Utilizing Scapula Retraction Exercises With or Without Glenohumeral Rotational Exercises With a Gradual Progression for Subacromial Pain Syndrome

BACKGROUND

Although exercise interventions are recommended in the management of subacromial pain syndrome (SPS), there is a lack of data regarding the exercises focusing on the principal biomechanical deficiencies that cause symptoms.

HYPOTHESIS

Utilizing progressive scapula retraction exercises (SRE) and glenohumeral rotation exercises (GRE) in the scapula stabilization program may lead to more reduction in symptoms and greater acromiohumeral distance (AHD) values.

STUDY DESIGN

A double-blind, randomized controlled trial.

LEVEL OF EVIDENCE

Level 2.

METHODS

A total of 33 patients were assigned randomly to either SRE or SRE+GRE. Both groups received a 12-week supervised rehabilitation program, including manual therapy and exercises (stretching and progressive scapula stabilization exercises). In addition, the SRE+GRE group performed GRE exercises at gradual elevation angles. From 12 to 24 weeks, patients performed exercise programs less frequently (3 times per week). Disability (shoulder pain and disability index [SPADI]), AHD (at 5 active abduction angles), pain intensity (visual analogue scale [VAS]), and patient satisfaction were recorded at baseline, 12 weeks, and 24 weeks. A total of 16 healthy individuals were recruited as a control group to compare AHD values. Data were analyzed using mixed model analyses of variance.

RESULTS

A statistically significant group-by-time interaction was found for AHD values (F4,92 = 6.38; P = 0.001), a significant group-by-time interaction for SPADI-disability (F1,33 = 5.148; P = 0.01), SPADI-total (F1,32 = 4.172; P = 0.03), and for pain during activity (F2,62 = 3.204; P = 0.05). However, no significant group-by-time interaction for SPADI-pain (F1,33 = 0.533; P = 0.48), for pain at rest (F1,31 < 0.001; P = 0.99), and at night (F1,32 = 2.166; P = 0.15). Yet, a significant time effect was observed.

CONCLUSION

Progressive SRE and GRE in the scapula stabilization program lessens symptoms and improves AHD values in patients with SPS. Moreover, this program could preserve outcomes and further increase AHD when applied less frequently.

CLINICAL RELEVANCE

Utilizing SRE and GRE in the scapula stabilization program at gradual shoulder abduction angles provides better rehabilitation outcomes.

Clinical Implication of Glenohumeral and Subacromial Synovitis in Rotator Cuff Tears

Background

Synovitis of the glenohumeral (GH) joint and the subacromial (SA) space is commonly observed during arthroscopic rotator cuff surgery.

Purpose

To investigate the distribution, severity, and clinical implications of synovitis in the GH joint and SA space in patients with a full-thickness rotator cuff tear (RCT).

Study Design

Case series; Level of evidence, 4.

Methods

Data were retrospectively collected from 207 patients with a full-thickness RCT who underwent arthroscopic repair. Preoperative parameters used in the clinical assessment included pain, range of motion (ROM), muscle strength, and functional scores. Macroscopic assessment of synovitis was performed intraoperatively in the 3 regions of interest (ROIs) of the GH joint and 4 ROIS of the SA space using an evaluation system. The distribution and severity of synovitis and the association between synovitis and clinical assessment were evaluated.

Results

Synovitis was more severe in the GH joint than in the SA space (P < .001). Synovitis in the posterior GH joint and the lateral SA space, where most of the rotator cuff was located, was the most severe area among the ROIs of the GH joint and the SA space, respectively (P < .05). All types of pain, except for pain at rest, were associated with synovitis in the posterior GH joint (P < .05). All ROM measures were associated with synovitis in the posterior and inferior GH joint (|r| > 0.20; P < .05 for both). The strength of the supraspinatus and the infraspinatus was associated with synovitis in the posterior GH joint (P < .05). Shoulder function was associated with synovitis in the posterior and inferior GH joint and more in the posterior GH joint (P < .05 for both). Synovitis in the SA space was not associated with any of the clinical parameters.

Conclusion

Synovitis in the posterior GH joint was the most severe form of synovitis in the GH joint in patients with a full-thickness RCT. Synovitis in the posterior GH joint was closely associated with increased pain and decreased ROM, muscle strength, and functional score. Synovitis in the SA space was milder and not associated with any clinical parameters.

Challenges for Optimization of Reverse Shoulder Arthroplasty Part II: Subacromial Space, Scapular Posture, Moment Arms and Muscle Tensioning

In part II of this comprehensive review on the optimization of reverse shoulder arthroplasty (RSA), we focus on three other challenges: 1. "Conservation of sufficient subacromial and coracohumeral space"; 2. "Scapular posture"; and 3. "Moment arms and muscle tensioning". This paper follows a detailed review of the basic science and clinical literature of the challenges in part I: 1. "External rotation and extension" and 2. "Internal rotation". "Conservation of sufficient subacromial and coracohumeral space" and "Scapular posture" may have a significant impact on the passive and active function of RSA. Understanding the implications of "Moment arms and muscle tensioning" is essential to optimize active force generation and RSA performance. An awareness and understanding of the challenges of the optimization of RSA help surgeons prevent complications and improve RSA function and raise further research questions for ongoing study.

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.

The morphology of the subacromial and related shoulder bursae. An anatomical and histological study

Shoulder bursae are essential for normal movement and are also implicated in the pathogenesis of shoulder pain and dysfunction. The subacromial bursa (SAB), within the subacromial space, is considered a primary source of shoulder pain. Several other bursae related to the subcoracoid space, including the coracobrachial (CBB), subcoracoid (SCB) and subtendinous bursa of subscapularis (SSB), are also clinically relevant. The detailed morphology and histological characteristics of these bursae are not well described. Sixteen embalmed cadaveric shoulders from eight individuals (five females, three males; mean age 78.6 ± 7.9 years) were investigated using macro-dissection and histological techniques to describe the locations, dimensions and attachments of the bursae, their relationship to surrounding structures and neurovascular supply. Bursal sections were stained with haematoxylin and eosin to examine the synovium and with antibodies against von Willebrand factor and neurofilament to identify blood vessels and neural structures respectively. Four separate bursae were related to the subacromial and subcoracoid spaces. The SAB was large, with a confluent subdeltoid portion in all except one specimen, which displayed a distinct subdeltoid bursa. The SAB roof attached to the lateral edge and deep surface of the acromion and coracoacromial ligament, and the subdeltoid fascia; its floor fused with the supraspinatus tendon and greater tubercle. The CBB (15/16 specimens) was deep to the conjoint tendon of coracobrachialis and short head of biceps brachii and the tip of the coracoid process, while the inconstant SCB (5/16 specimens) was deep to the coracoid process. Located deep to the subscapularis tendon, the SSB was a constant entity that commonly displayed a superior extension. Synovial tissue was predominantly areolar (SAB and SSB) or fibrous (CBB and SCB), with a higher proportion of areolar synovium in the bursal roofs compared to their floors. Blood vessels were consistently present in the subintima with a median density of 3% of the tissue surface area, being greatest in the SSB and SAB roofs (4.9% and 3.4% respectively) and least in the SAB floor (1.8%) and CBB roof and floor (both 1.6%). Nerve bundles and free nerve endings were identified in the subintima in approximately one-third of the samples, while encapsulated nerve endings were present in deeper tissue layers. The extensive expanse and attachments of the SAB support adoption of the term subacromial-subdeltoid bursa. Morphologically, the strong attachments of the bursal roofs and floors along with their free edges manifest as fixed and mobile portions, which enable movement in relation to surrounding structures. The presence of neurovascular structures demonstrates that these bursae potentially contribute blood supply to surrounding structures and are involved in mechanoreception. The anatomical details presented in this study clarify the morphology of the shoulder bursae, including histological findings that offer further insight into their potential function.

Shoulder Kinesio Taping Does Not Change Biomechanical Deficits Associated With Scapular Dyskinesis

Observable scapular dyskinesis is associated with biomechanical deficits. Preventative interventions aimed at correcting these deficits may aid in preventing the development and resolution of shoulder pain. Our purpose was to investigate the effects of kinesio taping (KT) on common biomechanical deficits associated with scapular dyskinesis and shoulder pain. Participants (n = 51) with observable scapular dyskinesis, and without shoulder pain were randomized to KT, KT-placebo, or a no-treatment control group. Measurements taken before, immediately after taping, and 3 days later included pectoralis minor muscle length, lower trapezius muscle strength, scapular upward rotation angle at 0° to 120° in scapular plane humeral elevation and acromiohumeral distance. There were no changes in scapular upward rotation, lower trapezius strength, and acromiohumeral distance immediately after taping or 3 days later compared to baseline (P > .05). The pectoralis minor increased in length in the KT group on day 3 compared to directly after taping (P = .03), but no difference between groups or interaction between time and group were determined (P > .05). Scapular dyskinesis prevalence did not change over time in any group (P > .05). In people with scapular dyskinesis free from shoulder pain, KT applied to the shoulder cannot be recommended to ameliorate the biomechanical deficits associated with shoulder pain.

Chronicity is associated with the glenohumeral synovitis in patients with a rotator cuff tear

Synovitis of the glenohumeral joint (GHJ) and subacromial space (SAS) is one of the most common findings during arthroscopic rotator cuff repair (RCR). The purpose of this study is to determine clinical factors associated with the degree of synovitis in patients with a rotator cuff tear and whether macroscopic synovitis affects early clinical outcomes following arthroscopic RCR. Arthroscopic videos of 230 patients treated with arthroscopic RCR were randomly reviewed by two experienced shoulder surgeons. The synovitis scores of the GHJ using Davis's grading system and the SAS using Jo's grading system were rated with a consensus. Univariate and multivariate analyses were used to identify the associations between the synovitis scores and various parameters, including demographics, preoperative, and postoperative clinical outcomes. Univariate analyses revealed that age, side, body mass index, duration of symptoms, preoperative stiffness, diabetes, muscle atrophy, fatty infiltration, tear size, preoperative clinical scores, and preoperative range of motion were significantly associated with the GHJ synovitis score (all p < 0.05). Multivariate analyses revealed that the duration of symptoms, tear size, and diabetes was significantly associated with the GHJ synovitis score (p = 0.048, p = 0.025, p = 0.011, respectively). Longer duration of symptoms, larger tear size, and the presence of diabetes was independently associated with increased GHJ synovitis in patients with a rotator cuff tear. These results suggest that GHJ synovitis might be more involved in the pathogenesis for pain and tear progression of rotator cuff disease compared with SAS synovitis.

Is There a Decrease in the Acromiohumeral Distance Among Recreational Overhead Athletes With Rotator Cuff-Related Shoulder Pain?

CONTEXT

Recreational overhead athletes are exposed to high overload, which increases the risk of shoulder injuries. Reduction of the acromiohumeral distance (AHD) is often associated with rotator cuff-related shoulder pain (RCRSP) among the general population. However, the AHD of symptomatic shoulders of recreational athletes has not yet been compared with their asymptomatic shoulders.

OBJECTIVE

To compare the AHD of a symptomatic to asymptomatic shoulder at rest (0°) and 60° abduction. To establish the relationship between AHD, pain, and functional limitations of recreational athletes with RCRSP.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

A total of 45 recreational overhead athletes with RCRSP were examined.

MAIN OUTCOME MEASURES

The AHD was measured by ultrasonography at 0° and 60° abduction (angles). Shoulder pain was assessed using a numeric pain scale, whereas functional limitations were assessed using the The Disabilities of the Arm, Shoulder, and Hand questionnaire. Differences in the between-shoulders condition (symptomatic and asymptomatic) were determined using 2-way analysis of variance for repeated measures. A Pearson correlation established the relationship between AHD, pain, and functional limitations.

RESULTS

No angles × shoulder condition interactions (P = .776) nor shoulder condition effects (P = .087) were detected, suggesting no significant differences (P > .05) between asymptomatic and symptomatic shoulders in the AHD at 0° or 60°. The AHD at 60° reduced significantly compared with 0° (3.05 [1.36] mm [2.77-3.33], angle effects: P < .001). The AHD at 0° and 60° was not correlated with pain or functional limitations (-.205 ≤ r ≤ .210, .167 ≤ P ≤ .585).

CONCLUSIONS

The AHD of recreational athletes is not decreased in symptomatic shoulders compared with asymptomatic shoulders. Reduction of the AHD in symptomatic shoulders is not associated with an increase in pain or functional limitations of recreational athletes with RCRSP.

POSTERIOR SHOULDER TIGHTNESS AND SUBACROMIAL IMPINGEMENT CHARACTERISTICS IN BASEBALL PITCHERS: A BLINDED, MATCHED CONTROL STUDY

BACKGROUND

Baseball pitchers frequently develop varying levels of posterior shoulder tightness (PST) and often present with characteristics associated with subacromial impingement.

PURPOSE

To determine if a group of baseball pitchers with excessive PST (bilateral internal rotation ROM difference >18 ° and bilateral total arc of motion difference >5 °) have differences in subacromial joint space, forward scapular posture, or glenohumeral elevation range of motion (ROM) when compared to a control group.

STUDY DESIGN

Descriptive, cross-sectional study.

METHODS

Thirty-five asymptomatic professional baseball pitchers with excessive PST were matched with 35 pitchers with acceptable levels of PST. The investigators measured subacromial space using diagnostic ultrasound, glenohumeral elevation ROM using a digital goniometer, and scapular posture using a double square, and were blinded to the group of each participant. Separate t-tests were used to determine significant differences between groups (p < 0.05).

RESULTS

The excessive PST group presented with significantly less subacromial space (p = .0007) and glenohumeral elevation ROM (p = .03) compared to the acceptable level PST group. The excessive PST group also had significantly more forward scapular posture than the control group (p = .03).

CONCLUSION

The baseball pitchers with excessive PST had less subacromial space and glenohumeral elevation ROM, as well as more forward scapular posture in their throwing arms compared to pitchers with acceptable levels of PST.

LEVEL OF EVIDENCE

3.

Relationship Between Middle Trapezius Muscle Activation and Acromiohumeral Distance Change During Shoulder Elevation With Scapular Retraction

CONTEXT

The scapular retraction exercises are widely used among clinicians to balance the activity of the scapular muscles as well as the rotator cuff muscles in different shoulder abduction positions.

OBJECTIVES

The aim of this study was to investigate the relationship between scapular (middle and upper trapezius) and shoulder muscles (middle deltoid and infraspinatus) activation level differences and acromiohumeral distance changes during shoulder abduction with scapular retraction.

DESIGN

Cross-sectional study.

SETTING

University research laboratory.

PARTICIPANTS

Nineteen asymptomatic individuals were included (mean [SD]: age = 22.4 [1.8] y).

MAIN OUTCOME MEASURE

The acromiohumeral distance was measured at 0° and 90° shoulder abduction when the scapula was in nonretracted and retracted position with ultrasound imaging. The relationship between muscle activation level changes and acromiohumeral distance difference was analyzed with the Pearson correlation test.

RESULTS

Middle trapezius muscle activity change correlated with acromiohumeral distance difference (r = .55, P = .02) from 0° to 90° shoulder abduction when scapula was retracted. For both nonretracted and retracted scapular positions, no correlations were found between middle deltoid, infraspinatus, and upper trapezius muscle activity changes with acromiohumeral distance differences during shoulder abduction (P > .05).

CONCLUSIONS

Active scapular retraction exercise, especially focusing on the middle trapezius muscle activation, seems to be an effective treatment option to optimize the acromiohumeral distance during shoulder abduction.

The Addition of Glenohumeral Adductor Coactivation to a Rotator Cuff Exercise Program for Rotator Cuff Tendinopathy: A Single-Blind Randomized Controlled Trial

BACKGROUND

Treatments for rotator cuff tendinopathy include rotator cuff muscle strengthening to promote better muscle recruitment in order to minimize subacromial narrowing during active movement. Glenohumeral adductor recruitment has also been shown to prevent such narrowing in asymptomatic individuals; therefore, adding glenohumeral adductor coactivation during rotator cuff strengthening could enhance the efficacy of rotator cuff strengthening. However, no study has explored its benefits.

OBJECTIVES

To compare the short-term efficacy of adding glenohumeral adductor coactivation to a rotator cuff-strengthening program to improve function, reduce symptoms, and increase acromiohumeral distance in adults with rotator cuff tendinopathy.

METHODS

In this single-blind randomized controlled trial, 42 participants with rotator cuff tendinopathy were randomly assigned to 2 groups, one that received strengthening of the scapular and rotator cuff muscles or one that received rotator cuff strengthening plus coactivation with pectoralis major and latissimus dorsi recruitment. The daily programs were performed at home for 6 weeks, with supervised training and follow-up sessions. Functional limitations/symptoms (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire as the primary outcome, and the Western Ontario Rotator Cuff index), pain (visual analog scale), and acromiohumeral distance were measured at baseline, 3 weeks, and 6 weeks. Data were analyzed using a mixed-model analysis of variance.

RESULTS

No significant group-by-time interaction was observed for the Disabilities of the Arm, Shoulder and Hand questionnaire, Western Ontario Rotator Cuff index, visual analog scale, and acromiohumeral distance (P≥.055). Significant time effects were obtained for the Western Ontario Rotator Cuff index and visual analog scale for pain with movement (P<.001).

CONCLUSION

The present findings show that adding glenohumeral adductor coactivation to a rotator cuff-strengthening program does not result in improved short-term efficacy in any of the measured outcomes. This study was registered with ClinicalTrials.gov (NCT02837848).

LEVEL OF EVIDENCE

Therapy, level 1b. J Orthop Sports Phys Ther 2019;49(3):126-135. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8240.

Active Scapular Retraction and Acromiohumeral Distance at Various Degrees of Shoulder Abduction

CONTEXT

  Performing shoulder-abduction exercises with scapular retraction has been theorized to reduce the potential for shoulder impingement. However, objective data to support this premise are lacking.

OBJECTIVE

  To evaluate the influence of active scapular retraction on acromiohumeral distance (AHD) at 4 shoulder-abduction angles using real-time ultrasound.

DESIGN

  Cross-sectional study.

SETTING

  University laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Twenty asymptomatic individuals (10 men, 10 women; age = 22.9 ± 2.8 years, height = 169.3 ± 9.5 cm, mass = 65.5 ± 12.9 kg) were recruited.

MAIN OUTCOME MEASURE(S)

  Real-time ultrasound images of AHD were obtained during nonretracted and retracted scapular conditions at 0°, 45°, 60°, and 90° of shoulder abduction. A 2-factor analysis of variance with repeated measures was used to evaluate the influence of shoulder retraction on AHD across shoulder-abduction angles.

RESULTS

  A scapular-retraction condition × shoulder-abduction-angle interaction for AHD was found ( F_3,57 = 4.56, P = .006). The AHD was smaller at 0° (10.5 versus 11.2 mm, respectively; t₁₉ = 2.22, P = .04) but larger at 90° (9.4 versus 8.7 mm, respectively; t₁₉ = -2.30, P = .04) of shoulder abduction during the retracted than the nonretracted condition. No differences in AHD were observed between conditions at 45° ( t₁₉ = 1.45, P = .16) and 60° ( t₁₉ = 1.17, P = .86) of abduction.

CONCLUSIONS

  The observed differences in AHD at 0° and 90° of shoulder abduction were small and did not exceed the established minimal detectable change for either angle. Our findings suggest that active scapular retraction during shoulder abduction has a minimal influence on AHD at 0° and 90° in healthy individuals. Further investigations are needed to determine whether scapular retraction influences AHD in individuals with subacromial impingement.

Tendon vascularity in overhead athletes with subacromial pain syndrome and its correlation with the resting subacromial space

BACKGROUND

Supraspinatus tendinopathy is one of the common causes of subacromial pain syndrome (SAPS) in overhead athletes. Changes in tendon vascularity have been reported in painful tendons; however, the prevalence and distribution have not been investigated in young overhead athletes.

METHODS

We conducted a cross-sectional study of 47 overhead athletes (male, 31; female, 16) aged 18 to 36 years with SAPS for >3 months. A sonographer graded the severity of the tendinopathy and area of vascularization. Ultrasound imaging was used to measure supraspinatus tendon thickness, vascularity, and resting subacromial space. A self-written program was used to semiquantify the intensity of vascularity, expressed as the vascular index.

RESULTS

The majority (87.2%) of the participants had signs of tendinopathy in the supraspinatus tendon, and 40 (85.1%) of the tendinopathic tendons had vascularity. The majority (66.0%) of the vascularized subjects presented with minimal increase in vascularity, and 19.1% had moderate to severe vascularization. Most (79.2%) of the vascularization was observed in the pericortical region. The vascular index was negatively correlated with the resting subacromial space in male athletes with a reduced subacromial space (ρ = -0.63; P = .038).

CONCLUSION

Of overhead athletes with SAPS, 87.2% had supraspinatus tendinopathy with minimal to moderate vascularization, with the majority of vascularization occurring in the pericortical region. In male athletes with a reduced subacromial space, greater vascularity in the supraspinatus tendon was associated with a smaller resting subacromial space.

Cross Sectional Area of the Supraspinatus Muscle and Acromio-humeral Distance in Overhead Athletes With and Without Shoulder Pain: A Cross-sectional Study

CONTEXT

The supraspinatus muscle has an important role in the stabilization of the glenohumeral joint. Identifying abnormalities concerning its size and the subacromial space in the presence of pain may be relevant to provide more specific treatments focused on the etiology of pain.

OBJECTIVE

To determinate whether painful shoulder causes changes in the supraspinatus cross-sectional area (CSA) and the acromio-humeral distance (AHD) between overhead athletes.

DESIGN

Cross-sectional study.

SETTING

University campus and local sports clubs' Physical Therapist room.

PARTICIPANTS

81 male overhead athletes were divided into 2 groups according to the presence of shoulder pain and clinical symptoms.

MAIN OUTCOME MEASURES

Ultrasonography measurements of the supraspinatus CSA and the AHD in 2 groups of overhead athletes with and without pain.

RESULTS

In the pain group, the CSA was significantly smaller compared with the no pain group. No differences between groups were found in the AHD measurement.

CONCLUSIONS

Shoulder pain in overhead athletes was associated with a reduction in their supraspinatus muscle CSA, but not in the AHD. These findings suggest that muscle atrophy exists in the presence of pain. However, in active overhead athletes, the AHD is not clearly reduced in overhead athletes with shoulder pain. Further studies are needed to understand this condition.

Comparison of Upper Extremity Physical Characteristics Between Adolescent Competitive Swimmers and Nonoverhead Athletes

CONTEXT

Alterations to upper extremity physical characteristics of competitive swimmers (posture, range of motion [ROM], and subacromial-space distance) are commonly attributed to cumulative training load during a swimmer's competitive career. However, this accepted clinical belief has not been established in the literature. It is important to understand whether alterations in posture and associated physical characteristics occur as a result of sport training or factors other than swimming participation to better understand injury risk and possible interventions.

OBJECTIVE

To compare posture, subacromial-space distance, and glenohumeral external-rotation, internal-rotation, and horizontal-adduction ROM between adolescent competitive swimmers and nonoverhead athletes.

DESIGN

Cross-sectional study.

SETTING

Local swimming pools and high school athletic training rooms.

PATIENTS OR OTHER PARTICIPANTS

Forty-four competitive adolescent swimmers and 31 nonoverhead athletes who were not currently experiencing any elbow, shoulder, neck, or back pain that limited their sport activity.

INTERVENTION(S)

Posture, subacromial-space distance, and glenohumeral ROM were measured using photography, diagnostic ultrasound, and a digital inclinometer, respectively.

MAIN OUTCOME MEASURE(S)

Forward shoulder posture, forward head posture, normalized subacromial-space distance, internal-rotation ROM, and external-rotation ROM.

RESULTS

No clinically significant differences existed between swimmers and nonoverhead athletes for posture, normalized subacromial-space distance, or external- or internal-rotation ROM. Swimmers presented with less horizontal-adduction ROM than nonoverhead athletes.

CONCLUSIONS

Factors other than swimming participation, such as school and technology use, play important roles in the adaptation of physical characteristics in adolescents. Adolescents, regardless of swimming participation, presented with postural deviations. It is important to consider factors other than swimming participation that contribute to alterations in physical characteristics to understand injury risk and injury-prevention strategies in competitive adolescent swimmers.

Posterior Capsular Plication Constrains the Glenohumeral Joint by Drawing the Humeral Head Closer to the Glenoid and Resisting Abduction

BACKGROUND

Shoulder pain is a common problem, with 30% to 50% of the American population affected annually. While the majority of these shoulder problems improve, there is a high rate of recurrence, as 54% of patients experience persistent symptoms 3 years after onset.

PURPOSE

Posterior shoulder tightness has been shown to alter glenohumeral (GH) kinematics. Clinically, posterior shoulder contractures result in a significant loss of internal rotation and abduction (ABD). In this study, the effect of a posterior capsular contracture on GH kinematics was investigated using an intact cadaveric shoulder without violating the joint capsule or the rotator cuff.

STUDY DESIGN

Controlled laboratory study.

METHODS

Glenohumeral motion, humeral load, and subacromial contact pressure were measured in 6 fresh-frozen left shoulders during passive ABD from 60° to 100° using an automated robotic upper extremity testing system. Baseline values were compared with the experimental condition in which the full thickness of posterior tissues was plicated without decompressing the joint capsule.

RESULTS

Posterior soft tissue plication resulted in increased compression between the humeral head and the glenoid (axial load) at 90° of ABD. Throughout ABD, the posterior contracture increased the anterior and superior moment on the humeral head, but it did not change the GH kinematics in this intact model. As a result, there was no increase in the subacromial contact pressure during ABD with posterior plication.

CONCLUSION

In an intact cadaveric shoulder, posterior contracture does not alter GH motion or subacromial contact pressure during passive ABD. By tightening the soft tissue envelope posteriorly, there is an increase in compressive load on the articular cartilage and anterior/superior force on the humeral head. These findings suggest that subacromial impingement in the setting of a posterior soft tissue contracture may result from alterations in scapulothoracic motion, not changes in GH kinematics.

CLINICAL RELEVANCE

This investigation demonstrates that posterior capsular plication increases the axial load on the shoulder joint during ABD. While a significant difference from baseline was observed in the plicated condition, posterior capsular plication did not change GH motion or subacromial contact pressure significantly.

Negative-pressure pulmonary oedema in a patient undergoing shoulder arthroscopy

An 18-year-old ASA-I patient who underwent elective left shoulder arthroscopy developed severe airway obstruction post-extubation due to fluid extravasation from the shoulder joint into the neck and airway tissue. Re-intubation for relief of obstruction resulted in negative-pressure pulmonary oedema. The patient was electively ventilated in the intensive care unit and recovered uneventfully. A high index of suspicion along with monitoring of neck circumference can prevent this kind of complication.

In vivo measurement of subacromial space width during shoulder elevation: technique and preliminary results in patients following unilateral rotator cuff repair

BACKGROUND

The shoulder's subacromial space is of significant clinical interest due to its association with rotator cuff disease. Previous studies have estimated the subacromial space width to be 2-17 mm, but no study has measured in vivo subacromial space width during shoulder motion. The purpose of this study was to measure the in vivo subacromial space width during shoulder elevation in patients following rotator cuff repair.

METHODS

Biplane X-ray images were collected during shoulder elevation of 11 patients who had undergone rotator cuff repair. Glenohumeral joint motion was measured from the biplane X-ray images for each subject's repaired and asymptomatic, contralateral shoulders. The joint motion data were combined with subject-specific CT models to measure the subacromial space width during shoulder motion.

FINDINGS

Subacromial space width decreased with shoulder elevation, ranging from 2.3 to 7.4 mm in the repaired shoulder and 1.2-7.1 mm in the contralateral shoulder. Subacromial space width in the repaired shoulder was only 0.5 mm less than the contralateral shoulder when averaged over 10-60 degrees of glenohumeral elevation.

INTERPRETATION

The results indicate that the humerus in the repaired shoulder is positioned more cranially on the glenoid than in the contralateral shoulder. It is unclear if these subtle differences in subacromial space width are due to the surgical procedure or post-operative stiffness, or if subacromial impingement contributed to the development of the rotator cuff tear. Future research will ascertain if these results represent a transient response to the surgery or a more fundamental difference in rotator cuff function between repaired and contralateral shoulders.