Increased levels of inflammatory markers in the subscapularis tendon and joint capsule in patients with subacromial impingement.

PURPOSE: To analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with subacromial impingement syndrome and compare them with samples from male patients with post-traumatic recurrent shoulder instability, to detect increased inflammatory activity that might be present inside the humeroscapular joint. METHODS: Twenty male patients scheduled for surgery for either subacromial decompression or Bankart reconstruction were included. Four biopsies from each patient were obtained during surgery from the capsule and the subscapularis tendon. Each specimen was analyzed for TNF-α, IL-6, CD-3 and CD-72. Multiplex fluorescence immunohistochemistry was performed on histological samples from the capsule and tendon to demonstrate the level of inflammatory markers. Fluorescence microscope images were acquired using an automated scanning system. On each slide, the number of pixels was registered and used in the analyses. RESULTS: The subacromial impingement syndrome group comprised eight patients, median age 53 (45-74) years, while the instability group 12, median age 27 (22-48) years (p < 0.00001). The amount of IL-6 and TNF-α was significantly higher in the subscapularis tendon of the patients with subacromial impingement syndrome compared with instability patients (p = 0.0015 and p = 0.0008 respectively). In the capsular samples, significantly higher amount of TNF-α and CD-72 was found in patients with subacromial impingement syndrome compared with instability patients (p < 0.0001 for both). On the other hand, the amount of CD-3 was significantly higher in the instability group (p = 0.0013). CONCLUSIONS: This study provides evidence that an extended inflammatory process is present, not only in the subacromial bursa but also in the glenohumeral joint in patients with subacromial impingement syndrome. LEVEL OF EVIDENCE: Level III. CLINICAL RELEVANCE: To develop a treatment targeted towards intra-articular inflammatory cytokines appears appealing.

More histologic and ultrastructural degenerative signs in the subscapularis tendon and the joint capsule in male patients with shoulder impingement.

PURPOSE: The purpose of the present study was to analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with shoulder impingement syndrome (SAIS) and compare them with samples from male patients with post-traumatic recurrent shoulder instability. The hypothesis of the study was that patients with SAIS would have more histologic and ultrastructural degenerative changes in their subscapularis tendon and joint capsule than patients with post-traumatic recurrent shoulder instability. METHODS: Male patients scheduled for surgery, with either subacromial decompression or Bankart reconstruction, were included. Four biopsies from each patient were obtained from the capsule and four from the subscapularis tendon during arthroscopic surgery. The histologic characteristics and the presence of glycosaminoglycans were assessed using the light microscope, and the ultrastructure was assessed using a transmission electron microscope. RESULTS: Eight patients, median age 53 (45-74) years (p < 0.0001), were included in the impingement group, and 12 patients, median age 27 (22-48) years, were included in the instability group. The histologic assessment revealed significantly higher cellularity and total degeneration score in the capsule (p = 0.016 and p = 0.014 respectively) in patients with subacromial impingement compared with the instability patients. The corresponding finding was not made for the subscapularis tendon. The ultrastructural evaluation revealed that the instability patients had more fibrils with a large diameter (indicating less degeneration) in both the subscapularis tendon and the capsule compared with the impingement patients (p < 0.0001). CONCLUSION: Male patients with subacromial impingement have more histologic and ultrastructural degenerative changes in their shoulder compared with patients with post-traumatic recurrent shoulder instability. CLINICAL RELEVANCE: It appears that in patients with subacromial impingement, the whole shoulder joint is affected and not only the subacromial space. It is the opinion of the authors that intra-articular therapeutic injections could be tried more often in these patients. LEVEL OF EVIDENCE: III.

Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone: A Prospective Randomized Study of Patients With a Minimum 10-Year Follow-up.

BACKGROUND: The long-term outcome after the treatment of subacromial impingement syndrome (SAIS) with either nonsurgical or surgical methods has not been thoroughly investigated. Hypothesis/Purpose: The purpose was to evaluate the long-term clinical outcome and the presence of rotator cuff injuries and osteoarthritis (OA) after the surgical and nonsurgical treatment of SAIS. The hypothesis was that, at a minimum 10 years after the initial treatment, patients who had undergone acromioplasty would have a better clinical outcome and run a lower risk of developing rotator cuff ruptures and OA as compared with those treated with physical therapy. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Eighty-seven patients with SAIS were randomized to 3 groups: open acromioplasty (open surgery group [OSG]), arthroscopic acromioplasty (arthroscopic surgery group [ASG]), and nonsurgical treatment (physical therapy group [PTG]). The Constant score, the Watson and Sonnabend score, and the 36-Item Short Form Health Survey (SF-36) questionnaire were used as outcome measurements. Furthermore, bilateral ultrasound examinations were performed to detect rotator cuff ruptures and bilateral radiographs to detect OA. Sixty-six patients (76%) attended the clinical follow-up at least 10 years after the initial treatment. RESULTS: The groups were demographically comparable at baseline. The Constant score improved significantly at follow-up for the OSG ( P = .003) and ASG ( P = .011), while no significant improvement was detected for the PTG. The OSG revealed a significant improvement versus the PTG at follow-up ( P = .011); otherwise, no significant differences were found. For the Watson and Sonnabend score, the OSG revealed a significant improvement in 13 of 14 questions. The corresponding finding was made for the ASG and PTG in 9 of 14 questions ( P = .14). According to ultrasound, 1 of 20 patients in the OSG had a full-thickness rotator cuff rupture on the index side. The corresponding finding was made for 1 of 18 patients in the ASG and 4 of 28 in the PTG ( P = .29). Per the radiographs, 3 of 20 patients in the OSG had moderate or severe OA in the index shoulder. The corresponding finding was made for 1 of 18 patients in the ASG and 0 of 28 in the PTG ( P = .12). CONCLUSION: After a minimum 10 years of follow-up, the surgical treatment of SAIS appears to render better clinical results than physical therapy alone. No significant differences were found among the groups in terms of the presence of full-thickness rotator cuff ruptures and OA.