Shoulder impingement syndromes: implications on physical therapy examination and intervention

Association of Coracoacromial Ligament Degeneration With Rotator Cuff Tear Patterns and Retear Rate

Background

Coracoacromial ligament (CAL) degeneration is thought to be a factor in external impingement in bursal-sided rotator cuff tears, but CAL release is associated with adverse effects.

Purpose

To investigate the association between CAL degeneration and the patterns of massive rotator cuff tears using multiple modalities and to assess the effect of CAL degeneration on supraspinatus tendon retear rates.

Study Design

Cohort study; Level of evidence, 2.

Methods

The authors prospectively recruited 44 patients who had undergone arthroscopic rotator cuff repair without acromioplasty or CAL release. Preoperative radiographs and magnetic resonance imaging (MRI) scans were reviewed to determine acromial morphology and CAL thickness, respectively. Rotator cuff tears were categorized as isolated supraspinatus or massive (involvement of ≥2 tendons), with massive tears categorized using the Collin classification. Acromial degeneration was analyzed using the Copeland-Levy classification. The CAL was biopsied intraoperatively and histologically analyzed using the Bonar score. At 6-month follow-up, the integrity of the repaired supraspinatus tendon was analyzed on MRI using the Sugaya classification. Finally, the associations among CAL degeneration, rotator cuff tear pattern, and arthroscopic grading were investigated.

Results

Patients with Collin type B rotator cuff tear had significantly higher CAL Bonar scores than those with Collin type A or isolated supraspinatus tears (10.0 vs 6.8 and 3.4; P = .03 and P < .001, respectively). Patients with a degenerative acromial undersurface of Copeland-Levy stage 2 or 3 had CALs with significantly higher Bonar scores than those with an intact acromial undersurface (8.4 and 8.2 vs 3.5; P = .034 and P = .027, respectively). The CAL Bonar scores of patients with different stages of the 6-month postoperative Sugaya classification were comparable (6.5, 7.2, 8.0, and 7.8 for stages 1, 2, 3, and 4, respectively; P = .751).

Conclusion

CAL degeneration was more severe in anterosuperior-type massive rotator cuff tears. Interestingly, even without acromioplasty, the severity of CAL degeneration did not affect the retear rate of the supraspinatus tendon.

Subacromial Content to Subacromial Space Ratio in Neutral Position of the Arm as Diagnostic Criteria of Subacromial Impingement Syndrome

Background

Shoulder impingement syndrome is one of the main causes of shoulder disability of working-class individuals. Currently, dynamic sonography of the shoulder is the modality of choice for the evaluation of shoulder impingement syndrome. The ratio of subacromial contents (SAC) and subacromial space (SAS) in neutral arm position could be used as a diagnostic parameter for the subacromial impingement syndrome (SIS), especially in patients who have difficulties in the elevation of their shoulders due to pain. To use the SAC to SAS ratio as a sonographic criterion for the diagnosis of SIS.

Methods

SAC and SAS of 772 shoulders were vertically measured in coronal view with linear transducer 7-14MHz of Toshiba Xario Prime ultrasound unit, while the patient arm was kept in the neutral position. The ratio of both the measurements was calculated, to be used as a diagnostic parameter of the SIS.

Results

The mean SAS was 10.79 ± 1.94 mm and SAC was 7.65 ± 1.43 mm. SAC-to-SAS ratio for normal shoulders was a focused value with narrow standard deviation (0.66 ± 0.03). However, shoulder impingement is confirmed by any value falls out of the range of ratio for normal shoulders. Area under the curve at 95% confidence interval was 96%, while the sensitivity at 95% confidence interval was 99.25% (97.83%-99.85%), and specificity was 80.86% (76.48%-84.74%).

Conclusion

SAC-to-SAS ratio in neutral arm position is a relatively more accurate sonographic technique for the diagnosis of SIS.

Dry Needling Alone or in Combination with Exercise Therapy versus Other Interventions for Reducing Pain and Disability in Subacromial Pain Syndrome: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis examined the effects of dry needling alone or in combination with exercise therapy for reducing pain and disability in people with subacromial pain syndrome. Systematic searches of randomized clinical trials (RCTs) were performed in five different databases. A meta-analysis was carried out with the data obtained, and the risk of bias and quality of the studies was assessed using the Cochrane ROB 2.0 and GRADE tools. Finally, five RCTs (n = 315) were included in the meta-analysis and qualitative analysis. Our results determine that dry needling alone or combined with exercise therapy showed improvements in pain in the short-term (5RCTs: SMD: -0.27; [-0.49, -0.05]; low-quality) and mid-term (4RCTs: SMD: -0.27; [-0.51, -0.04]; low-quality) compared to a range of interventions. However, no differences were shown for disability at short-term (3 RCTs: SMD: -0.97; [-2.04, 0.11]; very-low quality) and mid-term (3 RCTs: SMD: -0.85; [-1.74, 0.04]; very-low quality). Dry needling alone or in combination with exercise therapy may result in a slight reduction in pain in the short-term and mid-term. However, the evidence about the effect of this therapy on disability in the short- or mid-term is very uncertain compared to the range of interventions analyzed in this systematic review (Registration: INPLASY202260112).

Comparison of the effectiveness of proprioceptive neuromuscular facilitation exercises and shoulder mobilization patients with Subacromial Impingement Syndrome: A randomized clinical trial

INTRODUCTION

The aim of this study was to compare the effectiveness of Proprioceptive Neuromuscular Facilitation (PNF) exercises and shoulder mobilization (SM) in addition to conventional physiotherapy on pain, range of motion (ROM), functionality, and muscle strength in patients with Subacromial Impingement Syndrome (SIS).

METHODS

Forty-four patients were randomly allocated into three groups as conventional physiotherapy (control group; n = 14), conventional physiotherapy + PNF exercises (PNF group; n = 15), and conventional physiotherapy + SM techniques (SM group; n = 15). Pain, ROM, muscle strength, and functionality were evaluated by using VAS (Visual Analog Scale), goniometer, push-pull dynamometer, Constant-Murley score and DASH (Disabilities of the Arm, Shoulder and Hand) score. Patients were received 20 sessions (4 weeks) of treatment. Assessments were performed at baseline, and weeks two, four, and sixteen.

RESULTS

After treatment, significant improvements in outcome measurements were observed in all groups (all p < 0.05). PNF or SM groups were not superior to each other in terms of improving pain and functionality. SM group was superior to PNF group for improving shoulder flexion ROM at week 4 (p = 0.009). The improvements in shoulder extension muscle strength were greater in PNF group at weeks 2 and 16 compared with other groups (p = 0.030, 0.035).

CONCLUSION

PNF or SM, in addition to conventional physiotherapy, might help to improve pain and functionality more in patients with SIS. It is recommended to add SM or PNF to conventional treatment to maintain the ROM increase gained with SIS treatment after treatment, and to apply this treatment for 4 weeks for muscle strength increase.

Acromial morphology and morphometry associated with subacromial impingement syndrome

Acromion is a major associated structure of subacromial impingement syndrome, one of the most common diagnoses in chronic shoulder pain world-wide. The aims of this study are to study morphometry of acromion and to find risk group using acromial morphometry. Total samples were 392 scapulae. The samples were of both sexes, ranging from the age of 31 to 90. Acromion type and osteophytes were observed. Acromial parameters were measured. The relationships were analyzed among acromion type, acromial osteophyte, acromial parameters, age group, sex and side. Curved acromion had the highest prevalence in all age groups. Hooked acromion had the second highest prevalence since the age of 41. Hooked acromion prevalence was higher in male than in female. The highest prevalence of acromial osteophytes was on anteroinferior surface in all age group. The prevalence of acromial osteophytes on anteroinferior surface and acromial facet increased with age. In addition, acromion type was associated with only osteophytes on anteroinferior surface of acromion. Anterior one-third acromial thickness in the age of 31 to 50 was different from those of 51 to 90. There are differences between all parameters and sexes, but not side. General population with age above 50 and concerned male group with age above 40 who have chronic shoulder pain should be investigated for subacromial impingement syndrome. Surgical treatment is recommended because hooked acromion and osteophytes are mostly the root of problem.

The glenocapsular ligament and the posterosuperior part of the joint capsule of the shoulder are well vascularized

PURPOSE

A detailed structural anatomy of the posterosuperior shoulder capsule and "glenocapsular ligament" is still rather unknown. The purpose of this study was meticulously to investigate and describe the structure and blood supply of the glenocapsular ligament on the posterosuperior shoulder joint capsule.

METHOD

Sixteen fixed and twelve fresh cadaveric shoulder specimens with a mean age of 73.4 (±6.4) years were analysed. Dissection without arterial injection was performed on the 16 fixed specimens-using an alcohol-formalin-glycerol solution. Before dissection, the 12 fresh specimens received of arterial injection a 10% aqueous dispersion of latex solution. After the injection, these shoulders were also fixed in an alcohol-formalin-glycerol solution.

RESULTS

The glenocapsular ligament was found in all 28 specimens. Single or double parallel-running bundles of connective tissue fibres were found to form a capsular-ligamentous structure on the posterosuperior part of the joint capsule. One part of the ligament was mediosuperior, another posterosuperior. The mediosuperior part varied in shape, and in 12 of 28 cases, it was absent. The glenocapsular ligament arose from the supraglenoid tubercle and posterior part of the collum scapulae and inserted into the semicircular humeral ligament. The posterior ascending branch of the circumflex scapular artery directly fed small branches laterally and medially to the joint capsule, supplying the glenocapsular ligament and the deep layer of the joint capsule.

CONCLUSION

The glenocapsular ligament is a constant anatomical structure that consists of one or two different parts. The glenocapsular ligament and the posterosuperior part of the joint capsule appear well vascularized via the posterior ascending branch of the circumflex scapular artery.

CLINICAL RELEVANCE

It is the hope of the authors that this anatomical study can help surgeons who perform open or arthroscopic surgery to the posterior part of the shoulder. Knowledge of the vascular anatomy presented in this study may be especially important when incisions are made to the posterior part of the shoulder, and should minimize the risk of complications.