Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance

Ultrasound-Guided Hydrodissection of the Thoracodorsal Nerve and Axillary Nerve in a Gymnast With Shoulder Pain Associated With Superior Labral Anterior-Posterior Lesions: A Case Report

A 20-year-old male national-level gymnast presented with left shoulder pain attributed to a superior labral anterior-posterior (SLAP) lesion. Physical examination revealed pain in the anterosuperior area at maximum shoulder elevation, with a positive combined abduction test and horizontal flexion test indicating a restriction in glenohumeral joint motion. Rather than directly addressing the SLAP lesion, ultrasound-guided hydrodissections of the thoracodorsal and axillary nerves were performed, leading to immediate alleviation of pain and mobility constraints. This innovative approach, emphasizing shoulder function, offers a novel therapeutic strategy for SLAP-associated shoulder pain in athletes.

[Prognostic factors for substantial clinical benefit from musculoskeletal pathologies of the shoulder]

INTRODUCTION

shoulder plain is a common cause of complain, however a precise diagnosis is hard to achieve. This is why finding factors associated to a good prognosis could help to improve our clinical practice.

OBJECTIVE

to identify demographic and clinical characteristics from the initial assessment associated with substantial clinical benefit (SCB) in patients with shoulder pain one month after treatment or at patient's discharge.

MATERIAL AND METHODS

this was a secondary analysis of a prospective cohort of patients with shoulder pain. Demographic and clinical (self-reported scales) factors associated with SCB at discharge or four weeks after the initial assessment, were analyzed. SCB was defined as a score +5 on a Global Rating of Change. A logistic regression model was made in order to identify predictors of SCB. The area under the curve ROC was used to assess the performance of the model with its independent variables.

RESULTS

101 patients of 138 were analyzed. The median age was 55 (RIQ 37-61) years old, there were 55 (54.5%) women in the sample. The variables independently associated to SCB were fracture as a reason for admission [adjusted OR 11.8 (95% CI 1.4-101.8); p = 0.024], and durations of shoulder symptoms shorter than seven months [adjusted OR 4.63 (95% CI 1.9-11.1); p = 0.001].

CONCLUSION

the diagnosis of fracture and durations of shoulder symptoms shorter than seven months were independently associated with a SCB after one month of treatment or at the patient's discharge.

Clinical and ultrasound findings of 'swimmer's shoulder' and its association with training history in elite Portuguese swimmers: a cross-sectional study

OBJECTIVES

To assess the prevalence of shoulder injuries and ultrasound findings in elite Portuguese swimmers and their association with symptoms and personal or training-related factors.

METHODS

This cross-sectional study was conducted at the Portuguese Open and Youth Swimming National Championships between 27 and 30th July 2022. Each athlete entered details regarding personal and training history into a questionnaire and underwent a physical and ultrasound shoulder examination.

RESULTS

A total of 102 swimmers out of 662 Portuguese athletes were included in the study. Shoulder pain experienced during the previous season was reported by 42% of the athletes. A high prevalence of shoulder structural abnormalities was noted, specifically supraspinatus tendinosis (91%), tears (29%), and subacromial bursitis (29%). Specific training for injury prevention was associated with higher rates of infraspinatus tendinosis (p = 0.047), and supraspinatus tears were linked to greater swimming distances per week (p < 0.001) and practice (p < 0.001), more years of practice (p = 0.018), shoulder pain at the time of evaluation (p = 0.023), a higher number of missed competitions (p = 0.041), and shoulder injections (p = 0.009). Subacromial bursitis was associated with shoulder pain at the time of evaluation (p = 0.002) and during the previous season (p < 0.001), missed competitions (p < 0.001), and requirement for physical therapy (p = 0.006).

CONCLUSIONS

A high prevalence of shoulder morphological changes was found in surveyed swimmers and there were several associations with training load, regardless of individual characteristics of each athlete. It is essential to understand the true impact of current injury prevention programs and to develop effective measures to protect swimmers' health.

Clinical Diagnosis of Common Overlapping Shoulder and Cervical Spine Disorders: A Review of Current Evidence

» Pain in the shoulder is a common orthopaedic complaint that can be caused by shoulder or neck pathologies.» Shoulder and neck pathologies often coexist, among which one may be a predisposing factor for the other.» History, physical examination, and diagnostic injections can be used to discern the cause of shoulder pain and guide treatment.

Physical Examination Maneuvers for SLAP Lesions: A Systematic Review and Meta-analysis of Individual and Combinations of Maneuvers

BACKGROUND

Superior labrum anterior to posterior (SLAP) lesions are targeted on physical examination using a variety of provocative maneuvers.

PURPOSE/HYPOTHESIS

The purpose was to conduct a systematic review on the performance of physical examination maneuvers in diagnosing SLAP lesions and to perform a meta-analysis comparing the sensitivity and specificity of these examinations both individually and in combination. The null hypothesis stated that there would be no significant difference in the sensitivity or specificity of the included physical examination tests, neither individually nor in combination.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic review was performed with the inclusion criteria of studies that reported either the sensitivities and specificities or the number of true-positive, true-negative, false-positive, or false-negative results for at least 1 maneuver for identifying SLAP lesions. A meta-analysis was performed to determine the sensitivity and specificity of individual maneuvers. Additional analysis determined the performance of these maneuvers when combined in series and parallel. In series, all must be present to be considered positive. In parallel, any single positive test forces the overall combination to be considered positive. Only tests that were included in ≥3 studies were considered in the meta-analysis and those included in ≥4 studies were considered in the combination analysis.

RESULTS

Overall, 862 studies were identified, 18 of which were included in the systematic review and meta-analysis. The physical examinations included were the O'Brien (n = 16), speed (n = 8), Yergason (n = 6), anterior slide (n = 8), crank (n = 7), Jobe (n = 5), dynamic labral shear (n = 3), Kim 2 (n = 3), and biceps groove tenderness tests (n = 3). All combinations of 2 to 5 maneuvers in both series and parallel were considered. The O'Brien and crank test combination was the most sensitive 2-test combination in both parallel and series. The Yergason and anterior slide test combination was the most specific 2-test combination in parallel and series.

CONCLUSION

This systematic review and meta-analysis reports an updated meta-analysis considering the sensitivity and specificity of common physical examination maneuvers used in the diagnosis of SLAP lesions and considers these values for tests in both series and parallel combinations. The present analysis demonstrates improved specificities when tests are considered in series and improved sensitivities when considered in parallel combination.

Extracorporeal Shock Wave Therapy vs. Corticosteroid Local Injection in Shoulder Impingement Syndrome : A Three-Arm Randomized Controlled Trial

OBJECTIVE

The aim of this study was to examine the effects of combining extracorporeal shock wave therapy or local corticosteroid injections with a conventional physical therapy (CPT) program for patients with shoulder impingement syndrome.

DESIGN

This was a prospective single-blinded, randomized controlled study.

METHODS

Sixty patients with unilateral shoulder impingement syndrome >3 mos were allocated to group A (a 4-wk program of CPT plus a single local corticosteroid injection of 40 mg triamcinolone acetonide mixed with 1% xylocaine, n = 20), group B (CPT only, n = 20), and group C (CPT plus extracorporeal shock wave therapy, 2000 impulses, 0.2-0.3 mJ/mm 2 , one session per week for 3 wks, n = 20). Subacromial space, shoulder pain and disability index, and shoulder range of motion were assessed at baseline and 4 and 12 wks posttreatment.

RESULTS

There were no between-group differences at 4 wks. At the 12-wk follow-up, no significant differences were found between groups A and B. There was a significant difference in favor of group C compared with group A with the expectation of shoulder internal rotation and subacromial space. Group C was also superior to group B in all outcomes except for subacromial space.

CONCLUSION

The addition of extracorporeal shock wave therapy to CPT induced more noticeable intermediate-term effects than CPT plus local corticosteroid injection or CPT alone.

Nonoperative Treatment of Rotator Cuff Tears

Rotator cuff tears are common with prevalence increasing with age. Diagnosis by physical examination may require a cluster of tests. Although radiographs can be helpful, MRI, MRI arthrography, and ultrasound represent the most used imaging technique to identify rotator cuff tears. Although surgery is sometimes necessary, a large portion of patients may respond to conservative treatment including physical therapy and injections. Physical therapy should include restoring the range of motion, addressing any pectoralis minor or posterior capsule stiffness, and restoring motor control/strength to the scapula and rotator cuff. Other conservative treatments may include nonsteroidal anti-inflammatory drugs, corticosteroid injects, and platelet-rich plasma.

The long head of biceps at the shoulder: a scoping review

BACKGROUND

This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.

METHODS

PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.

RESULTS

214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.

CONCLUSIONS

The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.

PRE-REGISTRATION

OSF: https://osf.io/erh9m.

Physical Therapists Use of Diagnostic Ultrasound Imaging in Clinical Practice: A Review of Case Reports

Objective

Ultrasound diagnostic imaging (USI) is widely utilized in sports medicine, orthopaedics, and rehabilitation. Its use in physical therapy clinical practice is increasing. This review summarizes published patient case reports describing USI in physical therapist practice.

Design

Comprehensive literature review.

Literature Search

PubMed was searched using the keywords "physical therapy" AND "ultrasound" AND "case report" AND "imaging". In addition, citation indexes and specific journals were searched.

Study Selection Criteria

Papers were included if the patient was attending physical therapy, USI was necessary for patient management, the full text was retrievable, and the paper was written in English. Papers were excluded if USI was only used for interventions, such as biofeedback, or if the USI was incidental to physical therapy patient/client management.

Data Synthesis

Categories of data extracted included: 1) Patient presentation; 2) Setting; 3) Clinical indications; 4) Who performed USI; 5) Anatomical region; 6) Methods of USI; 7) Additional imaging; 8) Final diagnosis; and 9) Case outcome.

Results

Of the 172 papers reviewed for inclusion, 42 were evaluated. Most common anatomical regions scanned were the foot and lower leg (23%), thigh and knee (19%), shoulder and shoulder girdle (16%), lumbopelvic region (14%), and elbow/wrist and hand (12%). Fifty-eight percent of the cases were deemed static, while 14% reported using dynamic imaging. The most common indication for USI was a differential diagnosis list that included serious pathologies. Case studies often had more than one indication. Thirty-three cases (77%) resulted in confirmation of a diagnosis, while 29 case reports (67%) documented significant changes in physical therapy intervention strategies due to the USI, and 25 case reports (63%) resulted in referral.

Conclusion

This review of cases provides details on unique ways USI can be used during physical therapy patient care, including aspects that reflect the unique professional framework.

Survey on Knowledge, Use, and Diagnostic Applicability of Special Tests for Rotator Cuff Involvement in Clinical Practice

Background

Recently, researchers have commented that shoulder special tests cannot identify the structure causing rotator cuff symptoms and should only be considered pain provocation tests. Others have disagreed, reporting that special tests were able to accurately detect the presence of rotator cuff involvement.

Purpose

The purpose of this study was to determine the knowledge, use, and perceived effectiveness of 15 selected special tests utilized to examine patients with possible rotator cuff dysfunction.

Study Design

Descriptive study using survey.

Methods

An electronic survey was returned by 346 members of the Academies of Orthopedic and Sports Physical Therapy through list serves. Descriptions and pictures for 15 special tests of the shoulder were included in the survey. Information regarding years of clinical experience and American Board of Physical Therapy Specialties (ABPTS) specialist certification in Sports or Orthopedics was collected. Respondents were asked if they could identify and use the special tests to evaluate dysfunction of the rotator cuff - and how confident they were in ability of the tests to diagnose dysfunction of the rotator cuff.

Results

The four tests most readily known by respondents included the empty can, drop arm, full can, and Gerber's tests, and the four tests used regularly by the respondents included the infraspinatus, full can, supraspinatus, and champagne toast tests. The infraspinatus, champagne toast, external rotation lag (ERLS), and the belly-off tests were found to be the be most useful for establishing a diagnosis of the muscle-tendon complex involved. Years of experience and clinical specialization was not relevant to knowledge or use or these tests.

Conclusions

This study will allow clinicians and educators to understand which special tests are easily identified, regularly used, and perceived as helpful for the diagnosis of muscles involved in a rotator cuff dysfunction.

Level of Evidence

3b.

Novel Orthobiologic Preparation and Regenerative Rehabilitation of a Complex Shoulder Injury in a Competitive Adolescent Female Athlete

Background

Platelet-rich plasma (PRP) and prolotherapy have resulted in promising outcomes in patients with various types of shoulder injuries. However, there is a lack of preliminary evidence supporting preparation of PRP production, timely application of these therapies and regenerative rehabilitation protocols. The purpose of this case report is to describe the distinct method including orthobiologic preparation, tissue-specific treatment and regenerative rehabilitation of an athlete with a complex shoulder injury.

Case Presentation

A 15y/o competitive female wrestler with a complex shoulder injury presented to the clinic after unsuccessful conservative rehabilitation. Unique methods were incorporated to optimize PRP production, specific tissue healing and regenerative rehabilitation. Multiple injuries required different orthobiologic interventions at different time frames, in order to promote optimal healing and stability of the shoulder.

Outcomes

The described interventions resulted in successful outcomes including pain, disability, full return to sport, and regenerative tissue healing confirmed with diagnostic imaging.

Level of Evidence

5.

Parsonage-Turner Syndrome mimicking musculoskeletal shoulder pain: A case report during the SARS-CoV-2 pandemic era

Parsonage-Turner Syndrome or neuralgic amyotrophy is a peripheral neuropathy typically characterized by an abrupt onset of pain, followed by progressive neurological deficits (e.g. weakness, atrophy, occasionally sensory abnormalities) that involve the upper limb, mainly the shoulder, encompassing an extensive spectrum of clinical manifestations, somehow difficult to recognize. This case report describes the proper management of a 35-year-old, bank employee and sports amateur who reported subtle and progressive upper limb disorder with previous history of neck pain. SARS-CoV-2 pandemic era made patient's access to the healthcare system more complicated. Nevertheless, proper management of knowledge, relevant aspects of telerehabilitation-based consultation for musculoskeletal pain, advanced skills, tools and technologies led the physiotherapist to suspect an atypical presentation of Parsonage-Turner Syndrome. Further, neurologist consultation and electromyography suggested signs of denervation in the serratus anterior and supraspinatus muscle. Therefore, an appropriate physiotherapist's screening for referral is conducted to correct diagnosis and thorough treatment.

The association between number of shoulder diagnoses and positive clinical tests with self-reported function and pain: A cross-sectional study of patients with hypermobile joints and shoulder complaints

BACKGROUND

Patients with hypermobility spectrum disorder (HSD) and shoulder complaints may suffer from symptoms related to shoulder instability, laxity, and hypermobility. It is currently unknown whether having a more complex clinical status with several diagnoses (i.e., anterior instability (AI), multidirectional instability (MDI), and/or symptomatic localised shoulder hypermobility (LSH), relates to higher functional impairments and pain.

OBJECTIVES

To investigate the associations between either ≤1, 2, or 3 clinical shoulder diagnoses (AI, MDI, and LSH) or the number (0-10) of positive clinical shoulder tests with shoulder function using the western Ontario shoulder instability index (WOSI, 0-2100, 0 = best) and pain intensity using numerical pain rating scale (NPRS, 0-10, 10 = worse).

DESIGN

Exploratory cross-sectional study.

METHOD

From a randomised controlled trial, baseline data from 100 participants with HSD and shoulder complaints for at least three months were included. Associations were investigated using linear regression models, adjusted for age, sex, body mass index, and hand dominance.

RESULTS

Compared with having ≤1 diagnosis, neither participants with two (WOSI 76.9, 95% CI -136.3, 290.0; NPRS 0.3, 95% CI -0.9, 1.5) nor three (WOSI 35.5, 95% CI -178.5, 249.6; NPRS 0.1, 95% CI -1.1, 1.3) clinical shoulder diagnoses had significantly worse shoulder function or pain. Likewise, the number of positive clinical shoulder tests was not associated with function (WOSI -20.8 95%CI (-55.3, 13.7)) or pain (NPRS -0.1 95%CI (-0.2, 0.1)).

CONCLUSIONS

In participants with HSD and shoulder complaints, having more additional shoulder diagnoses or increased number of positive shoulder tests were not related to functional impairments or pain intensities.

Prognostic and diagnostic value of circRNA expression in prostate cancer: A systematic review and meta-analysis

BACKGROUND

Circular RNAs (circRNAs) are receiving increasing attention as novel biomarkers. Our goal was to investigate the diagnostic, clinicopathological, and prognostic utility of circRNAs in prostate cancer (PCa).

METHODS

Relevant literature was searched in PubMed, Web of Science, and EMBASE. Sensitivity, specificity, diagnostic odds ratio (DOR), negative likelihood ratio (NLR), positive likelihood ratio (PLR), and the area under the curve (AUC) were calculated to evaluate the diagnostic accuracy of circRNA expression. circRNAs' clinical, pathological, and prognostic value was examined using pooled odds ratios (ORs) and hazard ratios (HRs).

RESULTS

This meta-analysis included 23 studies, with 5 for diagnosis, 16 for clinicopathological parameters, and 10 for prognosis. For diagnostic value, the pooled sensitivity, pooled specificity, PLR, NLR, DOR, and AUC were 0.82, 0.62, 2.17, 0.29, 7.37, and 0.81, respectively. Upregulation of carcinogenic circRNAs was associated with poor clinical parameters (Gleason score: OR = 0.222, 95% CI: 0.145-0.340; T classification: OR = 0.274, 95% CI: 0.175-0.430; lymph node metastasis: OR = 0.353, 95% CI: 0.175-0.716; tumor size: OR = 0.226, 95% CI: 0.099-0.518) and could predict poor survival outcomes (HR = 2.408, 95% CI: 1.559-3.720, p < 0.001). Conversely, downregulation of tumor-suppressor circRNAs was also associated with poor clinical parameters (Gleason score: OR = 1.689, 95% CI: 1.144-2.493; T classification: OR = 2.586, 95% CI: 1.779-3.762) and worse prognosis (HR = 1.739, 95% CI: 1.147-2.576, p = 0.006).

CONCLUSION

Our results showed that circRNAs might be useful biomarkers for the diagnosis and prognosis of PCa.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42021284785.

MRI evaluation of shoulder pathologies in wheelchair users with spinal cord injury and the relation to shoulder pain

OBJECTIVE

To describe the number, specifics and co-occurrence of shoulder pathologies detected by MRI in manual wheelchair users with spinal cord injury and to evaluate the association between shoulder pathologies and presence of shoulder pain.

DESIGN

Cross-sectional observation study.

SETTING

Community.

PARTICIPANTS

Fifty-one wheelchair-dependent persons with spinal cord injury (44 males, 7 females, median age 50 years (IQR 14), median time since injury 24 years (IQR 16)) were allocated to pain or no-pain group based on the Wheelchair User Shoulder Pain Index.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

All persons underwent shoulder MRI. Pathologies were scored blinded by two experienced radiologists. Participant characteristics, number and severity of shoulder pathologies were analyzed descriptively. Logistic regression was performed to evaluate the association between MRI findings and shoulder pain.

RESULTS

The median number of co-occurring MRI findings per person ranged from 0 to 19 (out of 31 possible findings). The cluster of MRI findings occurring most often together were tendon tears of supraspinatus (present in 84%), subscapularis (69%) and biceps (67%) and osteoarthritis of acromioclavicular joint (80%). When correcting for age and time since injury, the logistic regression showed no statistically significant correlation between the individual pathologies and shoulder pain.

CONCLUSION

MRI findings of shoulder pathology are very frequent in persons with and without shoulder pain. Therefore, when diagnosing the cause of shoulder pain and planning interventions, health care professionals should keep this finding in mind and MRI should not be interpreted without careful consideration of clinical history and functional testing.

Number of Months of Baseball in the Previous Year and Preseason Olecranon Tenderness: Risk Factors for Shoulder and Elbow Injuries in High-School Baseball Players

OBJECTIVE

To identify risk factors for shoulder and elbow injuries in high-school baseball position players and pitchers in the preseason history and physical examination.

DESIGN

Retrospective cohort study.

SETTING

Community high-school baseball.

PARTICIPANTS

Three hundred seventy-one male baseball players' mean age 15.0 ± 1.8 years.

OUTCOME MEASURES

A preseason history and physical examination was performed on all athletes. Injury information was collected by weekly self-report and athletic trainer injury logs throughout the season. Comparisons between injured and noninjured players were performed using t tests and χ 2 analyses. Binary logistic regression models were developed to identify risk factors for injury.

RESULTS

Seventy-six injuries were recorded over the season. In univariate analysis, the injured group had greater months of baseball participation ( P = 0.007) and shoulder visual analog scale for the past year ( P = 0.003). The injured group also had more olecranon tenderness ( P < 0.0001, odds ratio [OR] 2.9) and decreased elbow arc of motion. All other factors were not significantly different ( P > 0.05). In multivariable logistic regression, months per year of baseball participation was the only factor significantly associated with injuries ( P = 0.010, OR = 1.21).

CONCLUSIONS

Baseball players who developed arm injuries during a season were more likely to play more months of baseball and report shoulder pain in the previous year. The presence of preseason olecranon tenderness was associated with nearly triple the risk of injury during the season. Every additional month of baseball participation in the previous year was associated with a 1.2× increased odds of injury. The presence of glenohumeral internal rotation deficit was not a predictor of injury.

SLAP Injury and the Superior Labrum

Injuries around the superior labrum are a common cause of shoulder dysfunction and pain. The injuries sustained result mainly from repetitive microtrauma but can also occur following a fall on outstretched hand. Both athletic and general populations can be affected. Injuries to the superior labrum are called superior labrum anterior and posterior (SLAP) tears. Based on cross-sectional imaging findings, the literature defines four main SLAP tears (I–IV) and six extended types (V–X). An accurate description of imaging findings of the SLAP tear type, along with concomitant findings, aids clinicians in treatment planning. We also briefly discuss management options, postoperative appearance of superior labral repair, and the diagnosis of a retear.

Physical Therapy Combined With Subacromial Cortisone Injection Is a First-Line Treatment Whereas Acromioplasty With Physical Therapy Is Best if Nonoperative Interventions Fail for the Management of Subacromial Impingement: A Systematic Review and Network Meta-Analysis

PURPOSE

To construct an algorithm to optimize clinical outcomes in subacromial impingement based on current, high-level evidence.

METHODS

A systematic review of all clinical trials on subacromial impingement published from 1999 to 2020 was performed. Demographic, clinical, range of motion (ROM), and patient-reported outcome measure (PROM) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model and treatments ranked via surface under the cumulative ranking curves with respect to 3 domains: pain, PROMs, and ROM.

RESULTS

A total of 35 studies comprising 3,643 shoulders (42% female, age 50 ± 5 years) were included. Arthroscopic decompression with acromioplasty ranked much greater than arthroscopic decompression alone for pain relief and PROM improvement, but the difference in absolute PROMs was not statistically significant. Corticosteroid injection (CSI) alone demonstrated inferior outcomes across all 3 domains (pain, PROMs, and ROM) with low cumulative rankings. Physical therapy (PT) with CSI demonstrated moderate-to-excellent clinical improvement across all 3 domains whereas PT alone demonstrated excellent ROM and low-moderate outcomes in pain and PROM domains. PT with nonsteroidal anti-inflammatory drugs or alternative therapies ranked highly for PROM outcomes and moderate for pain and ROM domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for pain, forward flexion, and abduction with very low-ranking outcomes for PROMs and external rotation.

CONCLUSIONS

Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes whereas CSI demonstrated poor outcomes in all 3 domains (pain, PROMs, and ROM). For patients with significant symptoms, the authors recommend PT with CSI as a first-line treatment, followed by acromioplasty and PT if conservative treatment fails. For patients with symptoms limited to 1 to 2 domains, the authors recommend a shared decision-making approach focusing on treatment rankings within domains pertinent to individual patient symptomatology.

LEVEL OF EVIDENCE

I, systematic review and network meta-analysis of Level I studies.

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.

Development and Validation of a Web-Based Dynamic Nomogram to Improve the Diagnostic Performance of Subscapularis Tendon Tear

Background

There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on magnetic resonance imaging (MRI). The omission of SSC tendon tears can lead to muscle atrophy, fatty infiltration and increased tear accompanied by aggravated shoulder pain and loss of function. An effective noninvasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a dynamic nomogram to improve diagnostic performance.

Methods

From July 2016 to October 2021, 528 consecutive cases of patients who underwent shoulder arthroscopic surgery with preoperative shoulder MRI were retrospectively analyzed. The least absolute shrinkage and selection operator (LASSO) method was used to identify the sensitive factors associated with SSC tendon tears, which were then incorporated into the nomogram. The prediction performance of the nomogram was evaluated by concordance index (C index) and calibrated with 1,000 bootstrap samples combined with external validation of another cohort.

Results

The LASSO method showed that six items including coracohumeral distance (oblique sagittal plane), effusion (Y-face), effusion (subcoracoid), malposition of the long head tendon of the biceps, multiple posterosuperior rotator cuff tears, and considering SSC tendon tears on MRI (based on direct signs) were determined as sensitive predictors. The nomogram achieved a good C index of 0.878 (95% CI, 0.839–0.918) with a good agreement on the risk estimation of calibration plots. The areas under the receiver operator characteristic (ROC) curves of the two methods showed that dynamic nomograms had better prediction performance than MRI diagnosis based on direct signs (training set 0.878 vs. 0.707, validation set 0.890 vs. 0.704).

Conclusion

The study identified sensitive predictors associated with SSC tendon tears and first developed a web-based dynamic nomogram as a good supplementary evaluation tool for imaging diagnosis that could provide an individualized risk estimate with superior prediction performance, even in patients with small or partial tears.

Bony Apprehension Test for Identifying Bone Loss in Patients With Traumatic Anterior Shoulder Instability: A Validation Study

BACKGROUND

The presence of bone loss has important implications for the surgical treatment of patients with recurrent shoulder instability. The bony apprehension test (BAT) is a physical examination maneuver that was designed to improve specificity from the anterior apprehension test (AAT) in detecting critical bone loss.

PURPOSE

The purpose of this study was to compare the BAT with the AAT and relocation test based on their abilities to predict critical bone loss. Several well-described criteria were utilized to capture critical (≥25%) and subcritical (≥13.5%) glenoid defects, as well as Hill-Sachs defects (≥19%). The ability of the BAT to predict bipolar bone loss was also assessed, as indicated by engaging Hill-Sachs defects and off-track lesions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

The study cohort included patients ≥18 years of age who were scheduled to undergo arthroscopic stabilization for traumatic anterior shoulder instability. Notable exclusion criteria included multidirectional shoulder instability, connective tissue disorders, and workers' compensation or litigation cases. Patients underwent physical examination immediately before surgery by the treating surgeon (ie, before the induction of anesthesia). Critical glenoid and humeral bone defects were measured on preoperative computed tomography scans. Hill-Sachs engagement and on- or off-track determination of bone loss were assessed arthroscopically and via computed tomography, respectively.

RESULTS

A total of 52 patients were included in the study. In cases of subcritical glenoid bone loss (≥13.5%) and critical Hill-Sachs defects (≥19%), the BAT had good and fair specificity (82% and 72%, respectively) but poor sensitivity (40% and 39%). The BAT also had poor sensitivity (0%), specificity (67%), and positive predictive value (0%) for higher percentages of glenoid bone loss (≥25%). When engaging Hill-Sachs lesions were assessed, the BAT had excellent specificity (94%) and positive predictive value (94%) but poor sensitivity (43%) and negative predictive value (44%). Furthermore, the BAT performed poorly at predicting off-track humeral lesions. The AAT demonstrated 100% sensitivity and 0% specificity in detecting all measures of bone loss.

CONCLUSION

The BAT performed poorly at identifying subcritical and critical bone loss and was not found to have any clinical value. Future work is needed to identify a physical examination test that could complement advanced imaging for preoperative assessment of critical bone loss.

The internal rotation and shift-test for the detection of superior lesions of the rotator cuff: reliability and clinical performance

Background

Using reliable and valid clinical tests are essential for proper diagnosis and clinical outcomes among injuries involving the rotator cuff. The addition of a new clinical examination test could improve the clinical diagnosis and informative value of the sensitivity and specificity of pathology. This study of diagnostic accuracy evaluated the use of a new rotator cuff test, called the internal rotation and shift-test (IRO/shift-test), to determine its reliability and clinical performance (sensitivity, specificity, positive (PPV)/negative predictive value (NPV)). Clinical diagnostic outcomes were confirmed with radiological findings (MRI).

Methods

100 patients from a specialized shoulder unit participated (64 male, 36 female, mean age: 55 ± 13.5 years). A single-blinded (no knowledge of prior clinical or technical diagnostics) study design was used with two experienced physicians performing the IRO/shift-test. For clinical performance, all clinical testing was compared with MRI.

Results

The intra-rater (ICC = 0.73, 95% CI: 60-82) and inter-rater (ICC = 0.89, 95% CI: 81-94) coefficients for the IRO/shift-test showed good-to-excellent reliability. 75% of the patients showed a positive IRO/shift-test, while 65% had a radiologically diagnosed superior rotator cuff tear. 60% of these patients had both a positive IRO/shift-test and objective rotator cuff tear via MRI. The sensitivity of the IRO/shift-test to detect superior rotator cuff lesions based on MRI diagnosis was calculated at 92% (95% CI: 86-99%), while specificity was 67% (95% CI: 50-84%). Predictive values were also found to be high with 86% PPV (95% CI: 78-94%) and 80% NPV (95% CI: 64-96%).

Conclusion

Our results demonstrate that the IRO/shift-test is a reliable and valid tool for assessing superior rotator cuff pathology. With good-to-excellent intrarater and inter-rater reliability and strong sensitivity and specificity this test should be considered a valuable addition to clinicians' cadre of clinical evaluation tools.

Identifying key factors associated with subscapularis tendon tears and developing a risk prediction model to assist diagnosis

Background

There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on MRI. The omission of SSC tendon tear can lead to muscle atrophy, fatty infiltration, and increased tearing accompanied by aggravated shoulder pain and loss of function. An effective non-invasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a risk prediction model to assist in diagnosis.

Methods

Data on 660 patients who received shoulder arthroscopic surgery with preoperative shoulder MRI were collected retrospectively. Of these, patients with SSC tendon tears were defined as the SSC tear group, and patients with intact SSC tendon were enrolled in the non-SSC tear group. Logistic regression analysis was used to identify the key predictors of SSC tendon tears which were then incorporated into the nomogram.

Results

Among 22 candidate factors, five independent factors including coracohumeral distance (CHD, oblique sagittal plane) (OR, 0.75; 95%CI, [0.67–0.84]), fluid accumulation (Y-face) (OR, 2.29; 95%CI, [1.20–4.38]), long head of biceps tendon (LHB) dislocation/subluxation (OR, 3.62; 95%CI, [1.96–6.68]), number of posterosuperior (PS) rotator cuff tears (OR, 5.36; 95%CI, [3.12–9.22]), and MRI diagnosis (based on direct signs) (OR, 1.88; 95%CI, [1.06–3.32]) were identified as key predictors associated with SSC tendon tears. Incorporating these predictors, the nomogram achieved a good C index with a good agreement on the risk estimation of calibration plots. Higher total points of the nomogram were associated with a greater risk of SSC tendon tears.

Conclusion

When evaluating the severity of SSC tendon injury, the combination of reliable predictors can improve the sensitivity and diagnostic performance of MRI. This model provides an individualized probability of risk prediction, which is convenient for clinicians to identify patients at high risk for SSC tendon tears to avoid missed diagnosis.

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.

Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis

Background:

Previous systematic reviews and meta-analyses on the diagnostic accuracy of shoulder clinical tests do not reach conclusions regarding subscapularis tears.

Purpose:

To compare the diagnostic accuracy of commonly used clinical tests for subscapularis tears.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

An electronic literature search was conducted using Medline, Embase, and the Cochrane Library/Central. Eligibility criteria were original clinical studies reporting the diagnostic accuracy of clinical tests to diagnose the presence of rotator cuff tears involving the subscapularis.

Results:

The electronic literature search returned 2212 records, of which 13 articles were eligible. Among 8 tests included in the systematic review, the lift-off test was most frequently reported (12 studies). Four tests were eligible for meta-analysis: bear-hug test, belly-press test, internal rotation lag sign (IRLS), and lift-off test. The highest pooled sensitivity was 0.55 (95% CI, 0.28-0.79) for the bear-hug test, while the lowest pooled sensitivity was 0.32 (95% CI, 0.13-0.61), for the IRLS. In all tests, pooled specificity was >0.90.

Conclusion:

Among the 4 clinical tests eligible for meta-analysis (bear-hug test, belly-press test, IRLS, and lift-off test), all had pooled specificity >0.90 but pooled sensitivity <0.60. No single clinical test is sufficiently reliable to diagnose subscapularis tears.

Registration:

PROSPERO (CRD42019137019).

Comparing shoulder maneuvers to magnetic resonance imaging and arthroscopic findings in patients with supraspinatus tears

BACKGROUND

Shoulder maneuvers and magnetic resonance imaging (MRI) are performed to diagnose supraspinatus tendon tears regardless of arthroscopy exam. Although there are many studies on this subject, there is a lack of studies comparing the sensitivity (Se) and specificity (Sp) of shoulder maneuvers and MRI to arthroscopic findings (intact, partial, or full thickness supraspinatus tendon tear).

AIM

To compare the diagnostic values of shoulder maneuvers with MRI for supraspinatus tendon tears in patients undergoing shoulder arthroscopy.

METHODS

A total of 199 consecutive patients from four orthopedic centers met the eligibility criteria of shoulder pain persisting for at least four weeks. They were prospectively enrolled in this study from April 2017 to April 2019. Seven clinical tests (full can, empty can, drop arm, Hawkins’, painful arc, Neer’s sign and resisted external rotation) and MRI were performed, and all were compared with surgical findings. Full can, empty can and resisted external rotation tests were interpreted as positive in the case of pain and/or weakness. We assessed the Se, Sp, accuracy, positive predictive value (PPV) and negative predictive value (NPV), positive and negative likelihood ratio and diagnostic odds ratio for overall, partial and full-thickness supraspinatus tears.

RESULTS

MRI had the highest Se for overall (0.97), partial (0.91) and full-thickness (0.99) tears; moreover, MRI had the highest NPV: 0.90, 0.88 and 0.98 for overall, partial and full-thickness tears, respectively. For overall supraspinatus tears, the Se and PPV were: Painful arc (Se = 0.85/PPV = 0.91), empty can (pain) (Se = 0.80/PPV = 0.89), full can (pain) (Se = 0.78/PPV = 0.90), resisted external rotation (pain) (Se = 0.48/PPV = 0.87), drop arm (Se = 0.19/PPV = 0.97), Neer’s sign (Se = 0.78/PPV = 0.93) and Hawkins’ (Se = 0.80/PPV = 0.88). MRI had the highest PPV (0.99). The Hawkin’s test had the highest false positive rate in patients with intact tendons (0.36). The Sp of the empty can and full can (both tests positive for pain and weakness), drop arm and MRI were: 0.93, 0.91, 0.98 and 0.96, respectively. For partial and full-thickness tears, the empty can test (positive for pain and weakness) had a Sp of 0.93, and the drop arm and MRI had the same Sp (0.98).

CONCLUSION

Physical examination demonstrated good diagnostic value, the drop arm test had a Sp as good as MRI for supraspinatus tears; however, MRI was more accurate in ruling out tears. The Hawkins’ test had high false-positive findings in patients with intact tendons.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Interrater reliability of physical examination tests in the acute phase of shoulder injuries

BACKGROUND

The physical examination is one of the cornerstones of the diagnostic process in patients with acute shoulder injuries. The discriminative properties of a given examination test depend both on its validity and reliability. The aim of the present study was to assess the interrater reliability of 13 physical examination manoeuvres for acute rotator cuff tears in patients with acute soft tissue shoulder injuries.

METHODS

In a large walk-in orthopaedic emergency department, 120 consecutive patients ≥40 years of age were included in a diagnostic study. Patients who had follow-up within three weeks of an acute shoulder injury without fracture on radiographs were eligible. Four emergency department physicians participated as examiners. In a subset of 48 patients, the physical examination tests were performed by two physicians, randomly chosen by their work rotation. The physicians were blinded to the findings of each other and the results of the ultrasound screening. The interrater reliability was assessed by Cohen's kappa, intraclass correlation coefficient (ICC), standard error of measurement (SEM) and Bland-Altman plots depending on whether the examination test result was registered as a binary, ordered categorical or continuous numerical variable.

RESULTS

The median age was 55.5 years, 46% were female. Twenty-seven percent had a rotator cuff full-thickness tear on ultrasound screening; all but one involved the supraspinatus tendon. Cohen's kappa for binary tests ranged from excellent to fair. Excellent agreement (kappa > 0.8) was found for the inability to abduct above 90° and abduction strength. External rotation strength expressed substantial agreement (kappa 0.7). The lowest scores were registered for Hawkins` test and the external rotation lag sign (kappa 0.25 and 0.40, respectively). The ICCs for active range of abduction and external rotation were 0.93 (0.88-0.96) and 0.84 (0.72-0.91), whereas the SEM was 15 and 9, respectively.

CONCLUSIONS

The results indicate that examination manoeuvres assessing abduction and external rotation range of motion and strength are more reliable than manoeuvres assessing pain in patients in the acute phase of traumatic shoulder injury. The poor agreement observed is likely to limit the validity in the present setting of two commonly used tests.

TRIAL REGISTRATION

The Norwegian Regional Ethics Committee South East ( 2015/195 ).

A Thoracic Outlet Syndrome That Concealed a Glioblastoma. Findings from a Case Report

Background: Glioblastoma is the most frequent and aggressive malignant brain tumor among adults. Unfortunately, its symptoms can vary considerably depending on the size, location and the anatomic structures of the involved brain. Case report: A 58-year-old male amateur cyclist who suffered from sharp arm pain was examined for a thoracic outlet syndrome due to a previous clavicle fracture. Because of ambiguous results of the neck and nerve plexus imaging, he was referred to a neurosurgeon who properly suspected a brain tumor. The neuroimaging of the brain shown a 3 cm disploriferative mass with a blood enhancement within the left parietal lobe. The mass was urgently removed, and its histologic analysis stated a grade 4 glioblastoma. Conclusion: This case report highlights the differential diagnosis process and the teamwork approach needed to diagnose a rare presentation of a brain glioblastoma, which started its symptoms mimicking a thoracic outlet syndrome caused by a previous bone fracture.

Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery: An Online Randomized Controlled Trial

OBJECTIVE

To investigate whether different labels for rotator cuff disease influence people's perceived need for surgery.

DESIGN

Randomized controlled experiment.

METHODS

Participants with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomized to 1 of 6 terms describing rotator cuff disease: subacromial impingement syndrome, rotator cuff tear, bursitis, rotator cuff-related shoulder pain, shoulder sprain, and episode of shoulder pain. Perceived need for shoulder surgery was the primary outcome. Secondary outcomes included perceived need for imaging, an injection, a second opinion, and to see a specialist; perceived seriousness of the condition; recovery expectations; and perceived impact on work attendance. Using a Bonferroni correction (significance, P<.003), adjusted between-group mean differences and 99.67% confidence intervals (CIs) were obtained using a 1-way analysis of covariance.

RESULTS

One thousand three hundred eight (80% of 1626) responses were analyzed. Participants' mean ± SD age was 40.3 ± 16.0 years, and 59% were women. Mean perceived need for surgery (0-10 scale) was low and slightly higher among those assigned to the rotator cuff tear label compared to the bursitis label (2.6 versus 2.1; adjusted mean difference, 0.7; 99.67% CI: 0.0, 1.4). Mean perceived need for imaging (0-10) was moderate and slightly higher among those assigned to the rotator cuff tear (4.7 versus 3.7; adjusted mean difference, 1.0; 99.67% CI: 0.2, 1.9) and subacromial impingement syndrome labels (4.7 versus 3.7; adjusted mean difference, 1.0; 99.7% CI: 0.1, 1.9) compared to the bursitis label.

CONCLUSION

There were small differences in the perceived need for surgery and imaging between some labels, which could be important at the population level. J Orthop Sports Phys Ther 2021;51(8):401-411. Epub 31 Mar 2021. doi:10.2519/jospt.2021.10375.

Supraspinatus tears: predictability of magnetic resonance imaging findings based on clinical examination

BACKGROUND

The shoulder physical examination is frequently performed to diagnose rotator cuff tears in clinical practice; however, there is insufficient evidence on which physical tests are efficient for shoulder impingements in primary care settings. The purposes of this study were (1) to analyze the accuracy of 8 clinical tests to diagnose supraspinatus tendon lesions and investigate whether the combination of these tests can improve the diagnostic values; (2) to assess which are the best positivity criteria for shoulder maneuvers-pain and/or weakness; and (3) to investigate the ability of these tests to distinguish between partial- and full-thickness tears.

METHODS

A total of 733 consecutive patients were prospectively evaluated by 4 shoulder surgeons in this multicenter diagnostic study from May 2017 to December 2018, and 8 clinical tests (empty-can, full-can test, drop arm, painful arc, Neer sign, Hawkins test, Patte test, and resisted external rotation) were compared with magnetic resonance imaging performed by blinded radiologists. We assessed the sensitivity, specificity, accuracy, positive and negative predictive values, and diagnostic odds ratio (DOR) for all tests.

RESULTS

For overall supraspinatus tears, the empty-can test showed the highest sensitivity (0.81), the Patte test (positive for pain and weakness) and the drop-arm test showed the highest specificity (0.99 and 0.98, respectively), and the best combination was the Neer sign and the drop-arm test (DOR, 12.92). The positivity criteria for pain associated with weakness showed the highest performance, with DORs of 16.94 for the Patte test and 10.45 for the empty-can test. The Patte test and resisted external rotation, positive for pain and weakness, showed the highest ability to distinguish between full- and partial-thickness tears (DOR, 5.69 and 5.35, respectively). The shoulder maneuvers showed low negative predictive values; the highest value (0.58) was found with the empty-can test.

CONCLUSIONS

(1) The clinical tests demonstrated excellent diagnostic values; the empty-can test had the highest sensitivity, whereas the drop-arm test and the Patte test had the highest specificity; and the best combination for detecting supraspinatus tears was the Neer sign and the drop-arm test. On the other hand, the physical examination findings showed limited values to rule out tears. (2) The best positivity criterion for shoulder maneuvers was pain associated with weakness. (3) The Patte test and resisted external rotation showed the highest ability to distinguish between full- and partial-thickness tears.

Reliable diagnosis of posterosuperior rotator cuff tears requires a combination of clinical tests

PURPOSE

Clinical diagnosis of posterosuperior rotator cuff tears remains uncertain due to a lack of evidence-based consensus. This review aimed to compare the diagnostic accuracy of commonly used clinical tests for posterosuperior rotator cuff tears.

METHODS

The authors conducted an electronic literature search using Medline, Embase and the Cochrane library/Central, to identify original clinical studies reporting diagnostic accuracy of clinical tests to diagnose the presence of posterosuperior rotator cuff tears involving the infraspinatus, supraspinatus and/or teres minor.

RESULTS

The electronic literature search returned 1981 records, of which 14 articles were eligible. Among 17 tests included in the systematic review, 6 tests were eligible for meta-analysis: drop arm sign, Jobe test, external rotation lag sign, Hawkins-Kennedy test, Neer test and painful arc abduction test. According to QUADAS-2 criteria, risk of bias was low in 1 study, moderate in 2 and high in 4. The highest pooled sensitivity was 0.77 (CI 0.67-0.85), for the Jobe test, while the lowest pooled sensitivity was 0.38 (CI 0.01-0.98), for the drop arm sign.

CONCLUSIONS

The Jobe test had the best pooled sensitivity, while the drop arm sign had the best pooled specificity. As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option. More reliable clinical diagnosis of posterosuperior rotator cuff tears could reduce the reliance on magnetic resonance imaging or arthrography and their associated costs and waiting times.

LEVEL OF EVIDENCE

Level II.

Effects of shockwave therapy on pain and disability in individuals with rotator cuff tendinopathy: a systematic review protocol

OBJECTIVE

The objective of this study is to systematically review randomized controlled trials comparing the effect of shockwave therapy with other forms of interventions on pain and disability in individuals with rotator cuff tendinopathy.

INTRODUCTION

Shoulder pain is a common musculoskeletal complaint in which rotator cuff tendons are usually affected. Shockwave therapy is a novel conservative treatment option for rotator cuff-related shoulder pain. A systematic review in 2004 reported conflicting results on the effectiveness of shockwave therapy in treating chronic rotator cuff tendonitis, whereby it is effective for calcific rotator cuff tendonitis but not for non-calcific ones. Hence, it is timely to review this topic with the addition of results from studies published since 2004.

INCLUSION CRITERIA

This review will consider randomized controlled trials that have evaluated shockwave therapy delivered via radial or focused extracorporeal means in individuals with rotator cuff tendinopathy without restrictions of race, gender, and age. Studies comparing individuals receiving shockwave therapy of varying dosages will be excluded in this review.

METHODS

A three-step search strategy will be used to locate studies published in English from databases. No search restrictions will be applied regarding the year of publication. Study selection, assessment of methodological quality, and data extraction will be conducted by two independent reviewers. Data will be pooled in a statistical meta-analysis, where possible. A funnel plot will be generated to detect any potential publication bias. The quality of the evidence will be analyzed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020160166.

Comparison of specific and non-specific treatment approaches for individuals with posterior capsule tightness and shoulder impingement symptoms: A randomized controlled trial

BACKGROUND

Posterior capsule tightness (PCT) is associated with shoulder pain and altered shoulder kinematics, range of motion (ROM), external rotation (ER) strength, and pain sensitization.

OBJECTIVE

To assess the effects of two interventions on shoulder kinematics, Shoulder Pain and Disability Index (SPADI) scores, ROM, strength, and pressure pain threshold (PPT) in individuals with PCT and shoulder impingement symptoms.

METHODS

In this prospectively registered randomized controlled trial 59 individuals were randomized to either an Experimental Intervention Group (EIG, n=31) or a Control Intervention Group (CIG, n=28). The low flexion (LF) test was used to determine the presence of PCT. Shoulder kinematics, SPADI scores, internal rotation (IR) and ER ROM, ER strength, and PPT were measured pre- and post-treatment. Those in the EIG received an intervention specific to pain and PCT and those in the CIG received a non-specific intervention, both 4 weeks in duration.

RESULTS

Individuals in the EIG demonstrated more scapular upward rotation (P=.03; mean difference (MD)=3.3°; 95% Confidence Interval (CI)=1.3°, 4.9°) and improved value on the LF test (P=.02; MD=4.6°; 95%CI=0.7°, 8.6°) than those in the CIG after treatment. Both groups presented less anterior (P<.01; MD=-0.7mm; 95%CI=-1.3mm, -0.2mm) and superior (P<.01; MD=-0.5mm; 95%CI=-0.9mm, -0.2mm) humeral translations, decreased SPADI score (P<.01; MD=-23.6; 95%CI=-28.7, -18.4), increased IR ROM (P<.01; MD=4.6°; 95%CI=1.8°, 7.8°) and PPTs for upper trapezius (P<.01; MD=60.1kPa; 95%CI=29.3kPa, 90.9kPa), infraspinatus (P=.04; MD=47.3kPa; 95%CI=2.1kPa, 92.5kPa), supraspinatus (P<.01; MD=63.7kPa; 95%CI=29.6kPa, 97.9kPa), and deltoid (P<.01; MD=40.9kPa; 95%CI=12.3kPa, 69.4kPa) after treatment.

CONCLUSION

The experimental intervention was more effective at improving PCT as measured through changes in the LF test. No benefit of the specific approach over the non-specific intervention was noted for the remaining variables.

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.

Diagnostic Value of Frequently Implemented Provocative Tests in the Assessment of Shoulder Pain-A Glimpse of Current Practice

Initial evaluation of chronic shoulder disability is a diagnostic challenge due to the anatomic complexity of the shoulder joints. For this purpose, several diagnostic tools utilizing provocative testing exist, but only a few have a reliable basis for their diagnostic value. Therefore, objectively determining the predictive value of these tests in identifying the precise anatomical source for disability—subacromial, intraarticular or other—is essential in order to proceed with further imaging evaluations for final objective diagnoses. Using validated clusters of provocative tests should improve their diagnostic values.

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.

Suprascapular Nerve Block Is an Effective Pain Control Method in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

Background

Effective pain control in patients who have undergone arthroscopic rotator cuff surgery improves functional recovery and early mobilization. Interscalene blocks (ISBs), a widely used approach, are safe and provide fast pain relief; however, they are associated with complications. Another pain management strategy is the use of a suprascapular nerve block (SSNB).

Hypothesis

We hypothesized that indwelling SSNB catheters are a more effective pain control method than single-shot ISBs. We also hypothesized that indwelling SSNB catheters will reduce the level of rebound pain and the demand for opioid analgesics.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Included in this study were 93 patients who underwent arthroscopic rotator cuff surgery between May 2012 and January 2019. These patients were assigned to either the indwelling SSNB catheter group, the single-shot ISB group, or the control (sham/placebo) group (31 patients per group). Level of pain was measured with a visual analog scale (VAS; 0 to 10 [worst pain]) on the day of the operation. The preoperative VAS score was recorded at 6 AM on the day of operation, and the postoperative scores were recorded at 1, 8, and 16 hours after surgery and then every 8 hours until postoperative day 3.

Results

The VAS pain scores were lower in the SSNB and ISB groups than in the control group up to postoperative hour (POH) 8, with the most significant difference at POH 8. At POH 1 and POH 8, the mean VAS scores for each group were 2.29 and 1.74 (SSNB), 2.59 and 2.50 (ISB), and 3.42 and 4.48 (control), respectively. VAS scores in the SSNB and ISB groups were consistently <3, compared with a mean VAS score of 3.1 ± 1.58 in the control group (P < .001). Compared with the ISB group, the SSNB group had significantly fewer side effects such as rebound pain duration as well as lower VAS scores (P < .001).

Conclusion

VAS scores were the lowest in the indwelling SSNB catheter group, with the most pronounced between-group difference in VAS scores at POH 8. Severity and recurring frequency of pain were lower in the indwelling SSNB catheter group than in the single-shot ISB group.

Clinical Tests of the Shoulder: Accuracy and Extension Using Dynamic Ultrasound

Shoulder pain is a common musculoskeletal disorder that has a significant impact on the patient's quality of life and functional health. Because the shoulder joint is a complex structure, the relevant symptoms of shoulder pain may not directly reflect the underlying pathology. Hence, several shoulder tests have been developed to examine shoulder problems, and their diagnostic accuracy varies. Familiarization with the performance of those physical tests and their strength and limitation are of utmost importance for physicians dealing with shoulder disorders. Therefore, the present narrative review focuses on summarizing the most commonly used tests in physical examination and their diagnostic performance on several shoulder pathologies. This article also discusses how ultrasound imaging can serve as an extension of those tests.

What Is the Diagnosis in Patients with Type 2 Diabetes Who Have a Painful Shoulder? Results from a Prospective Cross-Sectional Study

Background: Patients with diabetes mellitus have higher risk of developing shoulder pathology. However, only adhesive capsulitis is addressed in shoulder pain guidelines as a disorder associated with diabetes. Yet, patients with diabetes are at risk of having several other shoulder disorders, including focal neuropathy. Our aim was to quantify the presence of shoulder disorders using physical examination and ultrasound imaging in patients with type 2 diabetes (T2DM) suffering from shoulder pain in general practice. Methods: In this prospective cross-sectional study, patients with T2DM who had had a painful shoulder for at least four weeks were included. Patients filled out a questionnaire and underwent a physical examination of the shoulders and feet and ultrasound imaging of the shoulder. Results: A total of 66 patients were included, of whom 40.9% (n = 27) had bilateral complaints resulting in 93 symptomatic shoulders. Subacromial pain syndrome was most frequently diagnosed by physical examination (66.6%, 95% CI 51.6–72.0%; p < 0.0001), while ultrasound imaging showed that subacromial disorders were statistically significantly the most prevalent (90.3%, 95% CI 81.9–95.2%). Only two patients (3%) were diagnosed with neuropathic shoulder pain. Conclusion: When choosing treatment, general practitioners should be aware that in patients with T2DM the subacromial region is most frequently affected.

Diagnostic value of the hourglass biceps test for the detection of intra-articular long head of the biceps hypertrophy

Background

Shoulder surgeons performing tenodesis note a great variability in morphology of the proximal biceps. The hourglass biceps test measures the integrity of the intra-articular biceps tendon. The hourglass maneuver (HM) is positive when there is a passive flexion deficit compared to the contralateral shoulder in a relaxed patient in the supine position.

Hypothesis

Preoperative HM is correlated with an increased width of the biceps portion resected during tenodesis.

Methods

This prospective study evaluated all patients (N = 58) who underwent biceps tenodesis between January and September 2019. Two groups of patients were compared: group 1 (n = 20) had a positive HM and group 2 had a negative HM (n = 38). The smallest (s) and largest (L) width of the tendon were measured intraoperatively, and the L/s ratio was calculated. The HM was then evaluated as a diagnostic test by creating a contingency table and determining the sensitivity and specificity of the test for different L/s ratios. A receiver operating characteristic curve was created and the area under the curve (AUC) was calculated.

Results

A nonsignificant difference was found between the mean largest biceps width in group 1 compared to group 2 (11.65 mm [range: 5-21] vs. 9.71 mm [range: 6-20], respectively; P < .05). The AUC was 0.81; the sensitivity was 68.9% and specificity, 80.8%.

Conclusion

Preoperative positivity of the HM is linked to the increased width of the biceps portion resected during tenodesis. The hourglass biceps test should be predictive of intraoperative hourglass biceps according to our definition.

The inclusion of mobilisation with movement to a standard exercise programme for patients with rotator cuff related pain: a randomised, placebo-controlled protocol trial

Background

Rotator cuff related pain (RCRP) is one of the most common sources of musculoskeletal shoulder pain affecting the general population. Conservative treatment, in the form of exercise, is considered the first line approach, nonetheless, improvements seem to be modest. One therapeutic modality that might be an adjunct to the treatment of this condition is mobilisation with movement (MWM). MWM is a pain-free manual procedure that targets restricted and painful movements, commonly seen in patients with RCRP. The purpose of clinical trial is to determine whether MWM with exercise has benefits over sham MWM with exercise in RCRP.

Methods

A randomised, sham-controlled trial of 70 adults complaining of RCRP will compare the effects of MWM combined with exercise over sham MWM with exercise. Participants will be allocated to one of two groups: exercise and MWM (EG) or exercise and sham MWM (CG). Two weekly individual treatment sessions will be conducted over five weeks. All assessments will be performed by a blinded assessor. Primary outcome measures will be the shoulder pain and disability index (SPADI) and the numeric pain rating scale (NPRS), assessed at baseline, discharge and one-month follow-up. Secondary outcome measures will be active range of motion, self-efficacy and the global rating of change scale. The analyses will be conducted considering a statistically significant p-value ≤0.05. Normality will be assessed with the Kolmogorov-Smirnov test and homogeneity with the Levene’s test. For the primary outcome measures (SPADI and NPRS) and self-efficacy, a 2 × 3 ANOVA with treatment group (EG versus CG) and time (baseline, end of the treatment and follow-up) factors will be performed. Separate 2 × 2 ANOVA will be used for range of motion (baseline and end of the treatment). Global rating scale of change analysis will be conducted using descriptive statistics. Intention-to-treat analysis will be adopted.

Discussion

As there is a paucity of longitudinal studies investigating the use of MWM in patients with RCRP, this study will help to better understand its role together with a structured exercise programme.

Trial registration

Clinical Trials Registry number NCT04175184. November, 2019.

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.

A comprehensive review of the normal, abnormal, and post-operative MRI appearance of the proximal biceps brachii

The biceps brachii myotendinous unit, particularly the long head of the biceps tendon and its labral attachment, is a common cause of shoulder and arm pain. Its complex anatomy and normal variations can present a challenge when interpreting MR images. The purpose of this manuscript is to review the proximal biceps anatomy, variants, pathology, and post-operative appearance as seen on MRI. Recent data regarding the accuracy of clinical examination and MRI will be summarized.

Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology

HYPOTHESIS/BACKGROUND

In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE.

METHODS

The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test.

RESULTS

We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87).

CONCLUSION

This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.

One in six physiotherapy practices in primary care offer musculoskeletal ultrasound - an explorative survey

BACKGROUND

The first aim of this research was to investigate the current prevalence of musculoskeletal ultrasound in Dutch physiotherapy practices. The second aim was to explore experiences of physiotherapists with musculoskeletal ultrasound in a primary care setting with patients presenting with shoulder complaints.

METHODS

A random sample of 1000 owners of primary care physiotherapy practices was sent a questionnaire to investigate the prevalence of musculoskeletal ultrasound. A second questionnaire was sent to physiotherapists using musculoskeletal ultrasound to explore experiences with it in patients with shoulder complaints.

RESULTS

The net response rate of the first questionnaire was 57.7%. In 18% of the physiotherapy practices musculoskeletal ultrasound was offered. Sixty-nine physiotherapists returned the second questionnaire. Physiotherapists indicated they most often used musculoskeletal ultrasound in patients with shoulder complaints, mainly for suspected tissue damage (83.7%), followed by making a diagnosis (63.3%) and for determining the choice of treatment (36.7%). Physiotherapists reported the biggest advantage was that they were better able to diagnose presenting shoulder complaints. The most frequently mentioned disadvantage of the use of musculoskeletal ultrasound was that assessment is difficult and that there is a risk that findings may not be sufficiently linked to history and physical examination.

CONCLUSION

One in six physiotherapy practices in the Netherlands offer musculoskeletal ultrasound. It is mainly used for patients with shoulder complaints, with an emphasis on detecting tissue damage and as an aid for diagnosis. Physiotherapists trained to work with musculoskeletal ultrasound seem enthusiastic and are at the same time aware of its disadvantages.

Osteopathic treatment of patients with shoulder pain. A pragmatic randomized controlled trial

BACKGROUND

Shoulder complaints are common in the general population. Typically, the diagnosis of a specific pathology is lacking. The objective of this trial was to evaluate the effectiveness of an osteopathic treatment in patients suffering from shoulder pain.

METHODS

A pragmatic randomized controlled trial was conducted in patients with a history of shoulder pain of 6 weeks to 12 months, and a pain intensity level of at least 40% on the visual analogue scale (VAS). Participants were identified from the general population in Germany and allocated by means of external randomization to an intervention group or a control group. Patients in the intervention group received five osteopathic treatments at intervals of two weeks. Treatment was custom tailored and based on osteopathic principles. Controls received their osteopathic treatment after an 8-week untreated waiting period. Primary outcome parameters were pain intensity and frequency, measured by VAS and Likert Scales. Secondary outcome parameters were shoulder specific pain and disability (Shoulder Pain and Disability Index, SPADI), and quality of life (SF-36).

RESULTS

A total of 70 patients aged 25-70 years (average age 45.6 ± 13.4 years) were included, 36 in the intervention group and 34 in the control group. The inter-group comparison of changes revealed clinically relevant improvements in favor of the intervention group for the main outcome parameters maximal pain intensity (VAS: between group difference of means 41.5; 95% CI: 34.6 to 48.3; p < 0.005) and average pain intensity (VAS: between group difference of means 40.4; 95% CI: 33.2 to 47.5; p < 0.005). The proportion of participants with a low frequency of pain increased in the osteopathic group only (from 7 to 34 vs. 9 to 6 in the control group, p = 0.006), and the number of patients with a high frequency decreased in the osteopathic group only (from 29 to 2 vs. 25 to 28, p < 0.0005). Shoulder specific pain and disability also improved. The follow-up assessment in the intervention group showed further improvements.

CONCLUSIONS

Five osteopathic treatments over a period of eight weeks led to statistically significant and clinically relevant positive changes of pain and disability in patients suffering from shoulder pain.