Lessons in clinical reasoning - pitfalls, myths, and pearls: shoulder pain as the first and only manifestation of lung cancer.

OBJECTIVES: Lung cancer is the leading cause of cancer-related death and poses significant challenges in diagnosis and management. Although muscle metastases are exceedingly rare and typically not the initial clinical manifestation of neoplastic processes, their recognition is crucial for optimal patient care. CASE PRESENTATION: We present a case report in which we identify the unique scenario of a 60-year-old man with shoulder pain and a deltoid muscle mass, initially suggestive of an undifferentiated pleomorphic sarcoma. However, further investigations, including radiological findings and muscle biopsy, revealed an unexpected primary lung adenocarcinoma. We performed a systematic literature search to identify the incidence of SMM and reflect on how to improve and build on better diagnosis for entities as atypical as this. This atypical presentation highlights the importance of recognizing and addressing cognitive biases in clinical decision-making, as acknowledging the possibility of uncommon presentations is vital. By embracing a comprehensive approach that combines imaging studies with histopathological confirmation, healthcare providers can ensure accurate prognoses and appropriate management strategies, ultimately improving patient outcomes. CONCLUSIONS: This case serves as a reminder of the need to remain vigilant, open-minded, and aware of cognitive biases when confronted with uncommon clinical presentations, emphasizing the significance of early recognition and prompt evaluation in achieving optimal patient care.

Arthroscopic capsular release is more effective in pain relief than conservative treatment in patients with frozen shoulder.

BACKGROUND: Frozen shoulder is a common medical condition, but the ideal therapeutic method is yet to be determined. Our aim was to analyze the pain-relieving effect of different treatment options used for the management of this disease. METHODS: Medical records of 59 patients (22 male, 37 female, average age: 55.5 years ±9.9) with early stage primary frozen shoulder were evaluated, their demographic data, physical examination, concomitant diseases and treatment specific data were registered. Life quality and the level of pain were assessed using the Oxford Shoulder Score (OSS) and Numeric Rating Scale (NRS). Different treatment modalities and their effect on pain relief were recorded. Any existing correlation between life quality, pain and demographic data, concomitant diseases or the therapeutic method used was investigated. RESULTS: The level of pain measured on NRS improved from 7.9 ± 1.6 to 1.9 ± 2.2. The most effective therapeutic method in terms of pain relief was surgery, followed by physiotherapy and intraarticular steroid injection (NRS score after treatment: 2 - p < 0.0001; 3.3 - p < 0.0001; 4.9 - p < 0.0001, respectively). Non-steroidal anti-inflammatory drugs (NSAIDs) did not reduce pain significantly. OSS improved from 24 to 43.6 and was not affected by the investigated variables, time to recovery was not influenced by the demographic data, the type of treatment or concomitant diseases. CONCLUSIONS: Arthroscopic capsular release, physiotherapy and intraarticular steroid injection outperformed physical therapy and NSAID treatment in terms of pain relief. Despite of slight but persistent post-therapeutic pain found in half of the cases, treatment was considered satisfactory by the patients. Nor patient specific neither therapy specific data had a significant effect on the course of the disease.

Impact of Surgical Positioning on the Occurrence of Postoperative Ipilateral Shoulder Pain After Lung Resection by Video-Assisted Thoracoscopy: A Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate the impact of the ipsilateral arm position on ipsilateral shoulder pain after lung cancer resection by video-assisted thoracic surgery. DESIGN: A prospective randomized controlled trial. SETTING: A single academic center study. PARTICIPANTS: Patients undergoing video-assisted thoracic surgery pulmonary resection for cancer at the Institut Universitaire de Cardiologie et de Pneumologie de Québec from May 2020 to May 2022 were included. INTERVENTIONS: Patients randomly were assigned with a 1:1 ratio to a supported or suspended ipsilateral arm position. MEASUREMENTS AND MAIN RESULTS: Ipsilateral shoulder pain incidence, pain score, and opioid use were recorded in the postanesthesia care unit (PACU) on postoperative days 1 and 2. One hundred thirty-three patients were randomized, 67 in the suspended-arm group and 66 in the supported-arm group. Of the patients, 31% reported ipsilateral shoulder pain in the PACU with no difference between groups (19/67 [28.4%] v 22/66 patients (33.3%), p = 0.5767). There was no significant difference between the pain score in the PACU (3 [0-6] v 4 [0-6], p = 0.9055) at postoperative day 1 (4 [2-6] v 3 [2-5], p = 0.4113) and at postoperative day 2 (2 [0-5] v 2 [1-4], p = 0.9508). Ipsilateral shoulder pain score decreased rapidly on postoperative day 2. There was no statistical difference in opioid and gabapentinoid use between the groups. CONCLUSIONS: Ipsilateral arm position seems to have no impact on ipsilateral shoulder pain.

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block.

BACKGROUND: Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC. MATERIALS AND METHODS: A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved. RESULTS: Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness. CONCLUSIONS: In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Giant Cell Tumor of the Acromion: Case Report and Literature Review.

BACKGROUND/AIM: Giant cell tumor of bone (GCTB) is a locally aggressive neoplasm that typically occurs in the ends (epiphyses) of long bones of young adults. Flat bones are uncommon sites of involvement. Herein, we describe an unusual case of pathologically proven GCT of the acromion. CASE REPORT: The patient was a 39-year-old woman with no history of trauma who presented with a 3-month history of right posterior shoulder pain. Physical examination revealed mild swelling and tenderness in the posterior aspect of the right shoulder. Plain radiograph showed a purely lytic lesion, suggestive of a bone tumor. Computed tomography demonstrated an intraosseous lytic lesion with associated cortical thinning and lack of periosteal reaction. On magnetic resonance imaging, the lesion exhibited slightly higher signal intensity compared to skeletal muscle on T1-weighted sequences and heterogeneous high signal intensity on T2-weighted sequences. Strong enhancement was observed following gadolinium administration. The lesion was treated by extensive curettage with adjuvant therapy comprising ethanol and the remaining cavity was filled with polymethylmethacrylate bone cement. Histologically, the lesion was composed of round or spindle-shaped mononuclear cells admixed with numerous osteoclast-like giant cells. Immunohistochemically, the mononuclear neoplastic cells were diffusely positive for H3.3 G34W. The patient was asymptomatic and there was no evidence of local recurrence or distant metastasis 5 months after surgery. CONCLUSION: Although rare, acromial GCTB should be considered in the differential diagnosis of posterior shoulder pain, especially in young and early middle-aged adults.

Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial.

BACKGROUND: Despite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT. METHODS: The Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic "add-on" trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes). RESULTS: The average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82). CONCLUSIONS: In patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function. TRIAL REGISTRATION: The trial is registered on ClinicalTrials.gov: NCT03353272 (27/11/2017).

The relationship between publication of high-quality evidence and changes in the volume and trend of subacromial decompression surgery for patients with subacromial pain syndrome in hospitals across Australia, Europe and the United States: a controlled interrupted time series analysis.

AIMS: To evaluate the extent to which publication of high-quality randomised controlled trials(RCTs) in 2018 was associated with a change in volume or trend of subacromial decompression(SAD) surgery in patients with subacromial pain syndrome(SAPS) treated in hospitals across various countries. METHODS: Routinely collected administrative data of the Global Health Data@work collaborative were used to identify SAPS patients who underwent SAD surgery in six hospitals from five countries (Australia, Belgium, Netherlands, United Kingdom, United States) between 01/2016 and 02/2020. Following a controlled interrupted time series design, segmented Poisson regression was used to compare trends in monthly SAD surgeries before(01/2016-01/2018) and after(02/2018-02/2020) publication of the RCTs. The control group consisted of musculoskeletal patients undergoing other procedures. RESULTS: A total of 3.046 SAD surgeries were performed among SAPS patients treated in five hospitals; one hospital did not perform any SAD surgeries. Overall, publication of trial results was associated with a significant reduction in the trend to use SAD surgery of 2% per month (Incidence rate ratio (IRR) 0.984[0.971-0.998]; P = 0.021), but with large variation between hospitals. No changes in the control group were observed. However, publication of trial results was also associated with a 2% monthly increased trend (IRR 1.019[1.004-1.034]; P = 0.014) towards other procedures performed in SAPS patients. CONCLUSION: Publication of RCT results was associated with a significantly decreased trend in SAD surgery for SAPS patients, although large variation between participating hospitals existed and a possible shift in coding practices cannot be ruled out. This highlights the complexities of implementing recommendations to change routine clinical practice even if based on high-quality evidence.

A qualitative assessment of experiences and perception during pre-admission for rotator cuff repair surgery.

BACKGROUND: Rotator Cuff Related Shoulder Pain (RCRSP) is the most common type of shoulder pain and the most disabling common symptom in people with Rotator Cuff Tear (RCT). The patient's point of view concerning health status has become important in decision-making procedures and has therefore been considered a possible criterion standard for assessing treatment efficacy. The study aims to explore patients' experiences and perceptions during pre-admission for Rotator Cuff Repair surgery. METHODS: A qualitative descriptive study was conducted using a phenomenological approach based on Husserl's philosophical perspective. A consecutive sample of twenty RCT patients awaiting repair surgery agreed to participate and was interviewed until the information was saturated. None of the patients enrolled was lost during the data collection phases. Data were collected through open-ended interviews between December 2021 and January 2022. The credibility, reliability, confirmability, and transferability criteria of Lincoln and Guba have been adopted to guarantee the trustworthiness of the results. The data analysis was conducted according to inductive content analysis. RESULTS: Four main themes and sub-themes related to each have been identified from the phenomenological analysis. The major themes were: (1) Pain changes lifestyle habits, (2) Pain control requires specific strategies, (3) Suffering turns time into waiting, (4) Waiting for Surgery between trust and fear. CONCLUSION: Investigating patients' experiences and the emotional impact of Rotator Cuff Tear facilitates the development of specific educational and therapeutic strategies to improve care and post-intervention outcomes.

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

BACKGROUND: This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions. METHODS: PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English. RESULTS: 214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation. CONCLUSIONS: The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required. PRE-REGISTRATION: OSF: https://osf.io/erh9m.

Kinetic chain revisited: consensus expert opinion on terminology, clinical reasoning, examination, and treatment in people with shoulder pain.

BACKGROUND: The purpose of this study was to reach consensus on the most appropriate terminology and issues related to clinical reasoning, examination, and treatment of the kinetic chain (KC) in people with shoulder pain among an international panel of experts. METHODS: A 3-round Delphi study that involved an international panel of experts with extensive clinical, teaching, and research experience in the study topic was conducted. A search equation of terms related to the KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across 5 different domains (terminology, clinical reasoning, subjective examination, physical examination, and treatment) using a 5-point Likert-type scale. An Aiken coefficient of validity (V) ≥0.7 was considered indicative of group consensus. RESULTS: The participation rate was 30.2% (n = 16), whereas the retention rate was high throughout the 3 rounds (100%, 93.8%, and 100%). A total of 15 experts from different fields and countries completed the study. After the 3 rounds, consensus was reached on 102 items: 3 items were included in the "terminology" domain; 17 items, in the "rationale and clinical reasoning" domain; 11 items, in the "subjective examination" domain; 44 items, in the "physical examination" domain; and 27 items, in the "treatment" domain. Terminology was the domain with the highest level of agreement, with 2 items achieving an Aiken V of 0.93, whereas the domains of physical examination and treatment of the KC were the 2 areas with less consensus. Together with the terminology items, 1 item from the treatment domain and 2 items from the rationale and clinical reasoning domain reached the highest level of agreement (V = 0.93 and V = 0.92, respectively). CONCLUSION: This study defined a list of 102 items across 5 different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination, and treatment) regarding the KC in people with shoulder pain. The term "KC" was preferred and a agreement on a definition of this concept was reached. Dysfunction of a segment in the chain (ie, weak link) was agreed to result in altered performance or injury to distal segments. Experts considered it important to assess and treat the KC in particular in throwing or overhead athletes and agreed that no one-size-fits-all approach exists when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.

Efficacy of therapeutic ultrasound in the treatment of chronic calcific shoulder tendinitis: a randomized trial.

BACKGROUND: Calcific shoulder tendinitis (CST) is characterized by hydroxyapatite crystals deposition in the rotator cuff tendons. Therapeutic exercises have been the mainstay of CST treatment, and evidence for therapeutic ultrasound (T-US) utilization and efficacy is lacking. AIM: This study aimed to determine whether 4500 J T-US combined with therapeutic exercises is superior to therapeutic exercises alone regarding calcification size reduction and symptom improvement in chronic symptomatic CST. DESIGN: This is a double-blind, placebo-controlled study. SETTING: This study was conducted at a University Department for Rheumatic Diseases and Rehabilitation of a University Hospital. POPULATION: Patients with chronic CST were analyzed. METHODS: After eligibility allocation, 46 patients with sonographically confirmed CST were divided into two groups (56 shoulders, 26 per group). Both groups performed the same therapeutic exercises for half an hour under physiotherapist supervision. In the treatment group T-US (4500 J, 10 minutes per session at a frequency of 1 MHz and an intensity of 1.5 W/cm2), and in the placebo group, sham T-US was applied for 4 weeks. Patients were assessed for: calcification size, shoulder pain, global health (GH), shoulder mobility (ROM), handgrip strength, Health Assessment Questionnaire Disability Index (HAQ-DI), Shoulder Pain and Disability Index (SPADI), and overall rehabilitation satisfaction. RESULTS: All assessed variables improved in both groups. A significantly greater reduction in calcification size was recorded in the treatment group compared to placebo: -10.92% (IQR 4.61% to 19.38%) versus -5.04% (2.30% to 7.22%), P=0.008. There was a significantly greater decrease in HAQ-DI, reduction of VAS GH, and an increase in hand grip strength in the treatment group, while no significant differences were observed for other parameters between the groups. CONCLUSIONS: Our results showed that adding the 4500 J T-US to therapeutic exercises in chronic symptomatic CST therapy resulted in greater calcification size reduction immediately following the treatment, as well as hand grip strength, HAQ-DI, and VAS GH improvement. CLINICAL REHABILITATION IMPACT: 4500 J T-US combined with therapeutic exercises is more effective in reducing calcification size than therapeutic exercises alone in the treatment of chronic symptomatic CST.

Immediate response to injection is associated with conservative care outcomes at 12 weeks in subacromial shoulder pain.

BACKGROUND: Subacromial injection is known to influence pain of subacromial origin, yet its association with conservative care outcomes is unknown. This study investigated whether immediate response to subacromial injection of corticosteroid and local anaesthetic is associated with conservative care outcomes at 12 weeks post injection and/or progression to surgery. DESIGN: prospective prognostic cohort study. METHODS: Sixty-four participants with subacromial related shoulder pain attending initial orthopaedic outpatient appointment at an Australian public hospital, received subacromial injection of corticosteroid and local anaesthetic followed by up to 12 weeks of physiotherapy. Immediate response to injection was measured by change in shoulder range of motion (ROM) and pain immediately (within 20 min) before and after injection. The Shoulder Pain and Disability Index (SPADI) was measured at baseline, 6 and 12-weeks. RESULTS: Backward stepwise linear regression revealed immediate post-injection improvement in pain-free ROM (p = 0.001) and higher baseline symptoms (p = 0.016) were significantly associated with better 12-week SPADI outcomes. Longer symptom duration (p = 0.029) and higher age (p = 0.013) were significantly associated with poorer outcomes. Only 11 individuals progressed to surgery. The resultant model could explain 35% of the variation in change in SPADI at 12 weeks. CONCLUSION: Improvement in pain-free shoulder ROM immediately post injection is significantly associated with better 12-week conservative care outcomes. This information, derived from within consultation injection responses, could help inform decisions about potential treatment options. Further research with higher numbers and longer-term patient-reported outcomes could further clarify these findings. REGISTRATION: Australia and New Zealand Clinical Trials Registry 21 May 2012: 12612000532808.

Arthroscopic diagnosis of long head of biceps tendon instability in refractory anterior shoulder pain: A comparison study between pulley tear and non-tear lesions.

BACKGROUND: Long head of the biceps tendon (LHBT) instability and biceps reflection pulley (BRP) lesions are common cause of refractory anterior shoulder pain. We described a technique using dynamic arthroscopy to determine associated intraarticular pathologies. METHODS: Patients with refractory anterior shoulder pain and arthroscopically-diagnosed LHBT instability were enrolled. LHBT instability and the integrity of BRP and concomitant intra-articular lesions were investigated by ramp test. Demographics and arthroscopic findings were compared between patients with and without BRP tear. RESULTS: Forty patients were enrolled. BRP tear was noted in 25 patients (group A) and superior glenohumeral ligament (SGHL) insufficiency through ramp test in 15 patients (group B). Concomitant intraarticular pathologies were noted in 27 patients, including 19 in group A (76%) and eight in group B (53%), without significant group-wise difference (p = 0.138). The incidence of articular-side subscapularis tear was significantly higher in group A (p = 0.021), and those of the other intraarticular pathologies were similar between groups A and B. Fraying at the articular side of the subscapularis and supraspinatus tendons was frequent in group B, without difference of incidence as compared to group A (p = 0.5 and p = 0.084, respectively). CONCLUSIONS: LHBT instability was a common disorder in patients with refractory shoulder pain. In those patients, dynamic assessment of BRP lesions and SGHL insufficiency and meticulous survey of associated intra-articular pathologies, including subscapularis tear are necessary for making accurate diagnosis and treatment decision.

Pain sensitivity and shoulder function among breast cancer survivors compared to matched controls: a case-control study.

OBJECTIVE: Persistent pain and loss of shoulder function are common adverse effects to breast cancer treatment, but the extent of these issues in comparison with healthy controls is unclear for survivors beyond 1.5 years after treatment. The purpose of this study was to benchmark differences in pressure pain thresholds (PPT), maximal isokinetic muscle strength (MIMS), and active range of motion (ROM) of females with persistent pain ≥1.5 years after breast cancer treatment (BCS) compared with pain-free matched controls (CON), and examine the presence of movement-evoked pain (MEP) during assessment of MIMS. METHODS: The PPTs of 18 locations were assessed using a pressure algometer and a numeric rating scale was used to assess intensity of MEP. Active ROM and MIMS were measured using a universal goniometer and an isokinetic dynamometer, respectively. RESULTS: A two-way analysis of variance revealed that PPTs across all locations, MIMS for horizontal shoulder extension/flexion and shoulder adduction, active ROM for shoulder flexion, horizontal shoulder extension, shoulder abduction, and external shoulder rotation were significantly lower for BCS compared with CON (P < 0.05). MEP was significantly higher for BCS and MEP intensity had a significant, negative correlation with PPTs (P < 0.01). DISCUSSION/CONCLUSION: BCS with persistent pain ≥1.5 years after treatment demonstrates widespread reductions in PPTs and movement-specific reductions in MIMS and active ROM of the affected shoulder, along with MEP during physical performance assessment. IMPLICATIONS FOR CANCER SURVIVORS: BCS with persistent pain ≥1.5 years after treatment shows signs of central sensitization and may benefit from individualized rehabilitation.

A critical appraisal of web-based information on shoulder pain comparing biomedical vs. psychosocial information.

BACKGROUND: Websites have become a primary way for patients to access health-related information, which allows patients to not only understand their condition better but also to engage in better decision making with their health care provider. However, this can be a double-edged sword, as information patients access may not be of high quality, easily readable, or could be biased based on website authorship. This study examines the readability and content quality of common websites about shoulder pain, with a specific focus on biomedical vs. psychosocial information. METHODS: The Flesch reading-ease score (FRES) and Flesch-Kincaid grade level (FKGL) instruments were used to assess website readability. Health on the net code of conduct (HONcode) certification and the DISCERN tool were used to evaluate the reliability and quality of information. Lastly, shoulder-specific content quality and focus was gauged using a Shoulder-specific Website Appraisal Tool (SWAT) created for this study. A systematic search protocol was used to identify popular shoulder injury websites. The websites were identified using 5 search terms (shoulder pain, shoulder muscle pain, shoulder impingement, shoulder rotator cuff pain, and shoulder pain diagnosis) across 5 English-speaking regions (United States, Canada, United Kingdom, Australia, and New Zealand) using the Google search engine. The top 10 websites for each term and region combination were included and combined, yielding 41 original websites for appraisal; several (6) websites were omitted as duplicates, behind paywalls, or nontext (video) for a total of 35 websites appraised. RESULTS: On average, the FRES shoulder pain websites readability was 55.37, which is categorized as "fairly difficult" to read, and a seventh- or eighth-grade reading level based on the FKGL. For trustworthiness and bias, 57% (20 of 35) of the websites were HONcode certified. The quality of health care information using the DISCERN score averaged 50.92%. Examining shoulder-specific content quality, the average SWAT score was 10.54 out of 14 possible points, with only 1 website reporting information on psychosocial aspects of shoulder pain. CONCLUSIONS: This study suggests that shoulder pain websites present information that is at too high of a reading level for public consumption, has a strong bias toward biomedical causes of shoulder pain, and would benefit from implementation of website screening tools to improve evidence-based content.

Effectiveness of an expert assessment and individualised treatment compared with a minimal home-based exercise program in women with late-term shoulder impairments after primary breast cancer surgery: study protocol for a randomised controlled trial.

BACKGROUND: In breast cancer patients, late-term upper limb sequelae, such as shoulder pain and impaired shoulder function, remain common after primary breast cancer surgery. The aim of this trial is to evaluate whether an expert assessment of shoulder impairments, followed by an individualised treatment plan, is superior to a minimal physiotherapeutic rehabilitation program in reducing shoulder symptoms, among women with late-term shoulder impairments after primary breast cancer. METHODS/DESIGN: The study is designed as a stratified, parallel-group, assessor-blinded, randomised, controlled trial conducted in Denmark; 130 participants with late-term shoulder impairments 3-7 years after primary surgery for breast cancer will be recruited. Participants will be randomised (allocation 1:1) to either an expert assessment of shoulder impairments followed by an individualised treatment plan or to follow a minimal physiotherapeutic rehabilitation program delivered in a pamphlet. The primary outcome will be a change in shoulder pain and function from baseline to 12 weeks after initiating the treatment, as measured by the patient-reported outcome Shoulder Pain and Disability Index (SPADI) questionnaire. DISCUSSION: There has been an insufficient focus in research and clinical practice on late-term shoulder impairment in women following surgery for breast cancer. This trial will focus on interventions towards late-term shoulder impairments and is expected to provide evidence-based knowledge to physiotherapists and women about the management of shoulder pain and impaired shoulder function. TRIAL REGISTRATION: ClinicalTrials.gov NCT05277909. Registered on 11 March 2022.

Post-operative rehabilitation using a digital healthcare system in patients who had undergone rotator cuff repair: protocol for a single-center randomized controlled trial.

BACKGROUND: Operative repair of a rotator cuff tear requires up to 12 weeks of post-operative (post-op) home-based rehabilitation. Maintaining patients' compliance in the post-op rehabilitation program is a pivotal component for generating successful outcomes. By developing a post-op rehabilitation-oriented digital healthcare system and applying it in patients who had undergone rotator cuff repair, we aim to increase the efficacy of the rehabilitation program and raise patients' compliance levels. Here, we present a protocol developed for comparing the efficacy of rehabilitation using a newly developed augmented reality (AR)-based digital healthcare system with that of conventional rehabilitation for post-op rehabilitation of rotator cuff repair. METHODS: This study will recruit a total of 115 patients who had undergone rotator cuff repair within 3 days after surgery. Patients will be randomly allocated to rehabilitation using an AR-based digital healthcare system (digital group) or conventional rehabilitation (conventional group). Patients in both groups will perform brochure-based exercises from the immediate post-op period to post-op 6 weeks. From post-op 6 weeks to 12 weeks, patients in the digital group will use the AR-based system for post-op exercises, whereas patients in the conventional group will continue brochure-based rehabilitation exercises. The primary outcome will be scores on the Simple Shoulder Test at post-op 12 weeks. Secondary outcomes include numeric rating scale scores for pain, measures of range of motion and muscle strength of the affected shoulder, grip strength of the affected arm, scores on the Disabilities of the Arm, Shoulder and Hand test, the Shoulder Pain and Disability Index, and the EuroQoL-5D-5L quality-of-life measure. Analyses will be conducted using an intention-to-treat approach. DISCUSSION: This study will examine the effectiveness of an AR-based digital healthcare system for post-op rehabilitation in the patients after rotator cuff repair. The study will add evidence for the application of digital healthcare systems in post-op rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04511377. Registered on 10 August 2020.

"Shoulder pain and limitation of motion in a young girl: think different".

BACKGROUND: Primary Synovial Chondromatosis (PSC) is a rare benign tumor of the synovial membrane in which cartilage metaplasia produces calcific loose bodies within the articular space. Only a few cases are reported in the pediatric population and its etiology remains unknown. This condition typically affects large weight-bearing joints with pain, swelling and decrease range of motion. Due to its slow progressions, delayed diagnosis is frequent and differential diagnosis should consider other chronic arthritis and malignancies. While arthroscopic removal of loose bodies is the current treatment up to now, the association of partial or complete synovectomy is debated. CASE PRESENTATION: We report about a 14-year-old girl with a long-lasting right shoulder pain, especially during movements or exercise, localized tenderness and hypotonia of the glenohumeral joint. No previous trauma was mentioned. Blood exams, Mantoux test and plain radiography of the right shoulder were unremarkable. Ultrasound imaging revealed echogenic and calcified bodies stretching the glenohumeral joint and dislocating the long head of biceps tendon. Magnetic resonance showed a "rice-grain" pattern of the right shoulder. From an arthroscopic surgery, multiple loose white bodies were removed within the synovial membrane, and synovial chondromatosis was confirmed by histological analysis. At one month follow up visit, the patient completely recovered without pain. CONCLUSION: Synovial chondromatosis is a very uncommon cause of mono articular pain in children, especially when it affects shoulder. Pediatricians should keep in mind this condition to avoid delayed diagnosis and treatment, even in consideration of the low risk of malignant transformation. Through this case, we would highlight common diagnostic pitfalls and treatment of synovial chondromatosis.

Cryoanalgesia for shoulder pain: a motor-sparing approach to rotator cuff disease.

INTRODUCTION: Rotator cuff disease is a common cause of musculoskeletal pain and disability, and the management can be challenging. Joint denervation emerges as a new technique, but the literature on shoulder neural ablation procedure is largely limited to pulsed radiofrequency due to the concern of motor impairment. We described a novel motor-sparing approach of cryoablation for the management of shoulder pain based on the recent literature on the innervation of shoulder. METHODS: Four patients with a history of rotator cuff disease refractory to conservative therapy and not amenable to surgery underwent a ultrasound-guided cryoablation of the capsular branches of the shoulder joint after a positive diagnostic injection. The target articular branches were based on the anatomical landmarks described in recent publication. They were the acromial, superior and inferior branches of the suprascapular nerve, the anterior branch of the axillary nerve, the nerve to the subscapularis, which were all located around the superior, posterior and anterior glenoid. The lateral pectoral nerve articular branch was targeted at the coracoclavicular space. RESULTS: All four patients experienced at least 60% pain relief with improvement in function for 6-12 months following the procedure without any clinical evidence of motor impairment. No adverse effect was observed. DISCUSSION: Based on the current understanding of the glenohumeral joint articular branches and their relationship to the bony landmark, targeting the articular branches only was feasible and led to good outcomes. Further large prospective cohort study is needed.