Effectiveness of a joint mobilizations protocol for shoulder subacromial pain syndrome: A pilot study.

BACKGROUND: Subacromial pain syndrome (SPS) is the most frequent shoulder pathology. The aims of this prospective randomized study were to evaluate the effects of some specific shoulder joint mobilizations ("spin correction"), and the effectiveness of a rehabilitation program, named Shoulder Global Concept, in SPS patients. METHODS: 45 patients with SPS were randomly assigned to two groups, to benefit from a different first session of mobilizations: the experimental group received all specific mobilizations, while the control group received the same program but without the spin correction mobilizations. The second session was identical for both groups, with all specific mobilizations. Before and after the first two sessions, range of motion (ROM) in flexion, abduction, external and internal rotations, pain and functional status with Constant score and Quick Dash were evaluated. Evaluation was repeated with 24 patients after 11 rehabilitation sessions. Rehabilitation with Shoulder Global Concept included 13 mobilizations aiming at improving the ROM with passive and active-assisted mobilizations, static stretching, and muscle strengthening. RESULTS: All ROM were improved at the end of the first session for both groups, but significantly more in the experimental group for glenohumeral (GH) abduction and external rotation (p < 0.05). Functional scores, pain and strength were significantly improved after 11 rehabilitation sessions with the Shoulder Global Concept. CONCLUSION: This manual therapy method was able to improve shoulder mobility in one session. The additional joint mobilizations (spin correction) specifically increased GH abduction and external rotation. Rehabilitation of SPS with Shoulder Global Concept allowed to improve functional capacity and decrease pain.

Progressive Resistance Exercises plus Manual Therapy Is Effective in Improving Isometric Strength in Overhead Athletes with Shoulder Impingement Syndrome: A Randomized Controlled Trial.

Reduction in isometric strength of the scapulohumeral muscles is a commonly seen impairment in overhead athletes afflicted with shoulder impingement syndrome (SIS). The purpose of this study was to compare the effects of two different treatment programs: progressive resistance exercises plus manual therapy (PRE plus MT) and motor control exercises (MCE), on isometric strength of upper trapezius (UT), middle trapezius (MTr), lower trapezius (LT), serratus anterior (SA), supraspinatus (Supr.), anterior deltoid (A.D), and latissimus dorsi (LD). 80 male university-level overhead athletes clinically diagnosed with SIS were randomly allocated into either of the two groups: PRE plus MT and MCE group. Athletes in the PRE plus MT group underwent graduated exercises with resistance elastic band, stretching exercises, and mobilization of the thoracic and shoulder joints. MCE group was submitted to motor control exercises in varied planar positions. Athletes in both groups underwent management 3 times a week for 8 weeks. Isometric strength of UT, MTr, LT, Supr, A.D, SA, and LD was measured at three-time points: baseline, 4th week, and 8th week. Relative to baseline, both interventions were found to be effective in increasing and optimizing the isometric strength of muscles (p < 0.05) except for supraspinatus in the MCE group (p > 0.05). However, athletes in PRE plus MT group presented a more pronounced increase in isometric strength than those in the MCE group. Between groups analysis found the largest isometric strength improvement in PRE plus MT group for A.D, followed by Supr. and UT muscles (p < 0.05; effect size: 0.39 to 0.40). The study concluded that compared to MCE, PRE plus MT provides greater improvement in the isometric strength of scapulohumeral muscles.

Inclinometer Reliability for Shoulder Ranges of Motion in Individuals With Subacromial Impingement Syndrome.

OBJECTIVE: This study aimed to determine the intra- and interrater reliability of active and passive range of motion in the shoulders of individuals with subacromial impingement syndrome using a digital inclinometer. METHODS: The raters evaluated active and passive range of motion in the shoulder of 50 individuals with unilateral subacromial impingement syndrome in movements including flexion, abduction, extension, external rotation in a neutral position, external rotation with the arm at 90° of abduction, and internal rotation with the arm at 90° of abduction. The tests were performed by 2 examiners on the same day, with a 10-minute interval, and were repeated by 1 examiner after a 2- to 4-day interval. Reliability was analyzed using the intraclass correlation coefficient (ICC2,3). RESULTS: There was moderate to excellent interrater (ICC2,3 = 0.50-0.95) and intrarater (ICC2,3 = 0.74-0.94) reliability. In the interrater analysis, the standard error of measurement (SEM) ranged from 4.1° to 10°, the percentage SEM (%SEM) ranged from 2% to 17%, and the minimum detectable change ranged from 9.5° to 23.4°. In the intrarater analysis, the SEM ranged from 4° to 9.2°, %SEM ranged from 3% to 14%, and the minimum detectable change ranged from 9.3° to 21.4°. CONCLUSION: The digital inclinometer showed moderate to excellent reliability for measuring active and passive range of motion in shoulders with unilateral subacromial impingement syndrome.

Is the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire Adequate to Assess Individuals With Subacromial Pain Syndrome? Rasch Model and International Classification of Functioning, Disability and Health.

OBJECTIVE: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is widely used to assess patients with symptoms of subacromial pain syndrome (SPS). No study has analyzed the DASH by using the Rasch model in these patients and related the level of difficulty of the items with the International Classification of Functioning Disability and Health (ICF) domains. The purpose of this study was to evaluate the measurement properties of the DASH in individuals with SPS and to describe which ICF components are influenced by SPS based on the DASH. METHODS: The full version of the DASH was used to assess upper limb pain and function in individuals with SPS. Responses were assessed using the Rasch model. DASH items were grouped according to the level of difficulty and associated with the ICF domains to identify the most compromised aspect in these individuals. RESULTS: Reliability and internal consistency for the DASH were shown to be 0.93 and 0.95, respectively. Item 3 ("Turn a key") was the easiest and 25 ("Pain during specific activity") the most difficult. Only item 30 ("Less capable/confident/useful") was as an erratic item. Item 15 ("Put on a sweater") showed differential functioning by age and item 11 ("Carry a heavy object") by sex. Seven items showed differential functioning related to the angular onset of pain during arm elevation. Sixty percent of the most difficult items belonged to the "Body function" domain of the ICF. CONCLUSION: Although some psychometric properties of the DASH are adequate according to the Rasch model, adjustments to some items are necessary for individuals with SPS. Clinicians should be cautious when interpreting the DASH, especially in patients with angular onset of pain above 120 degrees of arm elevation. IMPACT: The information contained in this study should be used by clinicians to interpret the results of the DASH when assessing individuals with SPS. The DASH may not be adequate to assess those with shoulder pain above 120 degrees of arm elevation. These results are not generalizable to other shoulder pathologies.

Recruitment of Shoulder Complex and Torso Stabilizer Muscles With Rowing Exercises Using a Suspension Strap Training System.

BACKGROUND: Suspension training systems, which use body weight resistance under unstable conditions, may be effective for muscle strengthening in persons with scapular dyskinesis or subacromial impingement syndrome. HYPOTHESIS: Greater arm, scapular, and trunk muscle recruitment will occur during horizontal abduction row exercises. STUDY DESIGN: Descriptive laboratory study. LEVEL OF EVIDENCE: Level 5. METHODS: Surface electromyography data were collected from 28 participants (14 men, 14 women). A total of 13 right-sided muscles were studied at a sampling frequency of 1000 Hz. Maximal voluntary isometric contractions (MVICs) were established. Participants completed 3 repetitions per exercise in random order. We compared muscle recruitment during 3 rowing exercises: low row, high row, and horizontal abduction row. Data were compared with repeated-measures analyses of variance and post hoc Bonferroni corrections. RESULTS: For high row and horizontal abduction row conditions, the upper, middle, and lower trapezius and posterior deltoid demonstrated >60% MVIC magnitudes of recruitment, and the upper erector spinae demonstrated 40% to 60% MVIC magnitudes of recruitment, respectively. In contrast, in the low row exercise, 40% to 60% MVIC magnitudes of recruitment were observed only in the middle trapezius, latissimus dorsi, and posterior deltoid. CONCLUSION: With the suspension system, high row and horizontal abduction row exercises promote muscle strengthening (>50% MVIC) in the upper, middle, and lower fibers of the trapezius, posterior deltoid, and upper erector spinae. CLINICAL RELEVANCE: Rowing exercises performed with suspension straps may be recommended for muscle strengthening in patients with scapular dyskinesis and subacromial impingement syndrome as well as for healthy persons in need of enhanced scapular muscle performance.

Assessment of Mitochondrial Dysfunction in a Murine Model of Supraspinatus Tendinopathy.

BACKGROUND: The purpose of this study was to assess mitochondrial dysfunction in a murine model of supraspinatus tendinopathy. METHODS: Eighty-four mice (168 limbs) were included in the study. Supraspinatus tendinopathy was induced by inserting a microsurgical clip in the subacromial space of 63 mice bilaterally (126 limbs). Forty-two of these limbs were harvested at 4 weeks postoperatively, 42 underwent clip removal at 4 weeks after the initial procedure and were harvested at 2 weeks, and 42 underwent clip removal at 4 weeks and were harvested at 4 weeks. Forty-two limbs in the remaining 21 mice did not undergo surgical intervention and were utilized as the control group. Outcomes included biomechanical, histological, gene expression, superoxide dismutase (SOD) activity, and transmission electron microscopy (TEM) analyses. RESULTS: Radiographs confirmed stable clip position in the subacromial space at 4 weeks. Biomechanical testing demonstrated a 60% decrease in failure force of the supraspinatus tendons at 4 weeks compared with the control group. The failure force gradually increased at 2 and 4 weeks after clip removal. Histological analysis demonstrated inflammation surrounding the tendon with higher modified Bonar scores at 4 weeks after clip placement followed by gradual improvement following clip removal. The expression of mitochondrial-related genes was decreased at 4 weeks after clip placement and then significantly increased after clip removal. SOD activity decreased significantly at 4 weeks after clip placement but increased following clip removal. TEM images demonstrated alterations in morphology and the number of mitochondria and cristae at 4 weeks after clip placement with improvement after clip removal. CONCLUSIONS: Mitochondrial dysfunction appears to be associated with the development of tendinopathy. CLINICAL RELEVANCE: Mitochondrial protection may offer a potential strategy for delaying the development of tendinopathy and promoting tendon healing.

Tight shoulders: A clinical, kinematic and strength comparison of symptomatic and asymptomatic male overhead athletes before and after stretching.

A tightness of the posterior structures of the throwing shoulder has been hypothesised to be associated with injuries and pain because of alterations of the scapular kinematics and muscular imbalances. The aims of this study were to identify the clinical and biomechanical profile of symptomatic and asymptomatic overhead athletes with a tight shoulder and to evaluate the efficiency of a self-applied stretching program. Twenty male overhead athletes were recruited. Half of them reported a painful shoulder at the beginning of the study. For four weeks, the volunteers performed daily stretching exercises. Before and after the stretching program, gleno-humeral mobility, scapular kinematics, rotator muscles strength and pain were evaluated. Before stretching, the main difference between the groups was more impingement syndrome and rotator cuff tendon lesion positive tests in the symptomatic group (p < 0.027, effect size = 0.51). After the program, pain reported by the symptomatic volunteers was reduced by approximately 40% and the gleno-humeral internal rotation bilateral difference was significantly reduced by 77.6% (p < 0.009, effect size = 0.84). In the symptomatic group, the scapula at rest was significantly more posteriorly tilted (p = 0.027, effect size = 0.69) after the stretching; a position that has been shown to limit the risk of impingement. The absence of significant differences of the profiles of the symptomatic and asymptomatic overhead athletes before stretching may indicate that the initiation of early prevention programs, including self-applied stretching, should not rely solely on biomechanical and clinical parameters and might be recommended to all players with a tight shoulder.

Comparison of low-level laser treatment and extracorporeal shock wave therapy in subacromial impingement syndrome: a randomized, prospective clinical study.

The aim of this study was to compare the efficacy of low-level laser treatment (LLLT) and extracorporeal shock wave therapy (ESWT) in the treatment of subacromial impingement syndrome (SIS). Seventy-one patients with subacromial impingement were randomly assigned to LLLT (n = 37) and ESWT (n = 34) groups. The patients received a total of 15 sessions of LLLT or once a week for 3 sessions of ESWT. All patients, before treatment, at the end of treatment, and 3 months after treatment, were evaluated with range of motion (ROM), visual analogue pain scale (VAS pain), Shoulder Pain and Disability Index (SPADI), Beck Depression and Anxiety Inventories, the Short Form Health Survey (SF-36), and Pittsburgh Sleep Quality Index (PSQI). In both groups, there was a significant improvement in all outcome measures (p < 0.05) except the mental health score in the LLLT group. ESWT group showed more improvements in terms of SPADI disability and total scores, PSQI, and physical-mental health scores at the end of treatment (p < 0.05). The improvement in VAS pain day and SPADI scores at the third month was significantly more evident in the ESWT group (p < 0.05). Both LLLT and ESWT treatments are effective in the treatment of SIS in the short-medium term and can be used in clinical practice. Future larger prospective clinical trials are needed to investigate the long-term efficacy and optimal treatment protocol of LLLT and ESWT in SIS.

The role of 18F-FDG PET/CT in the diagnosis of frozen shoulder.

PURPOSE: Frozen shoulder is characterized by pain and reduced passive movement capability, and the diagnose is made clinically. However, pain is the major symptom in the first stage before stiffness occurs, and the condition can be mistaken for subacromial impingement. This study explored the possibility to use positron emission tomography/computed tomography (PET/CT) with a 18F Flour-Deoxy-Glucose (FDG) tracer in the diagnostic process. METHODS: Eleven patients with frozen shoulder and 9 patients with subacromial impingement received a 18F-FDG PET/CT scan before being treated surgically. During arthroscopy, the diagnoses were confirmed. Images were blindly analyzed visually by two nuclear medicine physicians. Also, semi-quantified analysis applying a set of standard regions was performed, and standard uptake value in both shoulder regions was recorded. RESULTS: Both the visual description of the pictures and the semi-quantified analysis generally showed increased FDG uptake in the affected shoulder regions of patients that had frozen shoulder and no uptake in patients with subacromial impingement. Kappa for interobserver agreement in the visual assessments was 0.74. Sensitivity was 92% and specificity 93% of the visual assessment, 77% and 93%, respectively, of the semi-quantified analyses, and by combining the two types of analyses sensitivity was 100% and specificity was 93% for the distinction between frozen shoulders and subacromial impingement/unaffected shoulders. CONCLUSION: 18F-FDG PET/CT seems to be a valid method to diagnose frozen shoulder. This is clinically relevant in diagnostically challenging cases, for instance in the first phase of frozen shoulder, which can be difficult to distinguish from subacromial impingement. LEVEL OF EVIDENCE: II.

Effects of Ultrasound-Guided Peritendinous and Intrabursal Corticosteroid Injections on Shoulder Tendon Elasticity: A Post Hoc Analysis of a Randomized Controlled Trial.

OBJECTIVES: The study aimed to investigate whether the shoulder tendons changed their elasticity after ultrasound-guided peritendinous or intrabursal corticosteroid injections. DESIGN: Post hoc secondary analysis of a double-blinded, randomized controlled study with 3 months of follow-up. SETTING: Outpatient rehabilitation clinic. PARTICIPANTS: Patients with subacromial impingement syndrome (N=60). INTERVENTIONS: Patients with unilateral shoulder pain were randomly assigned to receive standard ultrasound-guided subacromial or dual-target corticosteroid injections. The supraspinatus tendons were exposed to 40 mg triamcinolone acetonide in the formal group, whereas the long head of the biceps brachii tendons (LHBT) and supraspinatus tendons were individually infiltrated by 20 mg triamcinolone acetonide in the latter group. Patients' bilateral shoulders were divided into group 1 (n=30, receiving standard subacromial injections), group 2 (n=30, receiving dual-target injections), and group 3 (n=60, without injections). MAIN OUTCOME MEASURES: Strain ratio of LHBT and supraspinatus tendons using ultrasound elastography. RESULTS: The repeated-measures analysis of variance revealed no intragroup difference of the strain ratio of the LHBT (P=.412 for group 1, P=.936 for group 2, P=.131 for group 3) and supraspinatus tendon (P=.309 for group 1, P=.067 for group 2, P=.860 for group 3) across the 3 time points. Treating group 3 as the reference, the linear mixed model revealed no significant changes in tendon elasticity after either the standard subacromial injection (P=.205 for the LHBT and P=.529 for the supraspinatus tendon) or the dual-target injection (P=.961 for the LHBT and P=.831 for the supraspinatus tendon). CONCLUSIONS: Elasticity of the LHBT and supraspinatus tendons is unlikely to change after a single dose of peritendinous or intrabursal corticosteroid injections. Future studies with a shorter follow-up interval are needed to validate whether corticosteroid injections can cause transient changes of the tendon's elasticity.

No relationship between the acromiohumeral distance and pain in adults with subacromial pain syndrome: a systematic review and meta-analysis.

To determine whether subacromial space (i.e. acromiohumeral distance; AHD, and/or occupation ratio percentage) differs between people with subacromial pain syndrome (SAPS) and those without. To investigate whether there is a correlation between subacromial space and pain or disability in adults with SAPS and whether temporal changes in pain or disability are accompanied by changes in subacromial space. Systematic review and meta-analysis. Fifteen studies with a total of 775 participants were included. Twelve studies were of high quality and three studies were of moderate quality using the modified Black and Downs checklist. There was no between group difference in AHD in neutral shoulder position (mean difference [95% CI] 0.28 [-0.13 to 0.69] mm), shoulder abduction at 45° (-0.02 [-0.99 to 0.96] mm) or 60° (-0.20 [-0.61 to 0.20] mm). Compared to the control group, a greater occupation ratio in neutral shoulder position was demonstrated in participants with SAPS (5.14 [1.87 to 8.4] %). There was no consistent pattern regarding the correlation between AHD and pain or disability in participants with SAPS, and no consistent increase in subacromial space with improvement in pain or disability over time. The results suggest that surgical (e.g. sub-acromial decompression) and non-surgical (e.g. manual therapy, taping, stretching and strengthening) management of subacromial pain syndrome should not focus solely on addressing a potential decrease in subacromial space, but also on the importance of other biopsychosocial factors.

Relationship Between Intensity of Neck Pain and Disability and Shoulder Pain and Disability in Individuals With Subacromial Impingement Symptoms: A Cross-Sectional Study.

OBJECTIVE: This study aimed to verify a possible relationship between shoulder disability and shoulder pain intensity and the variables related to cervical-spine dysfunction, and determine which of these can differentiate moderate to severe shoulder pain (>4 on a numerical rating scale [NRS]) from mild shoulder pain (≤4 on the NRS) in individuals with subacromial impingement symptoms. METHODS: One hundred and forty volunteers with shoulder pain were evaluated. Demographic information and variables related to the shoulder and neck were collected. Self-reported pain and disability of the shoulder and cervical spine were measured using the Shoulder Pain and Disability Index (SPADI) and Neck Disability Index (NDI) questionnaires, respectively. An NRS was used to measure pain in the shoulder and cervical spine. A purposeful modeling strategy was used to determine the best model to predict shoulder disability and shoulder pain (dependent variables). Multiple logistic regression analysis followed by receiver operating curve analysis was used to determine which variables better differentiated moderate to severe shoulder pain from mild shoulder pain. RESULTS: Variables such as Neck Disability Index (NDI) score (ß = 1.09, P = .00) and age (ß = -0.19, P = .03) were associated with the total SPADI score. Neck pain was significantly associated with shoulder pain (ß = 0.40, P = .00). The combination of variables predicting moderate to severe shoulder pain was total SPADI score (odds ratio [OR] = 1.15, P = .003), neck pain (OR = 3.20, P = .04), and age (OR = 1.01, P = .05). CONCLUSION: Our results demonstrate the important connection between shoulder- and neck-related symptoms in individuals with subacromial impingement symptoms.

Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review.

OBJECTIVE: To systematically scope the reported advice and education in physical therapy management of patients with subacromial shoulder pain, and to define key themes of the advice and education. DESIGN: Scoping review. LITERATURE SEARCH: We searched MEDLINE, Scopus, Web of Science, and CINAHL, with publication dates from 2007 to September 2019. STUDY SELECTION CRITERIA: We included quantitative and qualitative research that reported on physical therapy interventions for subacromial shoulder pain. DATA SYNTHESIS: We performed a qualitative synthesis that identified items included in patient advice and education. RESULTS: Of 89 original studies included, there were 61 randomized controlled trials; 5 prospective studies; 16 nonrandomized observational intervention studies or case series; and 7 surveys, audits of physical therapy patient records, and focus groups with physical therapists. We identified 7 key themes for advice and education: exercise intensity and pain response, activity modification advice, posture advice, pain self-management advice, pathoanatomical and diagnosis information, behavioral approaches, and pain biology advice. CONCLUSION: While advice focused predominantly on the local tissue pathology model, 10% of studies included information about pain neuroscience education, psychosocial factors, motor imagery, or behavior change. J Orthop Sports Phys Ther 2020;50(6):285-293. doi:10.2519/jospt.2020.9152.

The immediate effects of a shoulder brace on muscle activity and scapular kinematics in subjects with shoulder impingement syndrome and rounded shoulder posture: A randomized crossover design.

BACKGROUND: Round shoulder posture (RSP) is one of the potential risks for shoulder impingement syndrome (SIS) due to alignment deviation of the scapula. Evidence on how the characteristics of a shoulder brace affecting the degree of RSP, shoulder kinematics, and associated muscle activity during movements is limited. RESEARCH QUESTION: The purposes of this study were (1) to compare the effects of a shoulder brace on clinical RSP measurements, muscle activities and scapular kinematics during arm movements in subjects with shoulder impingement syndrome (SIS) and RSP; and (2) to compare the effects of two configurations (parallel and diagonal) and two tensions (comfortable and forced tension) of the brace straps on muscle activities and scapular kinematics during arm movements in subjects with SIS and RSP. METHODS: Twenty-four participants (12 males; 12 females) with SIS and RSP were randomly assigned into 2 groups (comfortable then forced, and forced then comfortable) with 2 strap configurations in each tension condition. The pectoralis minor index (PMI), acromial distance (AD) and shoulder angle (SA) were used to assess the degree of RSP. Three-dimensional electromagnetic motion analysis and electromyography were used to record the scapular kinematics and muscle activity during arm movements. RESULTS: All clinical measurements with the brace were significantly improved (p < 0.05). Under forced tension, muscle activities were higher with the diagonal configuration than with the parallel configuration in the lower trapezius (LT) (1.2-2.3% MVIC, p < 0.05) and serratus anterior (SA) (2.3% MVIC, p = 0.015). For upward rotation and posterior tilting of the scapula, the diagonal configuration was larger than the parallel configuration (1.5°, p = 0.038; 0.4°-0.5°, p < 0.05, respectively). SIGNIFICANCE: Different characteristics of the straps of the shoulder brace could alter muscle activity and scapular kinematics at different angles during arm movement. Based on the clinical treatment preference, the application of a shoulder brace with a diagonal configuration and forced tension is suggested for SIS and RSP subjects.

Painful Shoulder: Exercise Can Reduce Pain and Improve Mobility and Function.

Shoulder pain is common, especially as we age. Pain that limits your ability to raise your arm above your head or rotate your shoulder is called "subacromial shoulder pain." The good news is that most people with subacromial shoulder pain improve with physical therapy. A review of the most up-to-date research published in the March 2020 issue of JOSPT concluded that shoulder exercises are the best way to manage this pain. J Orthop Sports Phys Ther 2020;50(3):142. doi:10.2519/jospt.2020.0501.

The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain.

BACKGROUND: Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population. METHODS: This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist. DISCUSSION: This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.

Effects of Modified Posterior Shoulder Stretching Exercises on Shoulder Mobility, Pain, and Dysfunction in Patients With Subacromial Impingement Syndrome.

BACKGROUND: Posterior shoulder stretching exercises (PSSEs) aim to reduce posterior shoulder tightness (PST). Position modification of traditional PSSEs has been suggested to minimize inadequate control of scapular and glenohumeral rotation, possibly leading to increased subacromial impingement. HYPOTHESIS: Modified PSSEs will have positive effects on shoulder mobility, pain, and dysfunction. STUDY DESIGN: Randomized controlled trial. LEVEL OF EVIDENCE: Level 1. METHODS: A total of 67 symptomatic patients with subacromial impingement syndrome (SIS) and shoulder internal rotation asymmetry were randomly assigned to 3 groups: modified cross-body stretch (MCS) (n = 22; treatment program + MCS), modified sleeper stretch (MSS) (n = 22; treatment program + MSS), and a control group (n = 23; treatment program consisting of only modalities, range of motion [ROM], and strength training but no PSSEs) for 4 weeks. Pain, PST, shoulder rotation ROM, and dysfunction were evaluated. RESULTS: Pain, PST, shoulder rotation ROM, function, and disability improved in all groups (P < 0.05). The MCS and MSS groups had better results compared with the control group with regard to pain with activity, internal rotation ROM, function, and disability (P < 0.05). There was no significant difference between the stretching groups (P > 0.05). CONCLUSION: All treatments improved pain, shoulder mobility, function, and disability in patients with SIS. However, modified PSSEs in addition to a treatment program was superior to the treatment program alone (without PSSEs) in improving pain with activity, internal rotation ROM, and dysfunction. Moreover, stretching provided clinically significant improvements. CLINICAL RELEVANCE: Modified PSSEs, in addition to a treatment program, are beneficial for patients with SIS. Both modified cross-body and sleeper stretches are safe and efficacious for improving shoulder mobility, pain, and dysfunction.

Shoulder mechanical impingement risk associated with manual wheelchair tasks in individuals with spinal cord injury.

BACKGROUND: Most individuals with spinal cord injury who use manual wheelchairs experience shoulder pain related to wheelchair use, potentially in part from mechanical impingement of soft tissue structures within the subacromial space. There is evidence suggesting that scapula and humerus motion during certain wheelchair tasks occurs in directions that may reduce the subacromial space, but it hasn't been thoroughly characterized in this context. METHODS: Shoulder motion was imaged and quantified during scapular plane elevation with/without handheld load, propulsion with/without added resistance, sideways lean, and weight-relief raise in ten manual wheelchair users with spinal cord injury using biplane fluoroscopy and computed tomography. For each position, minimum distance between rotator cuff tendon insertions (infraspinatus, subscapularis, supraspinatus) and the coracoacromial arch was determined. Tendon thickness was measured with ultrasound, and impingement risk scores were defined for each task based on frequency and amount of tendon compression. FINDINGS: Periods of impingement were identified during scapular plane elevation and propulsion but not during pressure reliefs in most participants. There was a significant effect of activity on impingement risk scores (P < 0.0001), with greatest impingement risk during scapular plane elevation followed by propulsion. Impingement risk scores were not significantly different between scapular plane elevation loading conditions (P = 0.202) or propulsion resistances (P = 0.223). The infraspinatus and supraspinatus tendons were both susceptible to impingement during scapular plane elevation (by acromion), whereas the supraspinatus was most susceptible during propulsion (by acromion and coracoacromial ligament). INTERPRETATION: The occurrence of mechanical impingement during certain manual wheelchair tasks, even without increased load/resistance, demonstrates the importance of kinematics inherent to a task as a determinant of impingement. Frequency of and technique used to complete daily tasks should be carefully considered to reduce impingement risk, which may help preserve shoulder health long-term.

Atypical biceps-related complication of proximal humerus fracture leading to internal shoulder impingement due to tendon stump dislocation.

Non-displaced proximal humerus fractures are usually managed non-operatively despite of minor malalignment. Biceps tendon rupture due to attrition after malunion is rare around the proximal humerus. Rupture of the long head of biceps (LHB) tendon usually occurs inside the joint close to the origin at the labrum. Treatment is usually non-operative with good outcomes. We report a rare case of a 48-year-old female patient with persistent locking and internal impingement 8 months after a proximal humerus fracture with anterior angulation leading to extra-articular reversed LHB tendon rupture with intra-articular dislocation of the proximal stump. Interposition of the tendon (3.5 cm) between the glenoid and the humeral head was confirmed on MRI arthrogram. Arthroscopic proximal tenotomy and stump removal resulted in immediate relief with improved function (subjective shoulder value 95%; Constant Score: 96). False interpretation of symptoms as posttraumatic stiffness should be avoided by a thorough examination and complementary MRI arthrogram investigation.

Absolute and Relative Reliability of Pressure Pain Threshold Assessments in the Shoulder Muscles of Participants With and Without Unilateral Subacromial Impingement Syndrome.

OBJECTIVE: The purpose of this study was to determine the relative and absolute reliability of the pressure pain threshold (PPT) in the shoulder muscles of participants with and without unilateral subacromial impingement syndrome. METHODS: Study of intraday intra- and interrater and interday intrarater reliability. Fifty-two participants symptomatic for unilateral subacromial impingement syndrome were divided into 2 groups (SG1 and SG2) of 26 participants each, and 26 participants asymptomatic for shoulder pain took part in the study. Two raters assessed the PPT in 4 shoulder muscles. Each rater assessed symptomatic (SG1) and asymptomatic participants twice on the same day, and one of the raters on 2 different days (SG2). The intraclass correlation coefficient, standard error of measurement (SEM95% and SEM%), and minimum detectable change (MDC95% and MDC%) were calculated. RESULTS: Relative reliability was good or excellent for all assessments, as well as for both groups and raters (intraclass correlation coefficient: 0.87-0.98). The SEM95% values for intra- and interday intrarater measures were between 0.43 and 1.50 kgf/cm2 and SEM% between 6.76 and 12.86%, whereas MDC95% values ranged from 0.60 to 2.12 kgf/cm2 and MDC% from 9.56 to 18.18%. In interrater measures, SEM95% was between 0.58 and 0.77 kgf/cm2 and SEM% between 10.10% and 13.71%, whereas MDC95% varied from 0.82 to 1.08 kgf/cm2 and MDC% from 14.29% to 19.39%. CONCLUSION: Relative reliability was good or excellent. This study presents absolute reliability values that could be used as a reference in the clinical use of PPT.