Novel Posterior Shoulder Stretching With Rapid Eccentric Contraction and Static Stretching in Patients With Subacromial Pain Syndrome: A Randomized Trial

BACKGROUND

In subacromial pain syndrome (SPS), it is unknown whether posterior shoulder stretching exercises (PSSE) with rapid eccentric contraction, a muscle energy technique, improve clinical and ultrasonographic outcomes more than no stretching or static PSSE.

HYPOTHESIS

PSSE with rapid eccentric contraction is superior to no stretching and static PSSE in improving clinical and ultrasonographic outcomes in SPS.

STUDY DESIGN

Randomized controlled trial.

LEVEL OF EVIDENCE

Level 1.

METHODS

Seventy patients with SPS and glenohumeral internal rotation deficit were randomized into the modified cross-body stretching with rapid eccentric contraction group (EMCBS; n = 24), static MCBS group (SMCBS; n = 23), or control group (CG; n = 23). In addition to 4-week physical therapy, EMCBS received PSSE with rapid eccentric contraction, SMCBS static PSSE, and CG no PSSE. The primary outcome was internal rotation range of motion (ROM). Secondary outcomes were posterior shoulder tightness, external rotation ROM (ERROM), pain, modified Constant-Murley score, short form of the disabilities of the arm, shoulder, and hand questionnaire (QuickDASH), rotator cuff strength, acromiohumeral distance (AHD), supraspinatus tendon thickness, and supraspinatus tendon occupation ratio (STOR).

RESULTS

Shoulder mobility, pain, function and disability, strength, AHD, and STOR improved in all groups (P < 0.05).

CONCLUSION

In patients with SPS, PSSE with rapid eccentric contraction and static PSSE were superior to no stretching in improving clinical and ultrasonographic outcomes. Stretching with rapid eccentric contraction was not superior to static stretching, but improved ERROM compared with no stretching.

CLINICAL RELEVANCE

In SPS, both PSSE with rapid eccentric contraction and static PSSE included in physical therapy program are beneficial to improve posterior shoulder mobility and other clinical and ultrasonographic outcomes. In the case of ERROM deficiency, rapid eccentric contraction might be preferred.

Distribution and analysis of subacromial spurs and the relationship with acromial classification and angle in healthy individuals

BACKGROUND

Subacromial spurs are considered the one of the pathology underlying shoulder impingement syndrome. Furthermore, few studies have focused on the morphology of the subacromial spurs in normal Chinese people. This study aimed to study the spur distribution and to illustrate the morphology of spurs, which may help guide the extent of acromioplasty.

METHODS

A total of 93 normal individuals were enrolled, and both shoulders of all enrolled individuals were analyzed. The subjects were divided and classified into three different groups by ages: group I = 18-40 years, group II = 41-60 years, and group III ≥ 61 years. The osteophyte distribution, osteophyte area, subacromial surface area and osteophyte area/subacromial surface area ratio were measured and illustrated using Mimics and 3-matic software. The shape of the acromion was classified according to the Bigliani and Morrison classification system. The acromial angle was also classified. Then, the relationship between osteophytes, acromial classification and acromial angle was analyzed.

RESULTS

Type II (curved shape) was the most common type of acromion, and the hooked shape was a rare form. A significant increase in the left subacromial surface area in males was observed in group III compared with group I (P < 0.001) and group II (P = 0.004). The total spur/subacromial area ratio was significantly higher in group II than I. An obvious increase in the right subacromial area was observed in group III compared with group I (P = 0.004). Furthermore, there was a significant increase in the right spur area (P = 0.021) and total spur/subacromial area ratio (P = 0.006) in females in group II compared with group I. Fewer spurs were observed on the left than on the right side (p = 0.0482). One spur was most common among type II acromions (29/36) (80.56%) on the left side and the right side (34/52, 65.38%).

CONCLUSIONS

Spurs osteophytes are mainly distributed with an irregular shape and mostly run through the medial and lateral sides of the subacromial surface in normal subjects. The characteristics of subacromial spurs are so diverse that a surgeon must conduct subacromial decompression completely based on the morphology of individual spurs.

Diagnostic Implications of Ultrasound Evaluation in Patients With Shoulder Impingement Syndrome

OBJECTIVE

To evaluate the diagnostic value of musculoskeletal ultrasound measurements of subacromial bursa (SAB) thickness, supraspinatus tendon (SUP) thickness, acromiohumeral distance (AHD), and SUP-to-AHD ratio (AHD%) in patients with shoulder impingement syndrome (SIS).

METHODS

This was a prospective cross-sectional observational study. Thirty patients with SIS (60 shoulders) admitted between January 2019 and January 2020 were enrolled. The SUP thickness, SAB thickness, AHD, and AHD% (calculated as AHD% = [(SUP / AHD) × 100%]) were measured in 60 shoulders using musculoskeletal ultrasound.

RESULTS

The affected shoulder displayed thicker SUP and SAB (t = 7.838), narrower AHD (t = 2.324), and larger AHD% (t = 6.875) than the unaffected shoulder (P < .05). The SUP thickness showed a linear positive correlation with AHD (r = .503) and AHD% (r = .792) in the affected shoulder (P < .05). On receiver operating characteristic analysis, AHD*AHD% showed the best diagnostic performance in both measurements (area under the curve: 0.877).

CONCLUSION

This study revealed that SIS symptoms may be related to a larger AHD% with SUP thickening. As diagnostic criteria, the cut-off values of AHD% (65.6%) and AHD*AHD% (0.504) have good sensitivity and specificity and can help improve the differential diagnosis of patients with SIS.

Effectiveness of single intra-bursal injection of platelet-rich plasma against corticosteroid under ultrasonography guidance for shoulder impingement syndrome: a randomized clinical trial

OBJECTIVE

To compare the effectiveness of intra-bursal injection of single-dose platelet-rich plasma (PRP) against corticosteroids under ultrasonography guidance in shoulder impingement syndrome (SIS).

MATERIALS AND METHODS

This single-blind randomized controlled trial was conducted on 60 participants with a clinical diagnosis of SIS from a selected orthopedic clinic. Thirty participants in each arm were given a single dose of either PRP or triamcinolone acetonide into the subacromial sub-deltoid bursa (SASD) under ultrasonography guidance. The outcome variables assessed were the severity score of pain and the degree of shoulder abduction. Post-treatment follow-up was done in 1 week, 3 months, 6 months, and 1 year.

RESULTS

At 1 week, the triamcinolone arm showed a statistically significant reduction of pain (p = 0.039) when compared to PRP. In the long term, PRP showed statistically significant improvement in shoulder abduction, compared to the triamcinolone injection (p = 0.012).

CONCLUSION

PRP and triamcinolone in the SASD bursa could be considered as safe treatment options for SIS under ultrasonography guidance. While triamcinolone was effective in short-term pain reduction, PRP was effective in long-term improvement in shoulder abduction.

The role of bone morphology of the greater tuberosity and lateral acromion on subacromial space during scaption: a three-dimensional dynamic simulation analysis

BACKGROUND

The bone morphology of the greater tuberosity and lateral acromion plays a central role in subacromial impingement syndrome. The critical shoulder angle (CSA) and greater tuberosity angle (GTA) are two-dimensional measurement parameters that have been validated to evaluate it radiologically. These markers are, however, static and don't consider the dynamic effect of glenohumeral motion.

OBJECTIVES

This study aimed to better understand the biomechanics in subacromial impingement with a dynamic simulation based on a validated 3D biomechanical model coupling joint kinematics and 3D reconstructed computed tomography.

STUDY DESIGN & METHODS

Sixty-one patients were included in this study: a case group of 44 patients with degenerative rotator cuff tears involving only the supraspinatus, and a control group of 17 without a rotator cuff tear. Patients with previous surgeries, traumatic cuff tears, and cuff tear arthropathy were excluded. CSA, GTA, and impingement-free range of motion (IF-ROM) of the glenohumeral joint in scaption were calculated. Correlation tests were used to determine the relationship between ROM and CSA, GTA, and combined CSA and GTA values.

RESULTS

CSA and GTA were significantly higher in the rotator cuff tear group (p = 0.001 and < 0.001), while IF-ROM was significantly higher in the control group (p = 0.001). There was no overall correlation between CSA and GTA (R = 0.02, p = 0.8). Individual correlation between both angles with IF-ROM was negatively weak for CSA (R = -0.4, p < 0.001) and negatively moderate for GTA and IF-ROM (R = -0.5, p < 0.001). However, combining both angles resulted in a negatively high correlation with IF-ROM (R = -0.7, p < 0.001).

CONCLUSION

Subacromial space narrowing during scaption is highly correlated to the cumulative values of GTA and CSA. These findings suggest that the combined bony morphology of the lateral acromion and greater tuberosity plays an important role in subacromial impingement.

LEVEL OF EVIDENCE

III.

[Subacromial shoulder impingement]

Impingement, especially subacromial impingement, is one of the most frequent causes of shoulder pain. It results in soft tissue pathologies due to constriction of the subacromial space. It can lead to tendon pathologies and bursitis. In addition to the clinical examination, imaging methods such as magnetic resonance imaging (MRI), MRI arthrography, ultrasound and X‑ray examinations are helpful in making a diagnosis or evaluating the cause of pain. Conservative treatment approaches, such as rest, medication, physiotherapy, manual therapy and infiltrations should primarily be used. If the symptoms do not improve after 3-6 months of conservative treatment, surgical treatment should be considered.

The Correlation between Various Shoulder Anatomical Indices on X-Ray and Subacromial Impingement and Morphology of Rotator Cuff Tears

OBJECTIVES

Rotator cuff injury caused by subacromial impingement presents different morphologies. This study aims to investigate the correlation between various shoulder anatomical indexes on X-ray with subacromial impingement and morphology of rotator cuff tears to facilitate surgical management.

METHOD

This retrospective study was carried out between January 2020 and May 2022. Patients who were diagnosed as sub-acromial impingement associated with rotator cuff tears (without tendon retraction) and received arthroscopic surgery were enrolled in this study. The radiographic indexes of acromial slope (AS), acromial tilt (AT), lateral acromial angle (LAA), acromial Index (AI), and sub-acromial distance (SAD) were measured on preoperative true AP view and outlet view. The location of rotator cuff tear (anterior, middle, posterior, medial, and lateral) and morphology of tear (horizontal, longitudinal, L-shaped, and irregular shaped) were evaluated by arthroscopy. Groups were set up due to different tear location and tear morphologies, by comparing the various radiographic indices between each group (one-way analysis of variance and t-test), the correlation between radiographic indices and tear characteristics was investigated.

RESULTS

We analyzed 92 shoulders from 92 patients with a mean age of 57.23 ± 8.45 years. The AS in anterior tear group (29.32 ± 6.91°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.000) and posterior tear group (24.01 ± 7.69°) (p = 0.041). The AS in posterior tear group (24.01 ± 7.69°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.029). The LAA in middle tear group (67.41 ± 6.54°) was significantly smaller than that in posterior group (72.74 ± 8.78°) (p = 0.046). The AS in longitudinal tear group (26.86 ± 8.41°) was significantly larger than that in horizontal tear group (22.05 ± 9.47°) (p = 0.035) and L-shaped group (21.56 ± 6.62°) (p = 0.032). The LAA in horizontal group (70.60 ± 6.50°) was significantly larger than that in L-shaped group (66.39 ± 7.31°) (p = 0.033). The AI in L-shaped tear group (0.832 ± 0.074) was significantly larger than that in horizontal tear group (0.780 ± 0.084) (p = 0.019) and irregular tear group (0.781 ± 0.068) (p = 0.047).

CONCLUSION

Acromion with a larger AS and a smaller LAA tend to cause anterior or posterior rotator cuff tears rather than middle tears in sub-acromial impingement. Meanwhile acromion with a larger AS tends to cause a longitudinal tear, a larger LAA tends to cause horizontal tears and a larger AI tends to cause L-shaped tears.

Shoulder Impingement Syndrome

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

Effectiveness of lyophilized growth factors injection for subacromial impingement syndrome: a prospective randomized double-blind placebo-controlled study

BACKGROUND

Platelet-derived lyophilized growth factors (L-GFs) use a standardized number of allogenic pathogen-free platelets instead of autologous platelets used in PRP as a source of growth factors. This study aimed to evaluate the efficacy of L-GF injection versus placebo in subacromial impingement (SIS) treatment.

METHODS

The current randomized double-blind placebo-controlled study included sixty patients (40 females and 20 males, aged between 24 and 75 years) diagnosed with SIS (both clinically and sonographically). Patients were randomly assigned to two equal groups. Under ultrasound guidance, group 1 received subacromial saline injection, and group 2 received L-GF injection. Clinical examination, pain visual analogue scale (VAS), shoulder pain and disability index (SPADI) and shoulder ultrasound were performed before and at the 8th week after injection.

RESULTS

Follow-up assessment showed statistically significant improvement in the L-GF group regarding active flexion, active and passive internal rotation and extension, SPADI-disability scale, VAS and thickness of the supraspinatus tendon by US. Regression analysis showed that group 1 was approximately 30 times more likely than the L-GF group to experience painful arc at follow-up. Both groups showed statistically significant improvement in SPADI-pain scale and SPADI-total, flexion and abduction (still the mean value of abduction was significantly higher in the L-GF group).

CONCLUSIONS

L-GF injection resulted in clinically significant reductions in pain and functional disability outcomes in patients with SIS. An objective significant reduction in the thickness of the supraspinatus tendon, measured by ultrasound, in the L-GF group hopefully encourages proper healing and functioning in SIS.

TRIAL REGISTRATION

The identification number is NCT04330027, date of first registration (01/04/2020). Unique on 21/11/2019, Protocol ID: 0106178.

Shoulder impingement syndrome in water polo players: muscle shortening manoeuvre controls pain intensity, recovers function and normalizes sonographic parameters

PURPOSE

To evaluate the effects of muscle shortening manoeuvre (MSM) by sonography (US) in professional water polo players with shoulder impingement syndrome (SIS).

METHODS

Twenty-four professional water polo players (mean age: 22.13 ± 3.34) with SIS were assigned to one of 2 different treatment interventions: Group (1) MSM: a series of fast accelerations in the upward direction was applied to the upper limb that's connected to a spring through a metal plate with a ring. The ring was linked to a pulley system that was submitted to forces acting in the opposite direction (added mass). Group (2) Simple traction: the series of fast accelerations were performed without the springs. Pain intensity, Yocum and Hawkins tests for SIS, Neer's impingement sign, range of motion, muscle strength and shoulder US were assessed. The examination was performed before, immediately after and 30 days after each treatment to study the US width of subacromial-subdeltoid bursa (SSB), thickness of supraspinatus (ST), long biceps tendons (LBT); hypoechoic halo of surrounding the long biceps (LBH) and subscapular tendons (STH); width of acromio-clavicular joint capsule (ACJ) and the distance between bone heads (ACD). Impingement sign (IS) was evaluated by dynamic examination.

RESULTS

Immediately after treatment with MSM, pain was much reduced (p = 0.002); Yocum and Hawkins tests were decreased (p = 0.008, p = 0.031); Neer's impingement sign was negative; range of motion and muscle strength were increased. US showed that the following parameters were significantly reduced: SSB (p = 0.001), LBT (p = 0.014), LBH (p = 0.014), SSH (p = 0.002), ACJ (p = 0.004), ACD (p = 0.001). IS was no more detected. After 30 days, the improvement of clinical and US findings was maintained. In the control group, after simple traction, no clinical amelioration of US parameters was found immediately after the procedure.

CONCLUSION

These data show that MSM could be significantly and rapidly effective against pain and the loss of function due to shoulder impingement in water polo players.

Machine Learning-Based Ultrasomics for Predicting Subacromial Impingement Syndrome Stages

OBJECTIVES

To determine the performance of machine learning (ML)-based ultrasomic analysis of subacromial impingement syndrome (SIS) stage evaluation.

METHODS

In this retrospective study, 324 patients with SIS were included. The SIS stage was evaluated with a Neer test. Regions of the musculi supraspinatus were manually segmented by an experienced radiologist. Then, 5936 ultrasomic features were extracted from the Ultrasomics Platform software. The Wilcoxon test was used to identify differentially expressed radiomic features. Then, these differentially expressed features were submitted to the least absolute shrinkage and selection operator (LASSO) for model construction. The area under the curve (AUC) of the receiver operating characteristic was used to evaluate the performance of the ultrasonic model for SIS stage evaluation.

RESULTS

Finally, a total of 223 early-stage and 101 advanced-stage SIS patients were randomly divided into a training cohort (n = 227) and a validation cohort (n = 97). After feature-dimensionality reduction, a total of 28 radiomic features were submitted to LASSO analysis. Finally, 10 radiomic features were finally included for radiomics model construction. The AUC results showed that the ultrasomics model had moderate performance for SIS stage evaluation in both the training cohort (AUC = 0.839) and the validation cohort (AUC = 0.789).

CONCLUSIONS

ML-derived ultrasomics can discriminate the SIS stage in patients with SIS. This noninvasive and low-cost approach may be helpful in the preliminary screening of shoulder pain.

[Clinical application of acromion radiological classification in diagnosis and treatment of rotator cuff injury]

OBJECTIVE

To develop a new classification of acromion based on the subacromial impingement theory and the Rockwood tilt view. And explore the application value of the new classification in the diagnosis and treatment of rotator cuff tear.

METHODS

The clinical data of 101 patients underwent shoulder arthroscopic surgery for impingement syndrome or rotator cuff tear from January to December 2017 were retrospectively analyzed. There were 34 males and 67 females, aged from 34 to 76 years with an average of (56.31±9.63) years old, course of disease from 2 to 12 months with average of 6 months. Preoperative radiographs of the routine anteroposterior view, Rockwood tilt view and the supraspinatus outlet view were obtained. Based on the subacromial impingement theory and Rockwood radiographs, the morphology of the acromion can be divided into three types:typeⅠ(flat type), typeⅡ(bump type), and type Ⅲ (impingement type). Two observers classified 101 shoulder Rockwood radiographs according to the new classification method and the supraspinatus Outlet radiographs according to the traditional acromial morphological classification method. Supraspinatus tendon injuries were classified into no tear, partial-thickness tear, and full-thickness tear according to the arthroscopic findings. Concordance test (Kappa value) between the inter-observer and intra-observer was carried out for the new classification method and the traditional classification method respectively. The rank sum test was used to compare the mean acromiohumeral distance(AHD) of the three acromion forms in the new acromion classification method. Spearman rank correlation test and Gamma method were used to analyze the correlation between the new acromion classification method and the degree of supraspinatus tendon tear.

RESULTS

The inter-observer consistency analysis of the new classification system was significantly better than that of the traditional classification (0.827 vs 0.278), the intra-observer consistency analysis of the new classification system were also significantly better than that of the traditional classification (0.921 vs 0.448, 0.890 vs 0.539). There was no statistical significance in the AHD among three types of the new classification(H=2.186, P>0.05). In all 101 patients, the highest proportion of impingement type acromion was 45.5% (46 cases), followed by bump type acromion was 36.6% (37 cases), and flat type acromion was 17.8% (18 cases). The incidence of supraspinatus tendon tear in the patients with impingement type acromion was significantly higher than that of the other two types of acromion, there was a spearman rank correlation between the new acromion type and the degree of the supraspinatus tendon tear(rs=0.719, P<0.001).

CONCLUSION

Rockwood radiographs of the shoulder can well display the anterolateral osteophytes of the acromion. The new acromion classification method based on Rockwood radiographs has high reliability and good reproducibility, in which impingement type of acromion is closely related to supraspinatus tendon tear. Compared with the traditional classification and AHD, the new classification method has more diagnostic value than for rotator cuff injury.

[CME Sonography 103: Subacromial Pain Syndrome (SAPS) and Subcoracoid Impingement (SCI)]

CME Sonography 103: Subacromial Pain Syndrome (SAPS) and Subcoracoid Impingement (SCI) Abstract. Pain in the shoulder can have its origin in different structures of the shoulder joint or in affected periarticular structures. Therefore, it is important to be able to make a specific diagnosis and identify the exact pathology behind it in order to initiate the most appropriate individually precise treatment. In this review, we discuss possible causes of impingement of the shoulder.

The Influence of Different Rotator Cuff Deficiencies on Shoulder Stability Following Reverse Shoulder Arthroplasty

BACKGROUND

The primary indication for reverse shoulder arthroplasty (RSA) is rotator cuff arthropathy caused by a deficient rotator cuff. Cuff deficiency in patients is highly variable in its distribution and extent, with mechanical implications that may significantly affect post-operative recovery. This study investigated the effects of variable cuff deficiency on the propensity for impingement between the scapula and humeral component and resulting subluxation, the source of two common complications (scapular notching and instability).

METHODS

Five different finite element models of an RSA were analyzed with varying degrees of rotator cuff deficiency: (1) baseline, with intact subscapularis, infraspinatus and teres minor, (2) no subscapularis, (3) no subscapularis or infraspinatus, (4) no infraspinatus, and (5) no infraspinatus or teres minor. The supraspinatus was not included in any models, as it is absent in rotator cuff arthropathy. Each model was moved through a prescribed arc of 45° internal/ external rotation originating from neutral.

RESULTS

Greater rotator cuff deficiency was associated with more impingement and larger magnitudes of subluxation. The largest subluxation (7.5 mm) and highest impingement-related contact stress (479 MPa) was in the model lacking all rotator cuff muscle groups. Posterior subluxation was present in most models lacking the infraspinatus, while anterior subluxation was present in all models lacking the subscapularis.

CONCLUSIONS

This study helps clarify how different rotator cuff deficiencies influence shoulder stability following RSA and can ultimately help predict which patients may be at greater risk for impingement-related scapular notching and subluxation.

CLINICAL RELEVANCE

Surgeons should carefully consider the nature of the rotator cuff deficiency and its influence on impingement and instability when planning for RSA.Level of Evidence: V.

A Prospective Randomized Study Comparing the Effectiveness of Midlateral and Posterior Subacromial Steroid Injections

The authors sought to compare the accuracy and effectiveness of the mid-lateral and posterior routes of subacromial injection. They conducted a prospective randomized study involving 50 shoulders scheduled to receive subacromial injection via the midlateral or posterior route. After injection, a blinded musculoskeletal radiologist interpreted the radiographs. Age, sex, body mass index, side of shoulder involved, circumference of the proximal humerus, and acromial type were assessed. The accuracy rates of the injections, modified University of California Los Angeles shoulder scores, and visual analog scale pain scores were compared. The accuracy rate of the midlateral route was significantly higher than that of the posterior route (92% vs 68%; P<.034). Although there were significantly improved modified University of California Los Angeles shoulder and visual analog scale pain scores in both groups after injection, differences in functional outcomes were not statistically significant (P>.05). Univariate analysis showed no correlation between accuracy and age, sex, body mass index, or circumference of the proximal humerus. However, injection route had some influence on accuracy, with a crude odds ratio of 5.41 (95% confidence interval, 1.017-28.791; P=.048) for the midlateral route. Midlateral was the preferred route for subacromial injection. [Orthopedics. 2019; 42(1):e44-e50.].

Radiological Variabilities in Subcoracoid Impingement: Coracoid Morphology, Coracohumeral Distance, Coracoglenoid Angle, and Coracohumeral Angle

BACKGROUND The aim of this study was to investigate the effects of coracoid morphology, coracohumeral distance, coracoglenoid angle, and coracohumeral angle variabilities on subcoracoid impingement development using magnetic resonance imaging (MRI). MATERIAL AND METHODS A total of 200 patients (87 males with mean age of 51.1±15.2 years and 113 females with mean age of 52.6±10.7 years) undergoing shoulder MRI were included in this retrospective study. All MRI studies were performed with standard positioning. Coracoid morphology and subscapularis tendon were evaluated. Coracohumeral distance, coracoglenoid angle and coracohumeral angle were measured in all subjects. One-way ANOVA was used to assess the difference between the groups. For binary comparisons, Tukey post hoc analysis was done. Pearson correlation analysis was performed between variables. RESULTS Type C coracoid was more frequent in the tendinosis and tendon tear groups. There was a significant difference between type C coracoid and the other coracoid types for coracohumeral distance values (P=0.016). There was a statistically significant decrease in coracoglenoid angle values and coracohumeral distance in patients with subscapularis tendon pathologies (P=0.000). A statistically insignificant increase in coracohumeral angle values was found in the subscapularis tendon pathologies. There was a positive correlation between coracohumeral distance and coracoglenoid angle (R=0.749 P=0.000). There was a negative correlation between coracohumeral distance and coracohumeral angle (R=-0.668 P=0.000) and between coracoglenoid angle and coracohumeral angle (R=-0.605 P=0.000). CONCLUSIONS In subscapularis tendon pathologies, decrease in coracohumeral distance and coracoglenoid angle was observed. A new approach uses coracohumeral angle to evaluate subcoracoid impingement. A statistically insignificant increase in coracohumeral angle was noted.

Effect of Arm Position on Width of the Subacromial Space of Upper String Musicians

OBJECTIVE

Musicians often end their musical career due to musculoskeletal injury. A leading source of shoulder pain in upper string musicians is rotator cuff disease (RCD). Multiple factors contribute to its development. Compressive overload of the soft tissues of the subacromial space resulting from a decrease in the width of the subacromial space has been identified as an extrinsic factor contributing to RCD development. The purpose of this study was to characterize the width of the subacromial space by measuring acromial-humeral distance (AHD) of upper string musicians, while their arms are in standard playing positions.

METHODS

Experienced musicians (n=23) were recruited from local communities. Shoulder ultrasound images were collected using standard imaging techniques. Images were collected and the AHD measured while the musician's arm was in positions associated with playing the violin.

RESULTS

On the right side, the arm position main effect was significant (p<0.001): the AHD in the 4th string position (8.8±1.9 mm) was less than the 1st string (11.3±1.4 mm) and resting (11.7±1.3 mm) positions. There was no difference in AHD between resting (10.0±5.8 mm) and instrument-support positions (10.6±1.5 mm). The resting AHD was smaller (p=0.04) on the right side compared to the left (12.2±1.4 mm). There was not statistically significant difference (p=0.138) in the occupation ratio (supraspinatus tendon thickness/AHD) between the right (mean 0.543±0.80 mm) and left sides (mean 0.510±0.087 mm).

CONCLUSIONS

The AHD measurement decreased in the playing positions compared to resting positions. Treatment interventions that help musicians maximize the width of their subacromial space might help reduce the prevalence of shoulder pain in this population.

Static and Dynamic Shoulder Imaging to Predict Initial Effectiveness and Recurrence After Ultrasound-Guided Subacromial Corticosteroid Injections

OBJECTIVE

To explore factors contributing to initial effectiveness and recurrence after ultrasound (US)-guided subacromial corticosteroid injections by assessing clinical measurements and static and dynamic shoulder US images.

DESIGN

Retrospective cohort study.

SETTING

Rehabilitation outpatient clinic.

PARTICIPANTS

Adults with shoulder pain referred for injection therapy (N=164).

INTERVENTION

US-guided subacromial corticosteroid injection.

MAIN OUTCOME MEASURES

The association of initial effectiveness (defined as >50% decrease in any of the 3 pain subdomains after the first injection) and recurrent shoulder pain that required repeated intervention with record-based clinical measurements and static/dynamic shoulder US.

RESULTS

This study included 164 patients, 106 of whom were responsive to a first injection. Among the 106 participants, 42 received a second injection because of recurrent shoulder pain. By using the multivariate logistic regression analysis, initial effectiveness was positively associated with right handedness, grade 2 subacromial impingement during the dynamic US examination, and bicipital groove tenderness. However, these patients had a negative association with subdeltoid bursitis, grade 3 subacromial impingement, and shoulder stiffness. Subdeltoid bursitis and a positive painful arc test were predictors of recurrent shoulder pain that necessitated a repeated injection in the Cox proportional hazards model.

CONCLUSIONS

The initial effectiveness and recurrence after US-guided subacromial corticosteroid injection were associated with certain clinical measurements and static and dynamic shoulder US, which should be carefully evaluated (and can be used) to guide the best treatment outcomes.

Acromion Types and Role of Corticosteroid with Shoulder Impingement Syndrome

OBJECTIVE

To determine the association between shoulder impingement and morphological characteristics of acromion and the role of sub-acromial injection of methylprednisolone in the short-term treatment for relieving pain and improve functional disability of these patients.

STUDY DESIGN

A descriptive study.

PLACE AND DURATION OF STUDY

Department of Orthopedic Surgery and Traumatology Unit-I (DOST-I), Mayo Hospital, Lahore, between November 2013 to June 2014.

METHODOLOGY

All patients presented in OPD with shoulder pain were included as subjects and evaluated by clinical test and categorised using X-ray scapula Y-view. Patients with impingement syndrome were correlated with Bigliani types and offered intra-lesional injection into sub-acromial space with 2ml of xylocaine 2% and 40 mg of methylprednisolone using 22 gauge needle. The effectiveness was assessed in terms of relieving pain and good functional outcomes; and rotator cuff tear was clinically assessed among impingement positive patient. The pain was assessed using visual analogue score before and after the administration of the injection. Demographic variables for frequencies and their associations were analysed using SPSS version 20.0. Significance level was p <0.05.

RESULTS

Among the 101 cases, there was no case of tear of rotator cuff tendon on clinical assessment. Majority of the patients (58.4%) were females with mean age of 31.38 ±1.13 years. Majority 57 (56.4%) of the patients had acromion type II (curved), which was the most common cause of shoulder impingement. Most had moderate pain. Thirty-four patients required intralesional steroid, which relieved the pain in 31 of them.

CONCLUSION

Shoulder impingement syndrome without tear of rotator cuff tendon was found in younger age group between 40 to 45 years, which was relieved by intralesional corticosteroid administration. These patients had type II (curved) acromion, according to Bigliani classification.

Supraspinatus outlet view in the diagnosis of stages II and III impingement syndrome

Purpose: To compare supraspinatus outlet view (SOV) findings at different stages of the impingement syndrome (IS) with findings in asymptomatic age- and sex-matched controls.

Material and Methods: Pre-operative SOVs were obtained of 37 shoulders of patients scheduled for unilateral open repair of a full-thickness rotator cuff tear (stage III IS) and 74 shoulders of patients scheduled for open (n=46) or arthroscopic (n=28) acromioplasty for tendinitis (stage II IS). Each view of a patient's shoulder was paired with a control view obtained from an age- and sex-matched person with no shoulder problems (n=111).

Results: There were no significant differences in acromial morphology as evaluated on the scale devised by Bigliani et al. or in the tilt, slope or length of the acromion between the study groups and their controls. However, hooked acromion seemed to be more common in the patients. The thickness of the anterior part of the acromion at the tendinitis stage and the acromial angle at the tear stage of IS were the only parameters that showed significant differences between patients and controls.

Conclusion: Variation of the morphology of the acromion as evaluated on a basis of the SOV is associated with IS, but the association is weak and its value in the diagnosis of IS is therefore only as an adjunctive to other diagnostic modalities.

Empty can and drop arm tests for cuff rupture : Improved specificity after subacromial injection

Shoulder disorders are common in the general population : they occur in about 25 of every 1000 patients per year. A rather large majority are caused by cuff disorders. Differentiating between impingement and cuff rupture is essential to adequate treatment. Clinical tests have been developed, but their accuracy is limited. This study was performed to improve clinical accuracy by combining single tests and adding a subacromial injection. We postulated that the empty can and drop arm tests would result in higher sensitivity and specificity after subacromial injection.

METHOD

We prospectively assessed 49 patients with the empty can and drop arm tests and used ultrasound to compare the individual and combined results.

RESULT

The ultrasound found six cuff ruptures. Specificity improved and sensitivity decreased after subacromial injection.

CONCLUSION

Only specificity improved after subacromial injection. Combining the test results led to an increase in both sensitivity and specificity without injection.

Problems With Large Joints: Shoulder Conditions

The shoulder is the most mobile joint in the body. It requires an extensive support system to create mobility while providing stability. Although there are many etiologies of shoulder pain, weakness, and instability, most injuries in the shoulder are due to overuse. Rotator cuff tears, labral tears, calcific tendinopathy, and impingement often result from chronic overuse injuries. Acute injuries include dislocations that can cause labral tears or other complications. Frozen shoulder refers to a typically benign condition of restricted range of motion that may spontaneously resolve but can cause prolonged pain and discomfort. The history combined with specific shoulder examination techniques can help family physicians successfully diagnose shoulder conditions. X-ray imaging typically is sufficient to rule out more serious etiologies when evaluating patients with shoulder conditions. However, imaging with magnetic resonance imaging (MRI) study or ultrasonography for rotator cuff tears, and MRI study with intra-articular contrast for labral tears, is needed to confirm these diagnoses. Corticosteroid injections and physical therapy are first-line treatments for most shoulder conditions. Surgical options typically are reserved for patients for whom conservative treatments are ineffective, and typically are performed arthroscopically.

Imaging of benign complications of exostoses of the shoulder, pelvic girdles and appendicular skeleton

Exostoses are the most common benign bone tumors, accounting for 10 to 15% of all bone tumors. They develop at the bone surface by enchondral ossification and stop growing when skeletal maturity has been reached. At first, exostoses are covered by a smooth cartilage cap that progressively ossifies with skeleton maturity. Then they may regress, partly or even completely. Osteochondromas may be solitary or multiple, with the latter associated with hereditary multiple exostoses (HME). Exostoses develop during childhood and become symptomatic during the third decade of life in the case of solitary exostoses, or earlier, in case of HME. They stop growing after puberty, when the epiphyseal plates close. Most exostoses remain asymptomatic. Local complications, usually benign, may occur, such as fractures or mechanical impingements upon nearby structures. In rare cases, sarcomatous degeneration occurs. Most of these complications have been described in case reports. This article describes the imaging features of benign complications of exostoses of the shoulder, pelvic girdles and appendicular.

Emerging technology in surgical education: combining real-time augmented reality and wearable computing devices

The authors describe the first surgical case adopting the combination of real-time augmented reality and wearable computing devices such as Google Glass (Google Inc, Mountain View, California). A 66-year-old man presented to their institution for a total shoulder replacement after 5 years of progressive right shoulder pain and decreased range of motion. Throughout the surgical procedure, Google Glass was integrated with the Virtual Interactive Presence and Augmented Reality system (University of Alabama at Birmingham, Birmingham, Alabama), enabling the local surgeon to interact with the remote surgeon within the local surgical field. Surgery was well tolerated by the patient and early surgical results were encouraging, with an improvement of shoulder pain and greater range of motion. The combination of real-time augmented reality and wearable computing devices such as Google Glass holds much promise in the field of surgery.

Muscle shortening manoeuvre reduces pain and functional impairment in shoulder impingement syndrome: clinical and ultrasonographic evidence

OBJECTIVES

To evaluate the short-term efficacy of muscle shortening manoeuvre (MSM), by inducing an increase in strength of the shoulder muscles, for the treatment of shoulder impingement syndrome (SIS).

METHODS

Sixty subjects (mean age: 58.6 years) with SIS were assigned to one of 3 different treatment interventions: 1) MSM: a series of fast accelerations in the upward direction was applied to the upper limb that was also submitted to forces acting in the opposite direction (added mass); 2) traditional physiotherapeutic technique: scapulothoracic gliding; 3) simple traction: the added mass was applied to the limb without the series of fast accelerations. Pain intensity, Neer's impingement sign, range of motion and muscle strength were assessed. Ultrasound (US) examination was performed before, immediately after and 30 days after each treatment to study the width of the subacromial-subdeltoid bursa, long biceps tendon sheath and acromioclavicular joint. Impingement was evaluated by dynamic examination.

RESULTS

After treatment with MSM, pain was significantly reduced (p<0.001), Neer's impingement sign was negative, range of motion and muscle strength were increased. US examination showed that the widths of the subacromial-subdeltoid bursa (p<0.001), long biceps tendon sheath (p<0.001) and acromioclavicular joint (p<0.001) were significantly reduced; impingement was no more detected. After 30 days, improvement in clinical and US findings was maintained. In the two control groups, no significant changes were observed after treatment.

CONCLUSIONS

Clinical and US findings demonstrate that MSM, by inducing an increase in muscle strength, is effective in the short-term treatment of SIS.

[Coracoplasty with mini-incision for treatment of subcoracoid impingement syndrome]

OBJECTIVE

To investigate the method and effectiveness of coracoplasty with mini-incision for subcoracoid impingement syndrome.

METHODS

Between May 2006 and September 2011, 4 patients with subcoracoid impingement syndrome were treated, including 3 cases of congenital dysplasia of the coracoid process and 1 case of anterior glenohumeral instability. There were 3 males and 1 female with an average age of 36 years (range, 20-56 years). The disease duration was 6-22 months (mean, 11.2 months). The patients had a history of chronic pain and click of the anterior should, which was aggravated in adduction, internal rotation, and flexion. The results of the coracoid impingement test were positive by Neer and Hawkins-Kennedy impingement sign. The axial CT in adduction position showed that the coracohumeral interval decreased and coracoid index increased. The 2 cm lateral coracoid incision was made and the 0.5-1.5 cm coracoid neck was revealed and cut by osteotomy. The coracoplasty was performed by amputating the conjoined tendon insertion of the short head of the biceps and the coracobrachialis muscle and suturing to proximal coracoid osteotomy surface. Shoulder was fixed with the external braces for 6 weeks.

RESULTS

Healing of incision by first intention was observed in all cases without any complication. All the 4 patients were followed up from 8 months to 5 years. At last follow-up, pain and click disappeared. The mean visual analogue scale (VAS), University of California at Los Angeles (UCLA), Constant, and simple shoulder test (SST) scores were significantly improved from 7.75, 10.25, 65.50, and 9.75 at preoperation to 0.25, 34.25, 91.25, and 0.25 at last follow-up respectively. The axial CT in adduction position and MRI showed that long coracoid process was removed; the coracohumeral interval was increased to 13.38 mm from 4.16 mm at preoperation; and the coracoid index was decreased to 0.28 mm from 13.08 mm at preoperation.

CONCLUSION

Coracoplasty with mini-incision is an effective method to relieve clinical symptoms of subcoracoid impingement, which has less complications and faster recovery.

Dynamic ultrasound of the subacromial-subdeltoid bursa in patients with shoulder impingement: a comparison with normal volunteers

OBJECTIVE

The purpose of the study was to determine if the thickness of the subacromial-subdeltoid (SASD) bursa during dynamic ultrasound and on static views differs between patients with shoulder impingement syndrome and healthy volunteers.

MATERIALS AND METHODS

Twenty-two patients with a clinical diagnosis of shoulder impingement syndrome and 23 healthy volunteers were recruited. A subset of patients showing an immediate symptom response following intrabursal injection was identified as "injection responders". Ultrasound of the shoulder was performed on all participants using three standard static views and two dynamic views (before and after arm abduction). The thickness of both the intrabursal fluid and the superficial peribursal fat was measured on all views. The bursal thickness measurements in the two groups were compared using a t test for significance.

RESULTS

The mean increase in SASD bursal fluid thickness following arm abduction was not statistically different among all patients (0.39 ± 0.41 mm) and controls (0.35 ± 0.32 mm), p = 0.72. The same was true comparing injection responders (0.46 ± 0.49 mm) with controls, p = 0.41. On static views, greater bursal fluid thickness was found in patients (1.01 ± 0.48 mm) compared with controls (0.67 ± 0.32 mm) when using the short axis view of the supraspinatus, p = 0.006. No statistically significant difference was found between injection responders and controls when measuring peribursal fat thickness on any view.

CONCLUSIONS

Gathering of the SASD bursa demonstrated during dynamic ultrasound does not necessarily indicate painful impingement of the bursa as it is found to a similar degree in patients with a clinical diagnosis of impingement and healthy volunteers.

Economic evaluations in shoulder pathologies: a systematic review of the literature

BACKGROUND

Economic evaluations provide decision makers with a tool for reducing health care costs because they assess both the costs and consequences of health care interventions. This study reviewed the quality of published economic evaluations for shoulder pathologies.

MATERIALS AND METHOD

A MEDLINE search was conducted to identify articles published from 1980 to 2010 that contained "cost" or "economic" combined with terms for several shoulder disorders and treatments. We selected studies that fit the definition of 1 of the 4 routinely performed economic evaluations: cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses. Study quality was determined by measuring adherence to 6 established health economic principles, as described in the literature.

RESULTS

The search retrieved 942 studies. Of these, 32 were determined to be economic evaluations, and 53% of the economic evaluations were published from 2005 to 2010. Only 8 of the 32 studies (25%) adhered to all 6 health economic principles. Publication in a nonsurgical journal (P < .05) or in more recent years (P < .01) was significantly associated with higher quality.

CONCLUSION

Future health care resource allocation will likely be based on the economic feasibility of treatments. Although the number and quality of economic evaluations of shoulder disorders have risen in recent years, the current state of the literature is poor. Given that availability of such data may factor in private and public reimbursement decisions, there is a clear demand for more rigorous economic evaluations.

Minor or occult shoulder instability: an intra-articular pathology presenting with extra-articular subacromial impingement symptoms

PURPOSE

Disruption in the balance of shoulder stability can produce a widely varied spectrum of clinical symptoms, ranging from minor shoulder instability to frank shoulder dislocation, followed by recurrent instability. In this study, a series of patients suffering from minor shoulder instability, all with clinical signs of preoperative subacromial impingement associated with instability, were treated. The shoulder instability alone was addressed, with the aim of eliminating the clinical symptoms of subacromial impingement and pain.

MATERIAL

In this study, 20 patients with minor shoulder instability, presenting with subacromial impingement symptoms, underwent arthroscopic treatment to address capsule-labral pathology. All patients underwent a preoperative assessment by one independent physiotherapist, using Constant and WOSI scores, as well as the Castagna test, on both the affected and non-affected sides. The Hawkins test and subacromial pain in 90° of abduction and internal rotation were also evaluated. All patients followed the same rehabilitation protocol by a second physiotherapist. All patients were followed up at 6, 12 and 24 months postoperatively by the same independent physiotherapist.

RESULTS

We observed that 20/20 patients had a positive Hawkins sign at >20° of internal rotation preoperatively, while 4/19 had a positive Hawkins sign--all with less pain--at the 24-month follow-up (P < 0.0001). Moreover, 20/20 had a positive Castagna test preoperatively, while 1/20 had a positive Castagna test at the 24-month follow-up. In terms of shoulder scores, at 24 months, the Constant score had improved from a median value of 70 (51-91) preoperatively to a median value of 91 (86-100). The median WOSI score was 48.3 (12.7-78.6) preoperatively and improved to 84.9 (39.5-98.5) at 24 months postoperatively.

CONCLUSION

Minor shoulder instability is an intra-articular pathology presenting with extra-articular subacromial impingement symptoms. By treating the intra-articular pathology, the extra-articular symptoms can be relieved in the vast majority of patients.

[Ultrasonographic measurement of the effect of rotatory cuff repair with coracoacromial ligament transfer on humeral head migration]

OBJECTIVES

In this study we evaluated whether ligament transfer caused humeral head migration in patients whose massive rotator cuff ruptures were repaired with total or partial coracoacromial ligament (CAL) transfer. The necessity of harvesting the ligament totally or partially in massive rotator cuff repairs was investigated with respect to the effect of the excision and transfer of the CAL on humeral head migration.

PATIENTS AND METHODS

Forty patients (12 males, 28 females; mean age 54.3 years; range 39 to 66 years) operated on with free CAL transfer for massive rotator cuff rupture between January 2003 and June 2008 were included in the study. The operations were performed by obtaining total CAL grafts in the first 13 cases and partial CAL grafts in the other 27 cases. Mean follow-up period was 26.5 months (range 12 to 52 months). Twenty-nine patients had the rupture on the right side and 11 patients had the rupture on the left side. In 31 patients the dominant side was affected.

RESULTS

In the early postoperative period (3-6 weeks) adequate acromiohumeral (AH) distance could not be obtained in patients underwent total excision and transfer of CAL (mean 9 mm; range 8.6 to 9.2 mm). Humeral migration was found to be regressed three months after active motion and recovery of normal cuff strength. During the follow-up the mean AH distance was found to be 10 mm (range 8 to 10.5 mm). Humeral head migration was not detected by ultrasonography in the early postoperative period in patients who underwent repair with partial CAL transfer.

CONCLUSION

Functionally good results have been obtained in the rotatory cuff repairs performed by CAL excision and transfer. Although humeral head migration was not detected ultrasonographically in the patients who had partial CAL excision and transfer at the early postoperative period, we observed a decrease in the AH distance in the patients who had total CAL excision and transfer. This migration was regressed and the cuff strength was recovered after intense rehabilitation with strengthening exercises and active motion.

A one-stop approach to the management of soft tissue and degenerative musculoskeletal conditions using clinic-based ultrasonography

BACKGROUND AND OBJECTIVE

One-stop clinics aim at assessment, investigation and initiating treatment in a single hospital visit. They have been proven to be cost-effective and to increase patient satisfaction in various specialties. The aim of this study was to describe the one-stop approach to managing soft tissue and degenerative musculoskeletal conditions using clinic-based musculoskeletal ultrasonography (MSUS).

METHODS

A retrospective case record review was carried out of patients assessed and managed in the musculoskeletal clinic by a musculoskeletal and sports physician over a 10-month period.

RESULTS

A total of 1,166 patients were assessed and managed in a total of 155 outpatient clinics. The age range of patients was 19 to 85 years (median age 45 years). The diagnoses included traumatic or overuse tendinopathy, degenerative arthritis, bursitis, acute/chronic sporting injuries and acute/chronic back pain. A total of 1,012 patients (87%) had conditions related to the appendicular system (shoulder girdle, upper limb, pelvic girdle and lower limb) and 154 patients were referred with spinal pain. All patients with appendicular system problems had a definite diagnosis and treatment initiated on the first visit to the clinic. In 658 (65%) patients, a diagnostic ultrasound was deemed an appropriate investigation to improve the accuracy of diagnosis and more than half of them (352 patients) needed ultrasound-guided injections as part of the management of their conditions. A portable GE Healthcare LOGIQe machine with a 10 MHz linear probe and colour Doppler flow imaging was used to perform all scans. No adverse incidents were reported.

CONCLUSIONS

The use of clinic-based MSUS enables a one-stop approach, reduces repeated hospital appointments and improves quality of care in an outpatient musculoskeletal clinic.

Shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears

BACKGROUND

Complex regional pain syndrome (CRPS) is one of the serious complications after surgical treatment of a rotator cuff tear. Both a measurement of body surface temperature and bone scintigraphy have been used as diagnostic tools for the early phase of CRPS.Unfortunately, few studies have been carried out that applied these methods to the patients after rotator cuff repair.

PURPOSES

To clarify both shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears.

SUBJECTS AND METHODS

Subjects comprised patients with unilateral rotator cuff tears (five men and five women, mean age 61 years). For measurements of shoulder surface temperature, a Thermochron was attached to both shoulders. As for bone scintigraphy, intravenous injection of technetium-labelled hydroxymethylenebisphosphonic acid (99mTc-HMDP)was performed, and then images were taken with a gamma camera.

RESULTS

During the measurements, the changes in body surface temperature for the affected and healthy shoulders remained within the standard deviation of the reference group. The intensity of radioisotope (RI) uptake for the affected shoulder joint was significantly increased compared to that for the healthy shoulder joint (P < 0.05).

CONCLUSION

RI uptake is increased in shoulders with rotator cuff tears, whereas shoulder surface temperature shows no differences on the affected and unaffected sides.

Ultrasonographic measures of subacromial space in patients with rotator cuff disease: A systematic review

PURPOSE

Recently sonography (US) has been used to measure the subacromial space outlet with a linear measurement of the acromiohumeral distance (AHD). The purpose of this article is to systematically review the literature on the influence of rotator cuff disease (RCD) on AHD using US.

METHODS

Computer-aided searches of databases were performed to identify comparative studies that measured US-generated AHD in adults with symptomatic RCD.

RESULTS

Five studies met the inclusion/exclusion criteria.

CONCLUSIONS

US images of AHD are smaller in patients with full-thickness tears than healthy individuals and subjects with subacromial impingement. AHD is potentially useful to prognosticate outcome in patients with subacromial impingement.

US-guided therapy of calcific tendinopathy: clinical and radiological outcome assessment in shoulder and non-shoulder tendons

PURPOSE

To analyze the effectiveness and complication rate of ultrasound (US)-guided perforation and lavage using a two-needle technique with 16 - 18 G needles in the treatment of patients with calcific tendinopathy in the shoulder, elbow, hip, and knee by radiological and clinical follow-up.

MATERIALS AND METHODS

A retrospective chart review was performed and 40 patients (13 male, 27 female; mean age, 53.5 years; range 24 -74 years) were identified as having received US-guided perforation and lavage due to symptomatic calcific tendinopathy of the rotator cuff tendons, triceps, extensor and flexor tendons at the elbow, rectus femoris tendon and patellar tendons. The radiographic outcome was assessed by comparison of the size and quality of the calcification before and 6 weeks after the procedure. On US images, the quality of the acoustic shadow was assessed, together with other alterations of the tendon and surrounding tissue. Patients were interviewed by telephone to assess the clinical outcome regarding pre-treatment and post-treatment pain and tendon function.

RESULTS

34 shoulder tendons and 6 non-shoulder tendons were identified. The mean calcium reduction was 39.9 mm(2) (range, 0 - 215; p < 0.001), while 80 % of patient showed a resolution of more than 60 % resulting in good clinical improvement. A very low complication rate was found (1 partial tear).

CONCLUSION

The US-guided perforation and lavage technique is an effective and safe treatment for rotator cuff calcifications as well as for other body tendons. Although the two-needle technique and large needles were used in this study, a very low complication rate was detected.

Work-related lesions of the supraspinatus tendon: a case-control study

OBJECTIVES

To examine the dose-response relationship between cumulative duration of work with highly elevated arms (work above shoulder level) as well as of manual material handling and ruptures of the supraspinatus tendon in a population-based case-control study.

METHODS

In 14 radiologic practices, we recruited 483 male patients aged 25-65 with radiographically confirmed partial (n = 385) or total (n = 98) supraspinatus tears associated with shoulder pain. A total of 300 male control subjects were recruited. Data were gathered in a structured personal interview. To calculate cumulative exposure, the self-reported duration of lifting/carrying of heavy loads (>20 kg) as well as the duration of work with highly elevated arms was added up over the entire working life.

RESULTS

The results of our study support a dose-response relationship between cumulative duration of work with highly elevated arms and symptomatic supraspinatus tendon tears. For a cumulative duration of >3,195 h work above shoulder level, the risk of a supraspinatus tendon rupture is elevated to 2.0 (95% CI 1.1-3.5), adjusted for age, region, lifting/carrying of heavy loads, handheld vibration, apparatus gymnastics/shot put/javelin/hammer throwing/wrestling, and tennis. The cumulative duration of carrying/lifting of heavy loads also yields a positive dose-response relation with disease (independent from work above shoulder level and from handheld vibration), with an adjusted odds ratio of 1.8 (95% CI 1.0-3.2) in the highest exposure category (>77 h). We find an increased risk for subjects exposed to handheld vibration with an adjusted OR of 3.2 (95% CI 1.7-5.9) in the highest exposure category (16 years or more in the job with exposure), but a clear dose-response relationship is lacking.

CONCLUSIONS

This study points to a potential etiologic role of long-term cumulative effects of work with highly elevated arms and heavy lifting/carrying on shoulder tendon disorders.

Sonography of the coracohumeral interval: a potential technique for diagnosing coracoid impingement

OBJECTIVE

Coracoid impingement has been recognized as an etiology for anterior shoulder pain; however, no imaging reference standard exists. We used sonography to compare the coracohumeral interval (CHI) in asymptomatic volunteers with the CHI in patients with coracoid impingement.

METHODS

Bilateral shoulder sonography was performed in 19 asymptomatic volunteers (10 men and 9 women) and in 8 shoulders in 7 patients (6 men and 1 woman) with a clinical diagnosis of coracoid impingement. With the arm adducted across the chest, the interval between the coracoid process and the lesser tuberosity of the humerus was measured using a linear array ultrasound transducer with a peak frequency of 13 MHz.

RESULTS

In the asymptomatic volunteers, the mean +/- SD for the CHI was 12.2 +/- 2.5 mm (range, 7.8-17.5 mm). In the symptomatic shoulders, the mean +/- SD for the CHI was 7.9 +/- 1.4 mm (range, 5.9-9.6 mm). Repeated measures analysis of variance revealed the CHI to be significantly narrower in symptomatic shoulders than in asymptomatic volunteers (P < .0001).

CONCLUSIONS

These data suggest a role for sonography in diagnosing coracoid impingement.

Reliability study of the sonographic measurement of the acromiohumeral distance in symptomatic patients

BACKGROUND

The purpose of this study was to evaluate the inter- and intra-observer reliability and accuracy of sonographic (US) acromiohumeral distance (AHD) measurement for both experienced and novice operators in US in patients suffering from subacromial impingement syndrome.

METHOD

A total of 43 patients (50 shoulders) diagnosed with subacromial impingement syndrome were recruited from an orthopedic outpatient clinic. The US measurement of AHD was obtained consecutively in a neutral position and in a 60 degrees abduction position. A total of 300 blinded measurements were taken.

RESULT

In the neutral abduction group the intra- observer interclass correlation coefficient (ICC) was 0.94 for the experienced operator and 0.92 for the novice operator. The inter-observer ICC was 0.70 and the accuracy was 1.1 mm. In the 60 degrees abduction group, the intra-observer ICC was 0.90 for the experienced operator and 0.87 for the novice operator. The inter-observer ICC was 0.64 and the accuracy was 1.4 mm. All ICCs were significant at a level of p < 0.0001.

CONCLUSION

The inaccuracy of the method was 1 mm regardless of the experience of the observer. US AHD measurement in patients with shoulder complaints is not as accurate as reported in healthy subjects. This may have important implications for the clinical use of this parameter.

Dynamic visualization of the coracoacromial ligament by ultrasound

Subacromial impingement syndrome (SIS) is prevalent in athletes who make throwing motions over their heads, as well as in the normal population, but it is difficult to diagnose precisely using physical examination and traditional imaging modalities. Furthermore, the diagnostic testing protocols have not been strictly standardized. We used ultrasound to dynamically visualize coracoacromial ligament (CAL) morphology during shoulder impingement tests: the CAL is the key impinging structure in SIS. Fifty normal shoulders were examined. With the transducer placed on the CAL, the shoulders were examined with seven different testing protocols described in the literature. The degree of CAL bulge from the resting position was measured, and the degree of bulge in different testing protocols was compared. We found that the Hawkins-Kennedy impingement test caused more CAL bulge than the Neer's impingement test, and the most prominent morphological change in the CAL occurred with an internally rotated and horizontally abducted shoulder. We conclude that high-resolution ultrasound is an excellent tool for dynamically inspecting the impinging structures, is applicable in clinical settings, and allows more accurate diagnosis of SIS.

Open versus arthroscopic subacromial decompressionA prospective, randomized study of 34 patients followed for 8 years

In a randomized prospective study, we selected 15 patients for arthroscopic subacromial decompression (ASD) and 19 patients for open subacromial decompression (OSD). All had impingement syndrome (Neer grade II), and had been unsuccessfully treated without surgery for more than 6 months. The UCLA Shoulder Rating Scale, Visual Analogue Scales for pain and satisfaction, isokinetic dynamometer recordings and physical testing were assessed preoperatively and at 1 (except isokinetic testing), 3, 6, and 12 months, and, finally, 8 years after surgery. We found essentially no differences in the clinical tests between the groups during this period. The use of ASD or OSD seems to be a matter of cosmesis and personal preference.

Shoulder impingement syndrome: correlations between clinical tests and ultrasonographic findings

OBJECTIVES

To compare the diagnosis of shoulder impingement syndrome (SIS) established by clinical and ultrasonographic examination and to evaluate the value of clinical tests for SIS as well as for rotator cuff pathology.

METHODS

One hundred patients with periathrophatia scapulohumeralis entered the study, including 64 females and 36 males aged between 20-84 years (mean 56.8 and 57.5, respectively). Clinical and ultrasonographic examinations were carried out by independent observers, a rheumatologist and a musculoskeletal-trained sonographer. Clinical tests for SIS and for each of the tendons of the rotator cuff, as well as static and dynamic ultrasonographic examinations were performed for both shoulders. Findings were compared and statistically analyzed.

RESULTS

The Hawkins test (72.2%) proved to be the most sensitive clinical test for the identification of SIS and the Neer test (95.3%) was the most specific one. When four tests were simultaneously positive, the specificity for the diagnosis was 98.5% but the sensitivity decreased to 40.3%. Jobe's test indicated supraspinatus involvement with a specificity of 90% but it was not able to disclose the type of lesions. The sensitivity and specificity of the tests aiming to elicit infraspinatus tendon pathology were of low value whereas those addressing subscapularis tendon involvement were rather of moderate value. SIS was clinically correctly diagnosed in 80.5% of cases, but its characteristic stages were poorly recognized (stage I 50%, stage II 70%, and stage III 30.7%).

CONCLUSIONS

Although clinical tests are insufficient for clinical diagnosis, the examination of the patient still plays an important role in rotator cuff disorders. Ultrasonography should be used for all patients suffering from painful shoulder in order to improve the diagnosis.

Quantification of two-dimensional glenohumeral rhythm in persons with and without symptoms of shoulder impingement

A repeated-measures design was used to assess glenohumeral rhythm in 10 patients with shoulder impingement and 10 pain-free persons and to assess the effects of subacromial injection on glenohumeral rhythm within the impingement group. Scapular-plane anterior-to-posterior x-rays of the scapula and humerus were obtained at 5 angles of arm elevation (resting, 30 degrees, 60 degrees, 90 degrees, 120 degrees). For the impingement group, x-rays were repeated after subacromial injection (10 mL of 1% lidocaine). No significant differences in glenohumeral rhythm were found between the impingement and control groups across all arm-elevation angles.

Arthroscopic subacromial decompression for stage-II impingement

PURPOSE

To evaluate outcomes of arthroscopic subacromial decompression for stage-II impingement.

METHODS

Records of 42 consecutive patients with stage-II impingement treated by arthroscopic subacromial decompression from January 2000 to February 2002 were reviewed. Clinical outcomes were measured using the UCLA shoulder rating scale, and radiological outcomes using anteroposterior and supraspinatus outlet shoulder radiographs.

RESULTS

The mean follow-up period was 14.6 (range, 12-30) months. Using the UCLA scale, 14 (33%) patients had an excellent result, 21 (50%) had a good result, 4 (10%) had a fair result, and 3 (7%) had a poor result. Mean component scores for the UCLA scale were: 8.0 for pain, 8.8 for function, 4.5 for forward flexion, and 4.5 for strength. The mean extent of resection was 2.9 mm in the anteroposterior and 2.0 mm in the supraspinatus outlet radiographs. There was no correlation between the extent of acromial resection and the UCLA shoulder rating scores.

CONCLUSION

Short-term results of arthroscopic subacromial decompression for stage-II impingement are favourable.

Injection of the subacromial-subdeltoid bursa: blind or ultrasound-guided?

BACKGROUND

Blind injection of the subacromial-sub-deltoid bursa (SSB) for diagnostic purposes (Neer test) or therapeutic purposes (corticosteroid therapy) is frequently used. Poor response to previous blind injection or side effects may be due to a misplaced injection. It is assumed that ultrasound (US)-guided injections are more accurate than blind injections. In a randomized study, we compared the accuracy of blind injection to that of US-guided injection into the SSB.

PATIENTS AND METHODS

20 consecutive patients with impingement syndrome of the shoulder were randomized for blind or US-guided injection in the SSB. Injection was performed either by an experienced orthopedic surgeon or by an experienced musculoskeletal radiologist. A mixture of 1 m'L methylprednisolone acetate, 4 mL prilocaine hydrochloride and 0.02 mL (0.01 mmol) Gadolinium DTPA was injected. Immediately after injection, a 3D-gradient T1-weighted magnetic resonance scan of the shoulder was performed. The location of the injected fluid was independently assessed by 2 radiologists who were blinded as to the injection technique used.

RESULTS

The accuracy of blind and US-guided injection was the same. The fluid was injected into the bursa in all cases.

INTERPRETATION

Blind injection into the SSB is as reliable as US-guided injection and could therefore be used in daily routine. US-guided injections may offer a useful alternative in difficult cases, such as with changed anatomy postoperatively or when there is no effective clinical outcome.

Coracoid impingement syndrome: a treatable cause of anterior shoulder pain

BACKGROUND

Coracoid Impingement Syndrome is a relatively uncommon but generally treatable cause of anterior shoulder pain that can be easily overlooked. It typically presents with anterior shoulder joint pain in activities involving forward flexion, adduction and internal rotation.

AIMS

To assess the outcome of a cohort of patients diagnosed with Coracoid Impingement Syndrome.

METHODS

Patients were investigated clinically and radiologically. They received appropriate therapeutic measures and were followed-up in an orthopaedic outpatient setting.

RESULTS

Twelve patients were identified over a four-year period. All patients have made good progress. Thus far, none have needed operative intervention for symptom relief.

CONCLUSION

Coracoid impingement syndrome is an uncommon cause of anterior shoulder pain but diagnosed patients can expect good symptomatic relief following referral to a dedicated shoulder unit. An increase in clinical awareness of the condition may prevent undue diagnostic delay in such cases.

Detection of subacromial bursa thickening by sonography in shoulder impingement syndrome

BACKGROUND

Normally, the subacromial-subdeltoid bursa is thinner than 2 mm using ultrasound examination. The subtle thickening of the bursa could be an early sign of subacromial impingement and possibly a rotator cuff tear. The aim of this study was to compare the thickness of subacromial bursa measured using ultrasonography in the painful shoulder with normal side, and also to differentiate Neer stages I and II impingements in patients with unilateral shoulder pain.

METHODS

We performed bilateral shoulder sonography in 268 consecutive patients with unilateral shoulder pain and clinical suggestion of rotator cuff pathology. The study group consisted of 102 cases of Neer stage I and 166 cases of Neer stage II impingement syndrome. The bursa thickness was calculated from the superficial peribursal fat to the upper margin of the supraspinatus.

RESULTS

A statistically significant association was detected (p < .0001) between the symptomatic shoulder and asymptomatic side (mean thickness, 1.27 mm/0.75 mm). The thickness of bursa in patients with Neer stage I impingement had no statistically important link the results of the patients with Neer stage II impingement.

CONCLUSION

Increased bursa thickness in the symptomatic side may be an alternative sonographic indicator of subacromial bursitis and partial-thickness rotator cuff tears, even when measured to be less than 2 mm. Sonographic examination of subacromial bursa thickness is not an appropriate technique to differentiate the Neer stages I and II impingement. Further study is needed to quantify the echogenicity of the supraspinatus tendon and to show a level of accuracy in patients with rotator cuff tendinosis or partial tears.

Cartilage lesions of the glenohumeral joint: diagnostic effectiveness of multidetector spiral CT arthrography and comparison with arthroscopy

This study assessed the diagnostic effectiveness of multidetector spiral CT arthrography (MDCTa) in detecting hyaline cartilage abnormalities of the shoulder joint, with correlation to arthroscopy. Shoulder MDCTa images prospectively obtained in 22 consecutive patients (mean age, 50 years; age range, 23-74 years; 12 female, 10 male) were evaluated for glenohumeral cartilage lesions. Two musculoskeletal radiologists independently analysed the cartilage surfaces of the humeral head and of the glenoid fossa in nine anatomical surface areas. Observations of MDCTa were compared to arthroscopic findings. The sensitivity and specificity of MDCTa for grade 2 (substance loss <50%) or higher and grade 3 (substance loss >or=50%) or higher cartilage lesions, the Spearman correlation coefficient between arthrographic and arthroscopic grading, and K statistics for assessing Intra and Interobserver reproducibility were determined. At MDCTa, sensitivities and specificities ranged between 80% and 94% for the detection of grade 2 or higher cartilage lesions, and between 88% and 98% for the detection of grade 3 or higher cartilage lesions. Spearman correlation coefficients between MDCTa and arthroscopic grading of articular surfaces ranged between 0.532 and 0.651. Interobserver agreement was moderate for grading all articular surfaces (kappa = 0.457), but substantial to almost perfect for detecting lesions with substance loss (kappa, 0.618-0.876). In conclusion, MDCTa is accurate for the study of cartilage surface in the entire shoulder joint. This technique may beneficially impact patient's management by means of selecting the proper treatment approach.

Sclerosing polidocanol injections to treat chronic painful shoulder impingement syndrome-results of a two-centre collaborative pilot study

The histological changes found in the supraspinatus tendon have similarities with the findings in Achilles-, patellar- and extensor carpi radialis brevis (ECRB)-tendinopathy. In recent studies, we have found a vasculo-neural ingrowth in chronic painful Achilles and patellar tendinopathy, and demonstrated good short-term clinical effects with injections of the sclerosing substance polidocanol. In this collaborative two-centre pilot study, 15 patients (10 males and 5 females, mean age 46 years) with a long duration of shoulder pain (mean 28 months), and given the diagnosis chronic painful shoulder impingement syndrome, were included. They had tried rest, traditional rehabilitation exercises and multiple subacromial corticosteroid injections, without effect. We found vascularity (neovessels) in chronic painful, but not in pain-free, supraspinatus tendons, and prospectively studied the clinical effects of ultrasound (US) and colour Doppler (CD)-guided injections of polidocanol, targeting the area with neovessels. The patients evaluated the amount of shoulder pain during horizontal shoulder activity on a visual analogue scale (VAS), and satisfaction with treatment. Two (median) (range 1-5) polidocanol treatments (with 4-8 weeks in between) were given. In four patients (considered treatment failure), cortisone was injected into an inflamed subacromial bursa at one separate occasion weeks after the last polidocanol injection. At follow-up, 8 (median) (range 4-17) months after the treatment, 14 patients were satisfied with the result. Using the visual analogue scale evaluation (VAS), the pain dropped from 79 before treatment to 21 at follow-up (P < 0.05). In the short-term perspective, sclerosing polidocanol injections targeting the neovessels in the supraspinatus tendon and/or bursa wall seems to have a potential to reduce the pain during shoulder loading activity.