical decision-making. This is the first randomized controlled trial comparing the effects of allowing pain versus avoiding pain during shoulder exercises in patients with chronic RC tendinopathy. If tolerating pain during and after exercise proves to be effective, it will potentially expand our understanding of "exercising into pain" for this patient group, as there is currently no consensus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05124769. Registered on August 11, 2021.

Immediate effects of Kinesio taping and Dynamic taping on acromiohumeral distance in individuals with symptomatic rotator cuff tendinopathy

BACKGROUND

It has been suggested that the reduction in subacromial space during arm elevation is one of the potential mechanisms in the etiology of Rotator cuff tendinopathy. While it is known that Kinesio taping reduces the narrowing of the acromiohumeral distance (AHD) during arm elevation, the effect of Dynamic taping remains unknown.

PURPOSE

This study aimed to compare the immediate effects of Kinesio taping and Dynamic taping on AHD in individuals with symptomatic Rotator Cuff Tendinopathy.

STUDY DESIGN

Two group pre-post-test repeated measures design was used.

METHODS

Thirty-two participants were randomly assigned to two groups: Kinesio taping group (n = 16) and Dynamic taping group (n = 16). AHD measurements were taken via ultrasound at 0° (rest) and 60° shoulder abduction both before and immediately after taping. Repeated measures ANOVAs were used for statistical analyses.

RESULTS

The study demonstrated that both taping methods led to a significant increase in AHD at both neutral and 60° abduction. However, the increase in AHD with Dynamic taping was statistically greater than with Kinesio taping in both neutral (p < 0.05) and 60° abduction (p < 0.001).

CONCLUSIONS

The findings of this study suggest that Dynamic taping techniques may be a more effective approach for improving AHD for symptomatic patients. Therefore, Dynamic taping has the potential to be clinically beneficial before engaging in exercises.

SPiRIT study protocol (Shoulder Pain: Randomised trial of Injectable Treatments): a randomised feasibility and pilot study of autologous protein solution (APS) vs corticosteroids for treating subacromial shoulder pain

BACKGROUND

The management of subacromial shoulder pain represents a significant challenge and is typically managed through either physiotherapy, joint injection or surgical intervention. Recent surgical trials have questioned the efficacy and there is a need to improve the evidence base for the non-surgical management of this condition. The study aims to provide evidence of the feasibility of conducting a randomised controlled trial to compare the efficacy of autologous protein solution (APS) against the current standard of care, corticosteroid injection (CSI) for subacromial shoulder pain. Autologous protein solution (APS) is a blood-derived biological injection which has been shown to have anti-inflammatory effects.

METHODS

A parallel-group two-arm randomised control trial will be conducted, comparing APS and CSI for shoulder pain. Fifty patients will be recruited. Feasibility will be assessed by examination of the conversion rate of eligible participants to the total number of participants recruited, whether it is possible to collect the appropriate outcome measures and the levels of retention/data compliance at follow-up dates.

DISCUSSION

CSI is the mainstay of conservative management of subacromial shoulder pain. Trials and systematic reviews have reported differing conclusions, but the consensus view is that any benefits seen from CSI use are most likely to be short-term and there remains a significant number of patients who go on to have surgical intervention despite CSI. Biological injections, such as APS are being increasingly used, in the anticipation they may offer improved longer lasting outcomes for shoulder pain. However, the evidence to demonstrate the comparative efficacy of CSI versus APS does not currently exist. If feasible, a fully powered study will offer clarity to the treatment pathway of thousands of patients each year with subacromial pain.

TRIAL REGISTRATION

The study is funded by the National Institute for Health Research-Research for Patient Benefit, NIHR 201473, Trial Registration Number (ISRCTN12536844: SPiRIT. Shoulder pain: randomised trial of injectable treatments-date of Registration 15/9/2021). Protocol Version V1.0_30Jul2021. IRAS Project ID: 294,982.

Advancements in the diagnosis and management of rotator cuff tears. The role of artificial intelligence

Background

This review examined the role of artificial intelligence (AI) in the diagnosis and management of rotator cuff tears (RCTs).

Methods

A literature search was conducted in October 2023 using PubMed (MEDLINE), SCOPUS, and EMBASE databases, included only peer-reviewed studies. Relevant articles on AI technology in RCTs. A critical analysis of the relevant literature was conducted.

Results

AI is transforming RCTs management through faster and more precise identification and assessment using algorithms that facilitate segmentation, quantification, and classification of the RCTs across various imaging modalities. Precise algorithms focusing on preoperative factors to assess RCTs reparability have been developed for personalized treatment planning and outcome prediction. AI also aids in exercise classification and promotes patient adherence during at-home physiotherapy. Despite promising advancements, challenges in data quality and symptom integration persist. Future research should include refining AI algorithms, expanding their integration into various imaging techniques, and exploring their roles in postoperative care and surgical decision-making.

Conclusions

AI-driven solutions improve diagnostic accuracy and have the potential to influence treatment planning and postoperative outcomes through the automated RCTs analysis of medical imaging. Integration of high-quality datasets and clinical symptoms into AI models can enhance their reliability. Current AI algorithms can also be refined, integrated into other imaging techniques, and explored further in surgical decision-making and postoperative care.

Are clinical outcomes associated with baseline sensory profiles in people with musculoskeletal shoulder pain? Protocol for a prospective longitudinal observational study

BACKGROUND

Musculoskeletal shoulder pain is a common problem and its symptoms often become persistent. The experience of pain is multidimensional, and therefore, a range of patient characteristics may influence treatment response. An altered sensory processing has been associated with persistent musculoskeletal pain states and may contribute to outcomes in patients with musculoskeletal shoulder pain. The presence and potential impact of altered sensory processing in this patient cohort is not currently known. The aim of this prospective longitudinal cohort study is to investigate if baseline sensory characteristics are associated with clinical outcomes in patients presenting to a tertiary hospital with persistent musculoskeletal shoulder pain. If found, a relationship between sensory characteristics and outcome may lead to the creation of more effective treatment strategies and improvements in risk adjustment and prognosis.

METHODS

This is a single-centre prospective cohort study with 6-, 12- and 24-month follow-up. A total of 120 participants aged ≥18 years with persistent musculoskeletal shoulder pain (≥3 months) will be recruited from an Australian public tertiary hospital orthopaedic department. Baseline assessments, including quantitative sensory tests and a standardised physical examination, will be performed. In addition, information will be obtained from patient interviews, self-report questionnaires and medical records. Follow-up outcome measures will comprise information from the Shoulder Pain and Disability Index and a six-point Global Rating of Change scale.

ANALYSIS

Descriptive statistics will be used to report baseline characteristics and outcome measures over time. Change in outcome measures at the primary endpoint of six months from baseline will be calculated using paired t-tests. Associations between baseline characteristics and outcomes at a 6-month follow-up will be reported using multivariable linear and logistic regression models.

DISCUSSION

Understanding the relationship between sensory profile and the variable response to treatment in people with persistent musculoskeletal shoulder pain may enhance our understanding of the mechanisms contributing to the presentation. In addition, through better understanding of the contributing factors, the results of this study may contribute to the development of an individualised, patient-centred approach to treatment for people with this highly prevalent and debilitating condition.

Effects of elastic kinesiology taping on shoulder proprioception: a systematic review

BACKGROUND

Shoulder injuries are associated with proprioceptive deficits. Elastic kinesiology tape (KT) is used for treating musculoskeletal disorders, including shoulder injuries, as it arguably improves proprioception.

OBJECTIVE

To synthesize the evidence on the effects of elastic KT on proprioception in healthy and pathological shoulders.

METHODS

Four databases (PubMed, WoS, CINAHL, SPORTDiscus) were searched for studies that investigated the effects of elastic KT on shoulder proprioception. Outcome measures were active joint position sense (AJPS), passive joint position sense (PJPS), kinesthesia, sense of force (SoF), and sense of velocity (SoV). Risk of bias (RoB) was assessed using the Cochrane Collaboration RoB tool for randomized controlled trials (RCTs), and the ROBINS-1 for non-RCTs, while the certainty of evidence was determined using GRADE.

RESULTS

Eight studies (5 RCTs, 3 non-RCTs) were included, yielding 187 shoulders (102 healthy and 85 pathological shoulders). RoB ranged from low (2 studies), moderate (5 studies), to high (1 study). Elastic KT has a mixed effect on AJPS of healthy shoulders (n=79) (low certainty). Elastic KT improves AJPS (subacromial pain syndrome and rotator cuff tendinopathy, n=52) and PJPS (chronic hemiparetic shoulders, n=13) among pathological shoulders (very low certainty). Elastic KT has no effect on kinesthesia among individuals with subacromial pain syndrome (n=30) (very low certainty).

CONCLUSION

There is very low to low certainty of evidence that elastic KT enhances shoulder AJPS and PJPS. The aggregate of evidence is currently so low that any recommendation on the effectiveness of elastic KT on shoulder proprioception remains speculative.

The role of progressive, therapeutic exercise in the management of upper limb tendinopathies: A systematic review and meta-analysis

BACKGROUND

Among upper limb tendinopathies, rotator cuff-related shoulder pain and lateral elbow tendinopathy are the most representative disorders. Therapeutic exercise arises as an effective approach, but there is no consensus about the optimal progression criteria.

OBJECTIVE

To compare progression criteria and effectiveness of isolated, progressive exercises in the management of upper limb tendinopathies. Additionally, to perform a meta-analysis of pain/function for the selected programs.

DESIGN

Systematic Review and Meta-Analysis.

METHOD

Database search of randomized-controlled-trials including progressive exercise was conducted in PubMed and Scopus until October 2020. Meta-analysis' inclusion criteria were: no data duplicity; 3-months follow-up; comparison between any type of progressive exercise program. Risk of bias was assessed with PEDro score, and level of evidence followed GRADE guidelines. Effect size was calculated with Cohen's d.

RESULTS

Eleven studies were included. GRADE revealed low-quality evidence for meta-analysis of pain during activity (d = 0.29) and function (d = 0.33) at 3 months. Progression criteria were categorised into two divisions, being pain the central concept. Pain (rest/activity/night) and function improved significantly within-group, but between-group changes were heterogeneous. Meta-analysis regarding pain showed good homogeneity with significant, moderate effects (I² = 20%; p = 0.005; mean d = 0.29); function yielded important heterogeneity with non-significant, moderate effects (I² = 81%; p = 0.17; mean d = 0.33).

CONCLUSIONS

Pain was the most frequent benchmark when modulating and progressing the exercises, although other criteria were found such as fatigue or self-perceived ability. Progressive exercise seems effective to manage upper limb tendinopathies, but the superiority of a progression criterion against others remains unclear. Low-quality evidence supported progressive exercise with eccentric components in adding a significant and moderate effect on pain/function at short-term.

Diagnostic Dilemma: Which Clinical Tests Are Most Accurate for Diagnosing Supraspinatus Muscle Tears and Tendinosis When Compared to Magnetic Resonance Imaging?

Background: The study aims to investigate the diagnostic accuracy of five clinical shoulder tests in the diagnosis of supraspinatus tears and tendinosis when compared to magnetic resonance imaging (MRI).

Methods: A total of 116 shoulders of 106 consecutive patients who experienced shoulder pain were assessed for this cross-sectional diagnostic accuracy study. Patients were assessed with the most commonly used clinical shoulder tests, including the Jobe test (empty can), Neer test, drop arm test, Hawkins test, and full can test to identify supraspinatus tears and tendinosis. MRI examinations were performed on a 1.5 Tesla MRI system, and images were assessed by a blinded radiologist. The primary outcomes were to determine the sensitivity, specificity, and accuracy of the five clinical tests and to establish their correlation with MRI for supraspinatus tears and tendinosis.

Results: The Hawkins test had a higher sensitivity and accuracy when diagnosing tears (sensitivity 89.66% [95% CI, 78.83-96.11] and accuracy 56.03% [95% CI, 46.51-65.23], respectively) and higher sensitivity in tendinosis (79.07% [95% CI, 63.96-89.96]). The drop arm test had a lower sensitivity but higher specificity in both tendinosis and tears (sensitivity 0% [95% CI, 0-8.22] and 12.07% [95% CI, 4.99-23.29], respectively, and specificity 87.67% [95% CI, 77.88-94.21] and 96.5% [95% CI, 88.09-99.58], respectively). The Neer test had a higher positive predictive value (PPV) of 37.21% in diagnosing tendinosis. When compared to the Hawkins test, the combination of the clinical tests had no statistically significant contribution to sensitivity and diagnostic accuracy.

Conclusion: The Hawkins test had higher accuracy in diagnosing tears and was the most sensitive in diagnosing supraspinatus tendinosis and tears when compared to the MRI findings. The Neer test may also be another reliable tool for the diagnosis of tendinosis due to its higher PPV.

Progression of rotator cuff tendon pathology in manual wheelchair users with spinal cord injury: A 1-year longitudinal study

OBJECTIVE

To investigate the progression of rotator cuff tendon pathology across one year in manual wheelchair (MWC) users with spinal cord injury (SCI) and matched able-bodied individuals, and to explore the association between pain, age, and duration of wheelchair use with the progression of rotator cuff pathology.

DESIGN

Longitudinal cohort study, 1-year follow-up.

SETTING

Outpatient clinic at a tertiary medical center.

PARTICIPANTS

Twenty-four adult MWC users with SCI (20 men) with an average age (SD) of 37(12) years and 24 age and sex-matched able-bodied individuals.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Presence of shoulder pain was collected. Magnetic resonance imaging (MRI) abnormalities of rotator cuff tendons including tendinopathy and tendon tears at baseline and 1-year follow-up visits were graded by a board-certified musculoskeletal radiologist, and three categories of tendon pathology scores including individual tendon scores, unilateral cuff scores, and bilateral cuff scores were calculated for each participant.

RESULTS

Fifty-four percent of the MWC users reported shoulder pain at both time points which was significantly higher than able-bodied cohort at baseline (17%, P = 0.012) and year 1 (21%, P = 0.021). Rotator cuff tendon pathology was detected as mainly mild tendinopathies and low-grade partial-thickness tears in both cohorts at both time points but was more common in MWC users. The results for the bilateral cuff scores indicated a significant (P < 0.008) progression of rotator cuff tendon pathology in the MWC users over one year. MRI findings did not change significantly for the able-bodied cohort across time. There was no association of pain, age, or duration of MWC use with progression of rotator cuff pathology in MWC user cohort.

CONCLUSION

MWC users had a higher prevalence of pain than matched able-bodied cohort, but pain was minimal and not function-limiting. Bilateral cuff TOTAL scores showed pathology progression in MWC users, but MRI findings remained stable in the able-bodied cohort. MWC users were 3.4 times more likely to experience pathology progression than the able-bodied cohort.

Volumetric evaluation of the subacromial space in shoulder impingement syndrome

INTRODUCTION

Shoulder impingement syndrome is evaluated radiologically with two-dimensional measurement parameters. None of these measurement parameters accurately reflect the three-dimensional geometry. The purpose of this study was to evaluate the volumetric status of the subacromial space in patients with shoulder impingement syndrome and to investigate its relationship with two-dimensional parameters.

HYPOTHESIS

The primary hypothesis of this study is that subacromial volume is reduced in patients with impingement syndrome. The second hypothesis is that the sagittal plane morphology of the acromion reflects the subacromial volume better than the coronal plane morphology.

PATIENTS AND METHODS

This retrospective study consisted of a total of 52 participants: 26 patients with impingement syndrome and 26 controls. Volumetric measurements were performed with using magnetic resonance imaging. The relationship between humerus and acromion was evaluated by acromiohumeral distance. The sagittal plane morphology of the acromion was evaluated with an objective acromial angle, while the coronal plane morphology was evaluated with a lateral acromial angle. The radiological parameters between groups were compared.

RESULTS

The mean subacromial volume was significantly smaller in the impingement group compared to the control group (p=0.01). The subacromial volume had a negative correlation with the objective acromial angle (R=-0.46; p=0.01) The mean tendon volume was significantly higher in the impingement group (p<0.001). The mean acromiohumeral distance in the impingement group (6.8mm±1.0mm), was calculated to be significantly lower than the control group (10.1mm±1.5mm) (p<0.001). There was a positive moderate correlation between subacromial volume and acromiohumeral distance (R=0.61; p=0.01).

DISCUSSION

This is the first study to demonstrate a reduction in subacromial volume in patients with impingement syndrome. The sagittal plane morphology of the acromion, rather than the coronal plane, appears to be more closely related to the subacromial volume.

LEVEL OF EVIDENCE

III; case-control study.

'Down to the person, the individual patient themselves': A qualitative study of treatment decision-making for shoulder pain

Introduction

Many inconsistencies have been identified in the translation of evidence‐based treatment recommendations for musculoskeletal shoulder pain into healthcare services, with little known about factors influencing decision‐making. The objective of this study was to explore the views and experiences of healthcare providers (HCPs) and people living with shoulder pain on treatment decision‐making.

Methods

Adopting a qualitative design, purposeful sampling was employed to recruit 13 individuals with nonspecific musculoskeletal shoulder pain and 30 HCPs. Data were collected through 1:1 semi‐structured interviews and analysed using an approach informed by Constructivist Grounded Theory. To facilitate analysis, two patient and public involvement (PPI) meetings were conducted.

Results

Most participants (69%) had shoulder pain of ≥1‐year duration. Biomechanical beliefs about shoulder pain predominated and were heavily influential in decision‐making for both patients and HCPs. Despite a consensus that therapeutic alliance facilitated decision‐making, the extent of collaboration between HCPs and patients in treatment decision‐making was rather limited. In addition to condition‐specific factors, Individual patient characteristics and resources also influenced treatment decisions.

Conclusion

Findings revealed the complexity of the decision‐making process for both patients and HCPs, exposing substantial gaps between the reported views and experiences of participants and the principles of client‐centred and evidence‐based practice. There is a pressing need to enhance the translation of evidence‐based knowledge into practice in this clinical area.

Patient or Public Contribution

In line with a consultative approach to collaborative data analysis, a subgroup of participants attended two PPI meetings to provide commentary and feedback on preliminary findings.

Digitally Assisted Versus Conventional Home-Based Rehabilitation After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

OBJECTIVE

The aim of this study was to evaluate the clinical impact of a 12-wk home-based digitally assisted rehabilitation program after arthroscopic rotator cuff repair against conventional home-based rehabilitation.

DESIGN

The digital therapy group performed independent technology-assisted sessions complemented with 13 face-to-face sessions, and the conventional therapy group had conventional face-to-face physical therapy (30 sessions). Primary outcome was functional change between baseline and 12 wks, measured through the Constant-Murley score. Secondary outcomes were the change in the QuickDASH Scale and shoulder range of motion.

RESULTS

Fifty participants enrolled; 41 completed the 12-wk program (23 digital therapy group vs. 18 conventional therapy group), and 32 (15 vs. 17) were available for the 12-mo follow-up assessment. No differences were found between groups regarding study endpoints at the end of the 12-wk program. However, follow-up results revealed the superiority of the digital therapy group for QuickDASH (P = 0.043), as well as an interaction between time and group in the Constant-Murley score (P = 0.047) in favor of the digital therapy group.

CONCLUSIONS

The results demonstrate that digital therapeutics can be used to achieve similar, if not superior, short- and long-term outcomes as conventional approaches after arthroscopic rotator cuff repair, while being far less human resource intensive than conventional care.Level of evidence: II.

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.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study

BACKGROUND

There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To identify the most relevant clinical descriptors for diagnosing RCRSP.

METHODS

A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.

RESULTS

Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus.

CONCLUSION

In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice

Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.

Herzratenvariabilitätsbasiertes Lifestyle-Coaching bei Patient*innen mit subakromialem Schmerzsyndrom – eine Pilotstudie

Hintergrund Mehrere Studien konnten einen Einfluss von psychologischem Stress auf Schmerzmodulation und Wundheilung aufzeigen. Die Erweiterung der physiotherapeutischen Behandlung um die psychosoziale Ebene des biopsychosozialen Modells stellt komplexe Anforderungen an die behandelnden Physioherapeut*innen.

Ziel Untersucht wurde der Einfluss von auf Herzratenvariabilität (HRV) basierendem Lifestyle-Coaching auf die Entwicklung der funktionellen Einschränkungen und das Schmerzempfinden bei Patient*innen mit subakromialem Schmerzsyndrom (SAPS). Es erfolgte zudem eine Analyse der Machbarkeit für Folgestudien.

Methode 15 Proband*innen mit SAPS wurden randomisiert in 2 Gruppen eingeteilt. Die Interventionsgruppe erhielt zusätzlich zu der in beiden Gruppen durchgeführten übungstherapeutischen Intervention ein Lifestyle-Coaching. Als Kontrollparameter wurden der SPADI-Score (SPADI), das maximale Schmerzempfinden (NRSmax) und anhand der Kurzzeit-HRV-Messung die High Frequency (HF), Low Frequency (LF), LF/HF-Ratio, Root Mean Square of Successive Difference (Rmssd) sowie die Standard Deviation NN (SdNN) erhoben. Bezüglich der Machbarkeit wurden mögliche Störfaktoren, Optimierungsmöglichkeiten und eine adäquate Stichprobengröße eruiert.

Ergebnisse Einen signifikanten Unterschied zeigten die Variablen des SPADI-Scores, SPADI (95 % CI –59,3 bis –4,6; p = 0,026; d = –1,5), NRSmax (95 % CI –5,5 bis –0,1; p = 0,042; d = –1,35) und der HRV-Messwert HF (95 % CI 505,3–1753,3; p = 0,002; d = 2,23) im Vergleich zur Kontrollgruppe.

Schlussfolgerung Das Design dieser Studie ist machbar und für Folgestudien mit größeren Stichproben geeignet. Anpassungen bei der Randomisierung sowie den verwendeten Assessments sollten dabei vorgenommen werden. Für eine gültige Aussagekraft der Ergebnisse wurde die dafür nötige Stichprobengröße mit n = 66 ermittelt. Die Auswertung der klinischen Parameter weisen auf eine Steigerung der parasympathischen Aktivität (HF) sowie einer Reduktion von SPADI und NRSmax hin. Letztere können hierbei als potentiell positive Wirkung auf die Funktion und Schmerzreduktion in der Interventionsgruppe eingeschätzt werden.

A novel method for determining the X-ray beam angulation of the supraspinatus outlet view

BACKGROUND

Rapid and accurate quantification of the supraspinatus outlet view (SOV) is a clinical challenge.

PURPOSE

To quantify the X-ray beam angle of the SOV using the horizontal angle of the subscapular spine line (SSSL) and to further verify the feasibility of this method.

MATERIAL AND METHODS

A total of 119 patients who underwent shoulder computed tomography (CT) examination were enrolled in the retrospective study. Three-dimensional (3D) CT reconstruction was performed and manually adjusted to provide the position similar to SOV. The rotation angle of the 3D image along the long axis of the human body (marked as β) was obtained. The horizontal angle of SSSL (marked as α) was measured on the anteroposterior localizer image of shoulder CT. Pearson correlation and linear regression correlation analysis were performed. In addition, the first-time success rate between the experience-based group and the measurement-based group were compared to verify the novel method.

RESULTS

We found a linear correlation between α and β (r = 0.962; P = 0.000). There was no significant correlation between the experience-based group and the measurement-based group in terms of age (P = 0.500), sex (P = 0.397), and side (P = 0.710), but there was a significant statistical difference in the first success rate between the two validation groups (χ² = 5.808^a, P = 0.016).

CONCLUSION

This novel quantitative measurement method for determining the X-ray beam angle of SOV using the horizontal angle of SSSL is feasible.

The role of scapular dyskinesis on rotator cuff tears: a narrative review of the current knowledge

Scapular dyskinesis can be present in healthy individuals as in patients with shoulder pathology.Altered patterns of scapular kinematics can cause or exacerbate rotator cuff tear pathology. However, more research is needed.Regardless of the cause or the consequence of rotator cuff tear, scapular dyskinesis impairs shoulder function, worsens the symptoms, and compromises the success of clinical intervention.The available literature suggests physical therapy as the first treatment for degenerative cuff tears, and scapular dyskinesis should be addressed if present. Non-responsive cases or traumatic tears may require surgery.Postsurgical physical therapy protocols after rotator cuff repair must consider scapular dyskinesia to improve the outcomes. Cite this article: EFORT Open Rev 2021;6:932-940. DOI: 10.1302/2058-5241.6.210043.

Comparative effectiveness of treatment options for subacromial shoulder conditions: a systematic review and network meta-analysis

Background:

There are currently many treatment options for patients with subacromial shoulder conditions (SSCs). Clinical decision-making regarding the best treatment option is often difficult. This study aims to evaluate the comparative effectiveness of treatment options for relieving pain and improving function in patients with SSCs.

Methods:

Eight databases [including MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Database of Systematic Reviews and World Health Organization (WHO) International Clinical Trials Registry] were searched from inception until April 2020. Randomised clinical/controlled trials of adult patients investigating the effects of nonsurgical (e.g. corticosteroid injections, therapeutic exercise, shockwave therapy) and surgical treatment for SSCs, compared with each other, placebo, usual care or no treatment, were retrieved. Pairs of reviewers screened studies independently, quality appraised eligible studies using the Cochrane risk of bias tool, extracted and checked data for accuracy. Primary outcomes were pain and disability in the short term (⩽3 months) and long term (⩾6 months). Direct and indirect evidence of treatment effectiveness was synthesised using random-effects network meta-analysis.

Results:

The review identified 177 eligible trials. Summary estimates (based on 99 trials providing suitable data, 6764 patients, 20 treatment options) showed small to moderate effects for several treatments, but no significant differences on pain or function between many active treatment comparisons. The primary analysis indicated that exercise and laser therapy may provide comparative benefit in terms of both pain and function at different follow-up time-points, with larger effects found for laser in the short term at 2–6 weeks, although direct evidence was provided by one trial only, and for exercise in the longer term [standardised mean difference (SMD) 0.39, 95% confidence interval (CI) 0.18, 0.59 at 3–6 months] compared with control. Sensitivity analyses excluding studies at increased risk of bias confirmed only the comparative effects of exercise as being robust for both pain and function up until 3-month follow-up.

Conclusion:

Current evidence shows small to moderate effect sizes for most treatment options for SSCs. Six treatments had a high probability of being most effective, in the short term, for pain and function [acupuncture, manual therapy, exercise, exercise plus manual therapy, laser therapy and Microcurrent (MENS) (TENS)], but with low certainty for most treatment options. After accounting for risk of bias, there is evidence of moderate certainty for the comparative effects of exercise on function in patients with SSCs. Future large, high-quality pragmatic randomised trials or meta-analyses are needed to better understand whether specific subgroups of patients respond better to some treatments than others.

Bilateral ultrasound findings in patients with unilateral subacromial pain syndrome

Background: Subacromial pain syndrome is a common musculoskeletal shoulder problem. The accuracy of clinical tests is low and techniques such as ultrasound and magnetic resonance imaging have been added to set up a diagnosis. Previous researchers have usually only examined the symptomatic shoulder. However, there might be similar findings in the asymptomatic shoulder. Objective:The aim of the present study was to investigate the prevalence of structural abnormalities of both shoulders in patients with clinically diagnosed unilateral subacromial pain syndrome using diagnostic ultrasound. Methods: Bilateral ultrasound examinations were performed in 115 consecutive patients, 54 men and 61 women. The patients were recruited from primary care centers in the area of Stockholm, Sweden. Results: Abnormal ultrasound findings were found in both shoulders and increased with age (p = .0004). Bursitis was the most common ultrasound finding and significantly more prevalent in the symptomatic shoulder compared to the asymptomatic shoulder (90%:74%; p = .0021), though 73% of the bursitis were bilateral. Supraspinatus is the most vulnerable tendon of the rotator cuff in both shoulders. In terms of partial-thickness tears and tendinosis, the tendon was affected more commonly in the symptomatic shoulder compared to the asymptomatic shoulder (30%:14%: 14%; p = .0026) and (24%:10%; p = .0054), respectively, but for calcification no significant difference between the shoulders was found (18%:12%; 0.1988). Conclusion: Ultrasound detected shoulder abnormalities were present in both symptomatic and asymptomatic shoulders. Bursitis and partial-thickness tears were more common in the affected shoulder when compared to the unaffected shoulder. Ultrasound as well as clinical examination findings and patient´s history should be taken into consideration when diagnosing patients with subacromial pain syndrome.

Are muscle weakness and stiffness risk factors of the development of rotator cuff tendinopathy in overhead athletes: a systematic review

Background:

Underlying muscle weakness and stiffness may increase the risk of developing rotator cuff tendinopathy. This systematic review aims to assess existing prospective studies to summarize whether muscle weakness and stiffness are risk factors for the development of rotator cuff tendinopathy in overhead athletes.

Methods:

A systematic search was performed using PRISMA guidelines. Prospective studies measuring muscle strength or stiffness and the incidence of rotator cuff tendinopathy were included. Quality assessment was performed with the Newcastle-Ottawa quality assessment scale.

Results:

The search yielded six studies, with a total of 523 trained overhead athletes followed up for one season. External rotation (ER) and internal rotation (IR) strength were described as protective factors against the development of rotator cuff tendinopathy. Athletes who did not sustain shoulder injuries had statistically stronger eccentric IR (p < 0.01) and ER (p < 0.05) strength in the pre-season assessment. Muscle stiffness indicated by limited range of motion of <106° for shoulder ER was described as a risk factor with an odds ratio of 1.12 (p < 0.001). Imbalance between ER and IR strength was reported as risk factors for shoulder injuries in two studies, with a relative risk of 2.57 (p < 0.05) reported in one study. Supraspinatus weakness was also reported as a risk factor for shoulder injuries in one study.

Conclusion:

Limited evidence support ER, IR weakness, limited ER range of motion, and very limited evidence support imbalance in ER/IR strength, and supraspinatus weakness as risk factors for rotator cuff tendinopathy in overhead athletes. No existing studies investigated the general population on this topic. Future cohort studies may improve on existing evidence with investigations on the general public, a longer follow-up time, clearly documented injury history, and a stringent diagnosis to rotator cuff tendinopathy.

Measuring outcomes in rotator cuff disorders

Measuring the outcome of treatment for rotator cuff disorders has evolved over the last three decades. Objective surgeon-derived outcomes such as clinical examination findings and imaging of the rotator cuff have the limitation of marginalising the patients perception of their condition. Patient reported outcome measures (PROMs) have evolved and become popular in an attempt to demonstrate meaningful outcome data. There are a large number in use today and as a result, the heterogeneity of scores used across the literature can make comparison difficult. Patient reported outcome scores can be general health related quality of life scores, joint-specific and disease specific. Qualitative outcomes are also being used now, and these help us to better understand the context of quantitative research scores. In this article, we provide an overview of the outcome measures used in rotator cuff disorders.

Elastofibroma presented as shoulder pain in an amateur swimmer: screening for referral in physiotherapy. A case report

Elastofibroma is a benign and rare fibroblast/myofibroblast tumor usually located near the periosteum of the ribs. Patients with elastofibroma can remain asymptomatic or can experience a clicking sensation during shoulder movements, shoulder stiffness, scapular and shoulder pain and dysfunction. Importantly, the symptoms can mimic a musculoskeletal condition being mistaken for orthopedic shoulder joint disease. A 54 years-old amateur swimmer self-referred to physiotherapy for left subscapular and shoulder pain. Concerns from the patient's history that caused suspicion of a medical condition included an insidious onset of nagging deep pain that increased with upper limb exertion and an audible thoracic clunk at arm end range flexion. Deep palpatory examination revealed a mass below the latissimus dorsi and rhomboids further screened by the physiotherapist with Rehabilitative Ultrasound Imaging. The physiotherapist referred the patient to a thoracic surgeon who removed the mass. After an exercise-based physiotherapy management program, the patient returned to previous activities including swimming after 5 months. The challenge for clinicians is to screen patients in whom shoulder pain may be related to non-musculoskeletal conditions. Prompt referral of patients presenting with the suspicion of elastofibroma to an appropriate physician may lead to a timely diagnosis and could avoid expensive and unnecessary rehabilitation procedures.

Short- and Long-Term Effects of a Scapular-Focused Exercise Protocol for Patients with Shoulder Dysfunctions-A Prospective Cohort

Current clinical practice lacks consistent evidence in the management of scapular dyskinesis. This study aims to determine the short- and long-term effects of a scapular-focused exercise protocol facilitated by real-time electromyographic biofeedback (EMGBF) on pain and function, in individuals with rotator cuff related pain syndrome (RCS) and anterior shoulder instability (ASI). One-hundred and eighty-three patients were divided into two groups (n = 117 RCS and n = 66 ASI) and guided through a structured exercise protocol, focusing on scapular dynamic control. Values of pain and function (shoulder pain and disability index (SPADI) questionnaire, complemented by the numeric pain rating scale (NPRS) and disabilities of the arm, shoulder, and hand (DASH) questionnaire) were assessed at the initial, 4-week, and 2-year follow-up and compared within and between. There were significant differences in pain and function improvement between the initial and 4-week assessments. There were no differences in the values of DASH 1st part and SPADI between the 4-week and 2-year follow-up. There were no differences between groups at the baseline and long-term, except for DASH 1st part and SPADI (p < 0.05). Only 29 patients (15.8%) had a recurrence episode at follow-up. These results provide valuable information on the positive results of the protocol in the short- and long-term.

Managing shoulder pain: a meta-ethnography exploring healthcare providers' experiences

OBJECTIVE

To review and synthesize qualitative research studies exploring the experiences of Healthcare Providers (HCPs) of managing shoulder pain.

METHODS

A meta-ethnographic approach was adopted to review and synthesize eligible studies. The findings from each included study were translated into one another using Noblit and Hares' seven-stage process. A systematic search of eleven electronic databases was conducted in February 2021. Methodological quality was assessed using the CASP Appraisal Tool.

RESULTS

Ten studies were included in the meta-synthesis, all deemed of high methodological quality. Three themes were identified; (1) Lack of consensus: "we all have different approaches." (2) Challenges to Changing Practice: It's "really hard to change and switch to a different approach," (3) Getting "Buy in" to Treatment: "…so you have to really sell it early".

CONCLUSION

Healthcare providers working with people with shoulder pain struggle to reconcile, often conflicting, research recommendations with their own clinical experience, beliefs and patient expectations. These findings help explain the continued lack of consensus on how best to manage shoulder pain in clinical practice.IMPLICATIONS FOR REHABILITATIONHealthcare providers (HCPs) working with people with shoulder pain struggle to resolve conflicts between evidence-based recommendations, clinical experience, their own shoulder pain beliefs and patient expectations and preferences.Stronger collaboration across professional disciplines is needed to address the current lack of consensus on the management of shoulder pain.Many HCP's find it difficult to engage patients with shoulder pain in exercise and they work hard to "sell" this approach to patients using strategies such as education, shared decision making and therapeutic alliance.

Scapulothoracic Dyskinesis: A Concept Review

PURPOSE OF REVIEW

Scapulothoracic dyskinesis (SD) occurs when there is a noticeable disruption in typical position and motion of the scapula, which can result in debilitating pain. The purpose of this review is to describe the current knowledge regarding the diagnosis and management of scapulothoracic dyskinesis by providing an evidence-based overview of clinical exams and treatment modalities available for orthopedic surgeons and provide insight into which treatment modalities require further investigation.

RECENT FINDINGS

SD is highly prevalent in athletes, particularly those participating in overhead activities (e.g., baseball, tennis, and swimming) and can coexist with several shoulder pathologies. A holistic approach in the diagnosis of SD has been supported in the literature; however, it is important to recognize that diagnosis is currently limited to the absence of a quantitative SD clinical assessment. The main goal of the treatment of SD is to regain proper scapular positioning and dynamics. The standard of care for the management of SD is conservative interventions aimed at optimizing scapular kinematics. Surgical intervention is only considered in the presence of concomitant pathology requiring surgery. Due to the complexity of coordinated movement of the shoulder girdle, recent literature has begun to move away from the use of traditional orthopedic tests, in favor of a more system-based approach for the diagnosis of SD. We present a concise review of clinical exams and treatment modalities available for orthopedic surgeons in the management of SD.

Understanding Shoulder Pain: A Qualitative Evidence Synthesis Exploring the Patient Experience

OBJECTIVE

The objective of this study was to review and synthesize qualitative research studies exploring the experiences of individuals living with shoulder pain to enhance understanding of the experiences of these individuals as well as facilitate health care developments.

METHODS

A meta-ethnographic approach was adopted to review and synthesize eligible published qualitative research studies. The findings from each included study were translated into one another using the Noblit and Hares 7-stage process. A systematic search of 11 electronic databases was conducted in March 2020. Methodological quality was assessed using the Critical Appraisal Skills Programme appraisal tool.

RESULTS

Nineteen studies were included in the meta-synthesis. Included articles explored the lived experiences as well as treatment-related experiences of participants. All of the included articles were deemed to be of high methodological quality. Three themes were identified: (1) negative emotional, social, and activity impact ("It has been a big upheaval"); (2) developing an understanding ("Why is it hurting so much?"); and (3) exercise ("Am I going to go through a lot of pain in moving it…?"). Across the included studies, the severe emotional and physical impact of shoulder pain was a core finding. Many people sought a "permanent" solution involving surgery. Openness to other treatment options was influenced by factors including understanding of pain, prior experiences, and treatment expectations.

CONCLUSION

These findings deepen our understanding of the impact of shoulder pain on peoples' lives and provide novel insight into the experience of treatment. Enhanced awareness of people's experiences of shoulder pain and treatment is crucial for clinicians when planning and implementing evidence-based recommendation.

IMPACT

To the knowledge of the authors, this is the first qualitative evidence synthesis to explore the treatment-related experiences of individuals with shoulder pain. Shoulder surgery was considered by many as the only means to achieve a more permeant resolution of symptoms.

LAY SUMMARY

Shoulder pain causes emotional and physical turmoil that can permeate every facet of life. People's understanding of their shoulder pain appears to be deeply rooted in a biomechanical view of pain, which influences their expectations relating to diagnosis and treatment.

Shoulder Pain of Spinal Source in the Military: A Case Series

Musculoskeletal injury (MSI) presents the greatest threat to military mission readiness. Atraumatic shoulder pain is a common military MSI that often results in persistent functional limitations. Shoulder orthopedic evaluation presents many diagnostic challenges, due in part to the possibility of a spinal source of symptoms. This case series outlines the use of mechanical diagnosis and therapy to screen the cervical and thoracic spine in active duty (AD) service members (SMs) with a chief complaint of unchanging or worsening shoulder pain. All three SMs previously received shoulder-specific diagnoses from experienced clinicians, yet repeated movements revealed a possible spinal nociceptive driver that guided targeted intervention. Treatment directed only at the cervical spine resulted in a clinically important improvement within an average of 10 days from the initial evaluation, return to duty (RTD) within an average of 32 days, and continued resolution at 3 months. SMs can independently complete the screening process with guidance from healthcare providers, ultimately shaping the treatment strategy and possibly facilitating self-management of future recurrence. This case series demonstrates that identification of shoulder pain of spinal source in the military population may be an important step in facilitating timely RTD. These cases also highlight the use of a standardized, systematic method to screen the cervical and thoracic spine that concurrently reveals the indicated treatment. Further research to determine the prevalence of shoulder pain of spinal source in the AD population and its impact on RTD rates has the potential to reduce the substantial burden of MSI in the military.

An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report

BACKGROUND

Shoulder pain (SP) may originate from both musculoskeletal and visceral conditions. Physiotherapists (PT) may encounter patients with life-threatening pathologies that mimic musculoskeletal pain such as Acute Myocardial Infarction (AMI). A trained PT should be able to distinguish between signs and symptoms of musculoskeletal or visceral origin aimed at performing proper medical referral.

CASE PRESENTATION

A 46-y-old male with acute SP lasting from a week was diagnosed with right painful musculoskeletal shoulder syndrome, in two successive examinations by the emergency department physicians. However, after having experienced a shift of the pain on the left side, the patient presented to a PT. The PT recognized the signs and symptoms of visceral pain and referred him to the general practitioner, which identified a cardiac disease. The final diagnosis was acute myocardial infarction.

CONCLUSION

This case report highlights the importance of a thorough patient screening examination, especially for patients treated in an outpatient setting, which allow distinguishing between signs and symptoms of musculoskeletal from visceral diseases.

Effectiveness of Focused Shockwave Therapy versus Radial Shockwave Therapy for Noncalcific Rotator Cuff Tendinopathies: A Randomized Clinical Trial

Background

The superiority of focused shockwave therapy (F-SWT) versus radial shockwave therapy (R-SWT) for treating noncalcific rotator cuff tendinopathies remains controversial. This study is aimed at comparing the effectiveness of F-SWT versus R-SWT for the management of noncalcific rotator cuff tendinopathies.

Methods

A total of 46 patients affected by noncalcific rotator cuff tendinopathies were randomly divided into 2 groups of 23 individuals. Patients in group A received 4 sessions of F-SWT, while patients in group B were treated by 4 sessions of R-SWT. In each session, mean energy flux density (EFD) for F-SW 3000 shots was 0.09 ± 0.018 mJ/mm² with 5.1 ± 0.5 Hz, while average pressure for R-SW 3000 shots was 4.0 ± 0.35 bar with 3.2 ± 0.0 Hz. Pain level and shoulder function were assessed with the numerical rating scale (NRS) and Constant-Murley Scale (CMS). The primary endpoint was the change in the mean NRS pain score from baseline to 24 weeks after the intervention. Secondary endpoints were changes in the mean NRS pain scores at all other follow-up points, changes in the mean CMS scores, and radiographic findings.

Results

There were no significant differences between the two groups regarding NRS pain score and CMS score within 24 weeks after intervention (all p > 0.05). However, F-SWT resulted in significantly lower NRS compared with R-SWT at 24 weeks and 48 weeks after treatment (2.7 ± 1.0 vs. 4.5 ± 1.2 and 1.4 ± 1.0 vs. 3.0 ± 0.8, respectively, all p < 0.001). Similar results were found in CMS changes and radiographic findings.

Conclusions

Both F-SWT and R-SWT are effective in patients with noncalcific rotator cuff tendinopathy. F-SWT proved to be significantly superior to R-SWT at long-term follow-up (more than 24 weeks). This trial is registered with ChiCTR1900022932.

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.

Rotator cuff-related shoulder pain: does the type of exercise influence the outcomes? Protocol of a randomised controlled trial

INTRODUCTION

Lifetime prevalence of shoulder pain is 70%, and approximately 50% of people with shoulder pain will experience pain for more than a year. Rotator cuff-related shoulder pain (RCRSP) is the most common shoulder condition and the main non-surgical intervention is exercise therapy. For approximately 30% of people with RCRSP, this approach does not lead to a significant reduction in symptoms. This may be due to an inappropriate dosage or choice of exercises. The aim of this investigation is to compare the short, mid and long-term effects, in terms of symptoms, functional limitations, kinesiophobia and pain catastrophising, of three different shoulder rehabilitation approaches (education, strengthening, motor control) in adults with RCRSP.

METHODS AND ANALYSIS

In this single-blind (assessor), parallel-group, randomised clinical trial, 123 adults presenting with RCRSP will take part in a 12-week rehabilitation programme. They will be randomly assigned to one of three groups (education only, strengthening approach or motor control-focused approach). Abbreviated version of the Disabilities of the Arm, Shoulder and Hand Questionnaire, the primary outcome, Western Ontario Rotator Cuff Index and Brief Pain Inventory will evaluate symptoms and functional limitations, while Tampa Scale of Kinesiophobia and Pain Catastrophizing Scale will evaluate pain-related fear and catastrophising at baseline and at 3, 6, 12 and 24 weeks. Ultrasonographic acromiohumeral distances and tendon thickness will be assessed at baseline and 12 weeks. Intervention groups will be compared on outcomes with intention-to-treat analyses using two-way repeated measures analysis of variance if the data are normally distributed or non-parametric analysis of longitudinal data if they are not.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Sectorial Rehabilitation and Social Integration Research Ethics Committee of the Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale Nationale (CIUSSS-CN). Results will be disseminated through international publications in peer-reviewed journals, in addition to international conference presentations.

TRIAL REGISTRATION NUMBER

NCT03892603; pre-results.

Heterogeneity among patients with subacromial pain - variabilities within clinical presentation and its impact on daily life

OBJECTIVE

The primary aim was to describe the variability within clinical presentation of patients with subacromial pain in primary care, secondly to investigate associations between clinical presentation and self-reported pain intensity, shoulder function, level of anxiety and depression, and health-related quality of life.

DESIGN AND SETTING

A cross-sectional study based on data from two clinical studies in primary care, one randomized controlled trial and one implementation study. Three components: active range of motion (AROM), rotator cuff function and scapular kinematics were analyzed to describe variability within clinical presentation and patient-reported measurements were used to investigate the impact on daily life.

PARTICIPANTS

Patients aged 30-67 years, describing pain for more than two weeks, with positive signs for a minimum of three out of the following five clinical tests: impingement sign according to Neer, impingement test according to Hawkins-Kennedy, Pattes maneuver, Jobe's test, and painful arc.

RESULTS

Among the 164 patients included, 24% displayed dysfunction in one, 50% two and 24% in all three components. Limited AROM was seen in 46%, rotator cuff dysfunction in 91% and scapular dyskinesia in 57% of the patients.

CONCLUSIONS

These results reveal a heterogeneity among primary care patients with subacromial pain confirming a large variability regarding the components AROM, rotator cuff function and scapular kinematics. All three components appear unique (not significantly correlated) where a rotator cuff dysfunction is very frequent while limited AROM and scapular dyskinesia are more inconsistent. There are significant, but rather weak, associations between clinical presentation and impact on daily life.

Scapular movement impairments in individuals with subacromial pain syndrome based on scapular assistance test and scapula reposition test outcomes

BACKGROUND

Individuals with subacromial pain present with a variety of contributing impairments related to the movement problem. The scapular assistance test (SAT) and scapula reposition test (SRT) are proposed to identify shoulder pain related to abnormal scapular movement or position. It remains unknown if scapular movement related impairments are present in those with positive tests.

OBJECTIVES

To determine if scapular motion related impairments differ based on the result of the SAT or SRT in individuals with subacromial pain syndrome.

DESIGN

Cross-sectional METHOD: Sixty individuals with subacromial pain syndrome were included. Prior to obtaining results of the SAT and SRT, a single examiner measured scapular upward rotation and posterior tilt active and passive motion, pectoralis minor length, and strength of the middle trapezius, lower trapezius, and serratus anterior. Dynamic scapular motion was qualitatively assessed with the Scapular Dyskinesis Test. The Mann-Whitney U test assessed for differences based on the outcome of the SAT and SRT.

RESULTS

There was a significant difference (P = .023) in pectoralis minor length for the SAT. Participants with a positive SAT had decreased muscle length compared to those who tested negative. There were no significant differences in scapular motion or strength based on the result of either the SAT or SRT.

CONCLUSIONS

A positive SAT was associated with greater pectoralis minor length impairment, but not muscle strength or mobility. The SRT did not identify greater impairments in any of the scapular movement related impairments assessed. Individuals may vary in contributing impairments related to SAT or SRT results.

Improving the Recovery of Patients with Subacromial Pain Syndrome with the DAid Smart Textile Shirt

Wearable technologies provide many possibilities for applications in medicine, and especially in physiotherapy, where tracking and evaluation of body motion are of utmost importance. Despite the existence of multiple smart garments produced for applications in physiotherapy, there is limited information available on the actual impact of these technologies on the clinical outcomes. The objective of this paper is to evaluate the impact of the Double Aid (DAid) smart shirt, a purely textile-based system, on the training process of patients with subacromial pain syndrome. A randomized controlled trial was performed where patients with subacromial pain syndrome had to perform the assigned training exercises while employing the DAid smart shirt system. The core point of each exercise was to perform a movement while holding the shoulders stationary. The smart shirt was designed to sense even slight shoulder motion thus providing the patient with feedback on the accuracy of the motion, and allowing the patient to adjust the movement. The appropriate muscles should be strengthened through an increased effort to control the shoulder motion. The recovery of patients using the feedback system at the end of the treatment was compared to that of a reference group through standardized tests—the Disabilities of the Arm, Shoulder, and Hand score (DASH score), Closed Kinetic Chain Upper Extremity Stability test (CKCUES test), and internal/external rotation ratio. The test group that used the DAid system demonstrated significantly better results of the performed tests for all applied outcome measures compared to the reference group (p < 0.001). An overall positive impact on the patient recovery was observed from the DAid smart shirt system when applied for rehabilitation training of patients with subacromial pain syndrome.

Subacromial Impingment Syndrome does not alter muscle onset activation patterns during shoulder cardinal movement at different speed and load

This study examines neuromuscular firing patterns in healthy and subjects diagnosed with SIS of the periscapular, prime-moving, and rotator cuff muscles during "clinical" cardinal plane physiological movements at different speeds and loads. EMG recordings were taken in 34 healthy and 34 subjects diagnosed with Subacromial Impingement Syndrome (SIS) of the prime movers, periscapular, and rotator cuff muscles during flexion, scaption, and abduction performed at fast, medium, and slow speeds with a loaded (3 kg) and unloaded arm. Differences in firing patterns between groups were analyzed by fitting mixed linear models with random intercepts per subject, and fixed factors for group, muscle, movement type, speed, and load. No difference in timing of activation was seen between the healthy and SIS. Onset timing of prime movers, periscapular, and rotator cuff muscles were prior to movement in all scenarios studied, with rotator cuff muscles firing last. Speed and load appear to independently vary muscle activation timing in a non-intuitive manner in both healthy and SIS. The lack of different firing neuromuscular patterns in subjects diagnosed with SIS and healthy subjects raises the need to consider individual assessment of motor patterns rather than generalized patterns.

[Circular RNA expression pattern and competing endogenous RNA network involved in rotator cuff tendinopathy]

Objective

To detect the differentially expressed circular RNA (circRNA) in rotator cuff tendinopathy and analyze the potential molecular mechanism of these parental genes.

Methods

Ten supraspinatus tendons donated from patients who underwent tendon repair surgery between June 2018 and June 2019 were used for RNA-sequence. All rotator cuff tendinopathy and normal tendon samples were confirmed by MRI, histological staining, and observation by arthroscopy. All pathological tendons were matched with tendon samples for patients' age, gender, body mass index, and Bonar score. The bioinformatic analysis was performed based on the differentially expressed circRNA and their parental genes, including gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and competing endogenous RNA (ceRNA) network construction.

Results

There were 94 differentially expressed circRNAs, including 31 up-regulated and 63 down-regulated, detected between the rotator cuff tendinopathy and normal tendon samples with |log2 fold change (FC)| >2, P<0.05. GO analysis showed that the genes were mostly enriched in response to cyclic adenosine monophosphate (cAMP). KEGG pathway analysis showed that the most genes were enriched in extracellular matrix-receptor interaction, protein digestion and absorption, cell cycle, and nuclear factor κB signaling pathway. ceRNA networks showed the interactions among circRNAs, mRNAs, and miRNAs. And circRNA.8951-has-miR-6089-DNMT3B was the most sum max energy.

Conclusion

This bioinformatic study reveals several potential therapeutic targets for rotator cuff tendinopathy, which paves the way to better treatment and prevention of this disorder.

Conjoint analysis of lncRNA and mRNA expression in rotator cuff tendinopathy

Background

Rotator cuff tendinopathy (RCT) is a common musculoskeletal disorder in the shoulder, whose underlying mechanism is unknown. Long non-coding RNAs (lncRNAs) are involved in the development of various diseases, but little is known about their potential roles in RCT.

Methods

In this study, we profiled lncRNAs and mRNAs involved in RCT in comparison with the normal tendon (NT) by RNA sequencing (RNA-Seq), to identify potential therapeutic targets. Gene ontology (GO), Kyoto encyclopedia of genes and genomes (KEGG) pathway, competing endogenous RNA (ceRNA), and co-expression network construction were used to identify the potential functions of these RNAs. Three lncRNAs and three mRNAs were validated by quantitative reverse transcription-polymerase chain reaction (qRT-PCR).

Results

In total, 419 lncRNAs and 1,541 mRNAs were differentially expressed between the RCT and NT groups with a fold change of >2 and P of <0.01. The GO and KEGG pathway analyses showed that the differentially expressed mRNAs were mainly enriched in complement activation and involved in the citrate cycle. The ceRNA network showed the interaction of differentially expressed RNAs, comprising 139 lncRNAs, 126 mRNAs, and 35 miRNAs. NONHSAT209114.1, ENST00000577806, NONHSAT168464.1, PLK2, TMEM214, and IGF2 were validated by PCR. We constructed a co-expressed network of these validated RNAs.

Conclusions

We preliminarily analyzed the profile of lncRNAs and mRNAs in RCT. The bioinformatic analysis revealed several potential therapeutic targets for RCT.

The challenge of the sporting shoulder: From injury prevention through sport-specific rehabilitation toward return to play

Shoulder injuries and sports-related shoulder pain are substantial burdens for athletes performing a shoulder loading sport. The burden of shoulder problems in the athletic population highlights the need for prevention strategies, effective rehabilitation programs, and a individually based return-to-play (RTP) decision. The purpose of this clinical commentary is to discuss each of these 3 challenges in the sporting shoulder, to assist the professional in: (1) preventing injury; (2) providing evidence-based practice rehabilitation and; (3) to guide the athlete toward RTP. The challenges for injury prevention may be found in the search for (the interaction between) relevant risk factors, develop valid screening tests, and implement feasible injury prevention programmes with maximal adherence from the athletes. Combined analytical and functional testing seems mandatory screening an athlete's performance. Many questions arise when rehabilitating the overhead athlete, from exercise selection, over the value of stretching, toward kinetic chain implementation and progression to high performance training. Evidence-based practice should be driven by the available research, clinical expertise and the patient's expectations. Deciding when to return to sport after a shoulder injury is complex and multifactorial. The main concern in the RTP decision is to minimize the risk of re-injury. In the absence of a "gold standard", clinicians may rely on general guidelines, based on expert opinion, regarding cutoff values for normal range of motion, strength and function, with attention to risk tolerance and load management.

Genetic factors in rotator cuff pathology: potential influence of col 5A1 polymorphism in outcomes of rotator cuff repair

Background

Investigations in genetics have provided valuable information about the correlation between gene variants and tendinopathy. Single Nucleotide Polymorphisms of COL5A1 gene are reported to be involved in Achilles tendinopathy, chronic degenerative tendon changes at the elbow, and other tendinopathies. The influence of Single Nucleotide Polymorphisms of COL5A1 was previously analyzed in rotator cuff disease with confounding results. Moreover, the rs12722 polymorphism in COL5A1 gene has been implicated in the aetiology of musculoskeletal soft tissue injuries in several association studies. This study aims to analyse the possible influence of rs12722 polymorphism in COL5A1 in the outcomes of rotator cuff repair.

Methods

Seventy-nine patients were included in the study. DNA was extracted from 1.2 ml of venous blood and genotyped for COL5A1 SNPs rs12722. Rotator cuff muscle strength and range of motion (ROM) in anterior elevation, external and internal rotation of the shoulder were evaluated.

Results

Patients presenting COL5A1 SNP rs12722 CC showed a ROM of passive external rotation statistically significantly higher compared to patients with CT genotype and TT genotype.

Conclusions

COL5A1 SNP rs12722 may influence the functional outcomes of RCRs, even though further studies are required to confirm these preliminary results.

Scapula motor control training with Proprioceptive Neuromuscular Facilitation in chronic subacromial impingement syndrome: A case report

INTRODUCTION

Shoulder complaints have high re-occurrence rates and scapular control seems to be a major influencing factor in sub-acromial impingement syndromes (SIS). Scapular dyskinesia disrupts the scapulohumeral rhythm, altering biomechanical loads on the rotator cuff in shoulder movements. As a result, this disturbs the natural healing process. Proprioceptive Neuromuscular Facilitation (PNF) seems to be a promising treatment approach because it has a focus on motor learning. This case report seeks to illustrate the clinical reasoning and feasibility of applying the comprehensive nature of PNF in a patient who was not responsive to standard physiotherapy.

CASE DESCRIPTION

A 47-year-old male, a former professional handball player, was diagnosed with a SIS based upon a rotator-cuff tendinopathy, scapular dyskinesia and degeneration of supraspinatus tendon. The patient presented complaints of right sided shoulder pain in overhead activities and in reaching behind the back.

PATIENT MANAGEMENT

PNF-based motor-control training was provided over a period of five weeks. This approach included specified PNF-pattern exercises with specific PNF-facilitation principles and techniques. The results were improvements beyond the minimal clinical important difference and/or minimal detectable change for physical functioning, pain, range of motion, and functional disability of the shoulder.

DISCUSSION AND CONCLUSION

PNF provided an opportunity for motor control training, restored altered movement patterns in the patient's daily life activities. The approach addressed motor learning effects and structural impairments. PNF-patterns have been described as: "mimicking functional activities" from daily life and from sports. In cases where standard strengthening and mobilization exercises are not effective, a specified PNF-based therapy has shown to be a feasible alternative.

Shock wave therapy for rotator cuff disease with or without calcification

BACKGROUND

Shock wave therapy has seen widespread use since the 1990s to treat various musculoskeletal disorders including rotator cuff disease, but evidence of its efficacy remains equivocal.

OBJECTIVES

To determine the benefits and harms of shock wave therapy for rotator cuff disease, with or without calcification, and to establish its usefulness in the context of other available treatment options.

SEARCH METHODS

We searched Ovid MEDLINE, Ovid Embase, CENTRAL, ClinicalTrials.gov and the WHO ICTRP up to November 2019, with no restrictions on language. We reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that used quasi-randomised methods to allocate participants, investigating participants with rotator cuff disease with or without calcific deposits. We included trials of comparisons of extracorporeal or radial shock wave therapy versus any other intervention. Major outcomes were pain relief greater than 30%, mean pain score, function, patient-reported global assessment of treatment success, quality of life, number of participants experiencing adverse events and number of withdrawals due to adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed the certainty of evidence using GRADE. The primary comparison was shock wave therapy compared to placebo.

MAIN RESULTS

Thirty-two trials (2281 participants) met our inclusion criteria. Most trials (25) included participants with rotator cuff disease and calcific deposits, five trials included participants with rotator cuff disease and no calcific deposits, and two trials included a mixed population of participants with and without calcific deposits. Twelve trials compared shock wave therapy to placebo, 11 trials compared high-dose shock wave therapy (0.2 mJ/mm² to 0.4 mJ/mm² and above) to low-dose shock wave therapy. Single trials compared shock wave therapy to ultrasound-guided glucocorticoid needling, ultrasound-guided hyaluronic acid injection, transcutaneous electric nerve stimulation (TENS), no treatment or exercise; dual session shock wave therapy to single session therapy; and different delivery methods of shock wave therapy. Our main comparison was shock wave therapy versus placebo and results are reported for the 3 month follow up. All trials were susceptible to bias; including selection (74%), performance (62%), detection (62%), and selective reporting (45%) biases. No trial measured participant-reported pain relief of 30%. However, in one trial (74 participants), at 3 months follow up, 14/34 participants reported pain relief of 50% or greater with shock wave therapy compared with 15/40 with placebo (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.62 to 1.94); low-quality evidence (downgraded for bias and imprecision). Mean pain (0 to 10 scale, higher scores indicate more pain) was 3.02 points in the placebo group and 0.78 points better (0.17 better to 1.4 better; clinically important change was 1.5 points) with shock wave therapy (9 trials, 608 participants), moderate-quality evidence (downgraded for bias). Mean function (scale 0 to 100, higher scores indicate better function) was 66 points with placebo and 7.9 points better (1.6 better to 14 better, clinically important difference 10 points) with shock wave therapy (9 trials, 612 participants), moderate-quality evidence (downgraded for bias). Participant-reported success was reported by 58/150 people in shock wave therapy group compared with 35/137 people in placebo group (RR 1.59, 95% CI 0.87 to 2.91; 6 trials, 287 participants), low-quality evidence (downgraded for bias and imprecision). None of the trials measured quality of life. Withdrawal rate or adverse event rates may not differ between extracorporeal shock wave therapy and placebo, but we are uncertain due to the small number of events. There were 11/34 withdrawals in the extracorporeal shock wave therapy group compared with 13/40 withdrawals in the placebo group (RR 0.75, 95% CI 0.43 to 1.31; 7 trials, 581 participants) low-quality evidence (downgraded for bias and imprecision); and 41/156 adverse events with extracorporeal shock wave therapy compared with 10/139 adverse events in the placebo group (RR 3.61, 95% CI 2.00 to 6.52; 5 trials, 295 participants) low-quality evidence (downgraded for bias and imprecision). Subgroup analyses indicated that there were no between-group differences in pain and function outcomes in participants who did or did not have calcific deposits in the rotator cuff.

AUTHORS' CONCLUSIONS

Based upon the currently available low- to moderate-certainty evidence, there were very few clinically important benefits of shock wave therapy, and uncertainty regarding its safety. Wide clinical diversity and varying treatment protocols means that we do not know whether or not some trials tested subtherapeutic doses, possibly underestimating any potential benefits. Further trials of extracorporeal shock wave therapy for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review. A standard dose and treatment protocol should be decided upon before further research is conducted. Development of a core set of outcomes for trials of rotator cuff disease and other shoulder disorders would also facilitate our ability to synthesise the evidence.

The Effectiveness of an Upper Extremity Neuromuscular Training Program on the Shoulder Function of Military Members With a Rotator Cuff Tendinopathy: A Pilot Randomized Controlled Trial

INTRODUCTION

Shoulder pain, a leading reason to consult a physician or physiotherapist, continues to be a challenge to rehabilitate, particularly with a military population. A rotator cuff (RC) tendinopathy, the most important source of shoulder pain, is one of the leading reasons for sick leave or a discharge from active military service. Research encourages the use of exercise prescription for the management of a RC tendinopathy, however the ideal method of delivery (group setting versus one-on-one) remains uncertain. The purpose of this single-blind (evaluator) pilot randomized clinical trial was to compare two 6-week rehabilitation programs, a newly developed group-supervised neuromuscular training program and usual one-on-one physiotherapy care, on the pain and symptoms of Canadian soldiers affected by a RC tendinopathy.

MATERIALS AND METHODS

Thirty-one soldiers with the Canadian Armed Forces were randomly assigned to (1) a group-supervised neuromuscular training program (UPEx-NTP) or; (2) one-on-one usual physiotherapy care (UPC). The primary outcome was the Disability of Arm, Hand and Shoulder (DASH) questionnaire. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) Index, pain levels at rest, and maximum isometric voluntary contractions (MIVC) of the abductors and external (lateral) rotators of the affected shoulder. Both were assessed at baseline (T0), 6 (T6) and 12 (T12) weeks. Analysis included two-way repeated measures of variance for intention-to-treat (ITT) and per-protocol analyses.

RESULTS

Eighty military members with a RC tendinopathy were contacted, resulting in 31 participants who were randomized for their active intervention, in the UPEx-NTP or UPC, respectively. No significant group (p ≥ 0.16) or group × time interactions (p ≥ 0.11) were found for either ITT or per-protocol analyses. A statistically significant time effect (p < 0.001) was established for the DASH and WORC, showing that both groups improved over time.

CONCLUSIONS

Our preliminary data demonstrates that both rehabilitation approaches, grounded in active exercises, were not statistically different from each other, and derived similar benefits over time for a military population. This suggests that a group intervention for a RC tendinopathy has potential to be just as effective as a one-on-one approach for a military population, an interesting avenue for an active working population. Larger sample sizes and further investigation are warranted regarding the cost and clinical resource benefits of a supervised group approach.

Pectoralis Minor Index: Does Ethnicity Hold Relevance? Estimation of Pectoralis Minor Length in the Indian Population and Its Correlation with Hand Length

OBJECTIVE

Pectoralis Minor Index (PMI) is a proposed parameter to evaluate the pectoralis minor length (PML), eliminating the effect of subject's variability of height. Neither a PMI standard value nor any cutoff value to label a shortened pectoralis minor (PM) has been accepted yet, which can be applied to every individual. Moreover, the length of the PM has never been correlated to any fixed reference in the body. Hence, we estimated the PML in the Indian population and investigated its correlation to the individual's hand length.

METHODOLOGY

A cross-sectional study was conducted including 100 adult subjects without any shoulder pathology. Subjects with history of fracture/treatment involving upper limb/spine were excluded. Two assessors evaluated the height, PM length and hand length of subjects. PMI and hand correlation was evaluated using their mean values.

RESULTS

Mean PML and PMI for dominant and non-dominant shoulder were calculated to be 18.11/18.21 cm and 10.53/10.59, respectively. Mean hand length of dominant and non-dominant hand was found to be 18.27 cm and 18.31 cm, respectively. Pearson correlation coefficient between right/left PML with right/left hand length was 0.67 and 0.63, respectively, suggesting a good correlation (p < 0.01).

CONCLUSIONS

PMI varies in different ethnic groups, which makes PMI a less reliable indicator for managing shoulder pain in ethnic groups where reference values are yet not available. Contralateral PMI can be used as a reference value in unilateral shoulder pathologies with short PML. Hand length can become an important parameter in evaluating painful shoulders even in bilateral pathologies. Hand length can be used as an easy and quick technique to compare the PML and effect of physiotherapy in patients with diagnosis of short PML, attending follow-up OPD. Though, a study comparing PML of normal subjects and patients with shoulder pain will be further required in different ethnic groups for further validation of this study.