Scapular stabilization exercise training improves treatment effectiveness on shoulder pain, scapular dyskinesis, muscle strength, and function in patients with subacromial pain syndrome: A randomized controlled trial.

INTRODUCTION: Subacromial pain syndrome (SPS) is a common cause of shoulder pain, and is associated with functional limitation, workdays lost, disability, and poor quality of life. PURPOSE: Our purpose was to investigate the effects of scapular stabilization exercises in patients with SPS. METHOD: Sixty-four patients with SPS who also exhibit observable scapular dyskinesis defined by the scapular dyskinesis test were recruited and randomized to scapular stabilization exercise training group or to control group. All participants received the same rehabilitation protocol including glenohumeral and scapular mobilization, pendulum exercises, shoulder stretching, range of motion exercises, strengthening, and proprioceptive exercises. Patients in the scapular stabilization exercise training group performed additional scapular stabilization exercises. The presence of scapular dyskinesis, shoulder pain severity, motion, muscle strength, scapular upward rotation, and shoulder disability were assessed before and after the four-week rehabilitation program. RESULTS: The scapular stabilization exercise training group had better improvement in scapular dyskinesis, pain, muscle strength, and shoulder disability compared to the control group (p < 0.05). However, there was no statistically significant time-group interaction regarding shoulder motion and scapular upward rotation (p > 0.05). CONCLUSIONS: Scapular stabilization exercises added to the shoulder mobilization, stretching, and strengthening are effective in improving scapular dyskinesis, reducing pain, increasing muscle strength and shoulder function in patients with SPS accompanied by scapular dyskinesis.

Effects of Eccentric Versus Concentric Strengthening in Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial.

BACKGROUND: Subacromial pain syndrome (SPS) is the most common cause of shoulder pain. Therapeutic exercise is the first-line treatment for SPS; however, the ideal exercise type remains unclear. Here, we compared the effects of eccentric and concentric strengthening in patients with SPS. HYPOTHESIS: Adding isolated eccentric strengthening to a multimodal physiotherapy program (MPP) would lead to greater improvements in outcomes compared with either MPP alone or adding isolated concentric strengthening to the MPP. STUDY DESIGN: Randomized controlled trial. LEVEL OF EVIDENCE: Level 2. METHODS: A total of 45 patients were randomized to eccentric strengthening (ESG), concentric strengthening (CSG), and control (CG) groups; all groups received the MPP. The strengthening groups also performed group-specific strengthening. Shoulder pain, abduction and external rotation (ER) strength, joint position sense (JPS), the Constant-Murley Score (CMS), and the Disabilities of the Arm, Shoulder and Hand score were collected at baseline, after 12 weeks of treatment, and at week 24. RESULTS: For CMS, ESG exhibited a greater, but not clinically meaningful, improvement than CSG and CG (P < 0.05). Eccentric abduction strength increased in ESG compared with CG. From baseline to follow-up, abduction strength increased in ESG compared with CSG and CG. Eccentric abduction strength increased in CSG compared with CG. JPS at abduction improved in the ESG compared with CG. Other between-group comparisons were not significant (P > 0.05). CONCLUSION: In SPS, eccentric strengthening provided added benefits, improving shoulder abduction strength and JPS at abduction, and was superior to concentric strengthening for improving shoulder abduction strength. Neither strengthening approach had an additional effect on shoulder function, pain, ER strength, or rotational JPS. CLINICAL RELEVANCE: Clinicians could implement eccentric strengthening as a motor control retraining for strength and proprioception gain rather than for pain relief and reducing disability.

Effects of manual therapy in addition to stretching and strengthening exercises to improve scapular range of motion, functional capacity and pain in patients with shoulder impingement syndrome: a randomized controlled trial.

BACKGROUND: The current study aimed to measure the effectiveness of manual therapy in addition to stretching and strengthening exercises in patients with shoulder impingement syndrome to improve functional capacity, pain, and scapular range of motion. METHODS: This is a single-blinded randomized controlled trial. Thirty-two participants with chronic shoulder impingement syndrome were randomly allocated into two groups. Both groups received stretching and strengthening exercises while the treatment group was given manual therapy additionally. Treatment was started after the patients signed an informed consent form. The data were collected from the University of Lahore Teaching Hospital between March 2022 and December 2022. The study aimed to measure pain using a numeric pain rating scale, functional capacity was assessed by the disability of the arm and shoulder, and goniometry was used for scapular ranges, i.e., scapular protraction and upward rotation. Each treatment session lasted 45 min for the treatment group and 30 min for the control group. The treatment comprised five days a week for four weeks, after which post-intervention measurements were taken. RESULTS: Thirty-two participants were enrolled in the study, and 16 were divided into each group. The mean age of the participants in the treatment group was 38.19 ± 7.31 while the comparison group was 35.69 ± 7.98. An independent sample t-test was run on the data with a 95% confidence interval, statistically significant results were obtained, i.e., p-value < 0.05, post-intervention in the treatment group. Both groups have significantly improved functional capacity and scapular protraction (p < 0.005), however, pain and scapular upward rotation were not found statistically significant in the control group (p > 0.05). CONCLUSION: The addition of manual therapy along with exercise therapy showed clinical and statistical significant results for pain, functional capacity, and scapular range of motion. It demonstrated superior effects than exercise therapy alone for the chronic condition of SIS. TRIAL REGISTRATION: The trial was registered in the Iranian Registry of Clinical Trials ( https://www.irct.ir/ ) with the registration number: IRCT20230526058291N1, (Date: 12/08/2023).

Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis.

BACKGROUND: Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions. METHODS: Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed. RESULTS: A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups. CONCLUSION: NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.

Clinical and ultrasound findings of 'swimmer's shoulder' and its association with training history in elite Portuguese swimmers: a cross-sectional study.

OBJECTIVES: To assess the prevalence of shoulder injuries and ultrasound findings in elite Portuguese swimmers and their association with symptoms and personal or training-related factors. METHODS: This cross-sectional study was conducted at the Portuguese Open and Youth Swimming National Championships between 27 and 30th July 2022. Each athlete entered details regarding personal and training history into a questionnaire and underwent a physical and ultrasound shoulder examination. RESULTS: A total of 102 swimmers out of 662 Portuguese athletes were included in the study. Shoulder pain experienced during the previous season was reported by 42% of the athletes. A high prevalence of shoulder structural abnormalities was noted, specifically supraspinatus tendinosis (91%), tears (29%), and subacromial bursitis (29%). Specific training for injury prevention was associated with higher rates of infraspinatus tendinosis (p = 0.047), and supraspinatus tears were linked to greater swimming distances per week (p < 0.001) and practice (p < 0.001), more years of practice (p = 0.018), shoulder pain at the time of evaluation (p = 0.023), a higher number of missed competitions (p = 0.041), and shoulder injections (p = 0.009). Subacromial bursitis was associated with shoulder pain at the time of evaluation (p = 0.002) and during the previous season (p < 0.001), missed competitions (p < 0.001), and requirement for physical therapy (p = 0.006). CONCLUSIONS: A high prevalence of shoulder morphological changes was found in surveyed swimmers and there were several associations with training load, regardless of individual characteristics of each athlete. It is essential to understand the true impact of current injury prevention programs and to develop effective measures to protect swimmers' health.

Effectiveness of Pulse Electromagnetic Field Therapy in Patients With Subacromial Impingement Syndrome: A Double-Blind Randomized Sham Controlled Study.

OBJECTIVES: To evaluate the 3-month effects of pulsed electromagnetic field therapy (PEMF) in the treatment of subacromial impingement syndrome (SIS). DESIGN: Planned analysis of a randomized controlled trial with 4- and 12-week follow-ups. SETTING: Physical medicine and rehabilitation clinic, treatment unit. PARTICIPANTS: Of the 250 individuals screened for eligibility, participants with a diagnosis of SIS (N=80) were randomized to intervention or control groups. INTERVENTION: The first group received PEMF + exercise and the second group received sham PEMF + exercise 5 days a week for a total of 20 sessions. MAIN OUTCOME MEASURES: Visual Analog Scale (VAS), Constant Murley Score (CMS), Shoulder Pain and Disability Index (SPADI), Short Form-36 (SF-36) Quality of Life Questionnaire, and shoulder muscle strength measurement with an isokinetic dynamometer. Evaluations were performed before treatment (T0), after treatment (T1), and 12th week (T2). RESULTS: Evaluation at T1 and T2 showed improvement in most parameters in both groups compared with baseline. In the comparison between the 2 groups at T1 and T2, more improvement was found in the PEMF group in most parameters. CONCLUSIONS: In our study, PEMF was found to be superior to sham PEMF in terms of pain, ROM, functionality, and quality of life at the first and third months.

Manual Therapy and Exercise Have Similar Outcomes to Corticosteroid Injections in the Management of Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-Analysis.

Subacromial pain syndrome (SAPS) is the most frequent diagnosis in patients with shoulder pain presenting with persistent pain and significant functional decline. Although exercise and manual therapy (EMT) and corticosteroid injections provide first-line treatment options, evidence for the best management of SAPS remains inconclusive. We aimed to evaluate the effectiveness of EMT compared with corticosteroid injections on disability, recovery rates, and pain in patients with SAPS through a systematic review and meta-analysis approach. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), ScienceDirect, the Cochrane Library, and grey literature databases were searched. Only randomized controlled trials evaluating the effectiveness of EMT alone or as an additive intervention compared to corticosteroid injections were included. Methodological quality was evaluated with the PEDro score and certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. In total, 8 trials with 946 patients were included. EMT presented no difference in disability compared with corticosteroid injections at very short- (standardized mean difference {SMD}: 0.19; 95%CI: -0.20, 0.58), short- (SMD: -0.16; 95%CI: -0.58, 0.25), mid- (SMD: -0.14; 95%CI: -0.44, 0.16), and long-term (SMD: 0.00; 95%CI: -0.25, 0.25) follow-up. No difference was found between the comparators in self-perceived recovery at very short- (risk ratio: 0.93; 95%CI: 0.71, 1.21) and mid- (risk ratio: 0.98; 95%CI: 0.90, 1.07) follow-up and in pain rating at very short- (SMD: -0.18; 95%CI: -0.73, 0.38), short- (SMD: 0.05; 95%CI: -0.26, 0.37), and long-term (SMD: 0.04; 95%CI: -0.26, 0.34) follow-ups. The addition of corticosteroid injections to EMT provided no better results in shoulder disability compared with EMT (SMD: 0.45; 95%CI: -0.47, 1.37) or corticosteroid injections alone (MD: 2.70; 95%CI: -7.70, 13.10) in the mid-term. Based on very low to moderate certainty of evidence, EMT has similar effects to corticosteroid injections on improving all outcomes in patients with SAPS at all follow-up periods. Based on low certainty of evidence the combination of both interventions does not change the treatment outcome compared with each intervention alone.

MRI is a Reliable Method for Measurement of Critical Shoulder Angle and Acromial Index.

Objective The objectives of this study are to compare absolute values of acromial index (AI) and critical shoulder angle (CSA) obtained in both radiographs and magnetic resonance image (MRI) of the shoulder; and to compare the interobserver and intra-observer agreement for AI and CSA values measured in these image modalities. Methods Patients who had medical indication of investigating shoulders conditions through radiographs and MRI were included. Images were taken to two fellowship-trained shoulder surgeons, which conducted measurements of AI and CSA in radiographs and in MRI. Twelve weeks after the first evaluation, a second evaluation was conducted. Inter- and intra-observer reliability was presented as an Intraclass Correlation Coefficient (ICC) and agreement was classified according to Landis & Koch criteria. The differences between two measurements were evaluated using Bland-Altman plots. Results 134 shoulders in 124 subjects were included. Mean intra-observer ICC for CSA in X-rays and in MRI were 0.936 and 0.940, respectively; for AI, 0.908 and 0.022. Mean inter-observer ICC for CSA were 0.892 and 0.752 in X-rays and MRI respectively; for AI, ICC values were 0.849 and 0.685. All individual analysis reached statistical power ( p < 0.001). Mean difference for AI values measured in X-rays and in MRI was 0.01 and 0.03 for observers 1 and 2, respectively. Mean difference for CSA values obtained in X-rays and MRI was 0.16 and 0.58 for observers 1 and 2, respectively. Conclusion Both MRI and X-rays provided high intra- and interobserver agreement for measurement of AI and CSA. Absolute values found for AI and CSA were highly correlated in both image modalities. These findings suggest that MRI is a suitable method to measure AI and CSA. Level of Evidence II , Diagnostic Study.

[Concordance between ultrasound-arthroscopy of the shoulder in rotator cuff injury]. / Concordancia entre ecografía-artroscopía de hombro en lesión del mango rotador.

Background: Rotator cuff injury occurs over tendons that insert into the humeral tuberosity. Ultrasonography detects the size and extent of tendon tears. Its sensitivity and specificity range from 91-100% and 85-86%, respectively. It has been shown that a trained orthopedic surgeon can perform shoulder ultrasonography for the accurate diagnosis of rotator cuff pathology. Objective: To determine the concordance between ultrasound-arthroscopy of the shoulder in rotator cuff injuries at the Unidad Médica Atención Ambulatoria No. 55 (Ambulatory Care Unit No. 55) in León, Guanajuato, Mexico. Material and methods: Experimental study of a sample of 37 patients with a diagnosis of rotator cuff injury, in whom preoperative ultrasound and later shoulder arthroscopy of the same side were performed. The data were subjected to concordance with Cohen's Kappa Index. Results: There were 37 patients in whom we identified an overall concordance of 81%. Cohen's Kappa index was 0.76, considered a good concordance. Out of the 7 patients without correlation, in 1 patient the ultrasound showed partial rupture and by arthroscopy showed complete rupture of the supraspinatus. In 2 patients ultrasonography showed complete rotator cuff tear; during arthroscopy, both showed massive rotator cuff tear. Conclusions: Preoperative shoulder ultrasonography performed by traumatology presents a good concordance in the diagnosis of rotator cuff tears confirmed by arthroscopy.

Introducción: la lesión del mango rotador ocurre sobre tendones que se insertan en la tuberosidad humeral. La ecografía detecta el tamaño y la extensión de los desgarros del tendón. Su sensibilidad y especificidad oscila entre 91-100% y 85-86%, respectivamente. Se ha demostrado que un cirujano ortopédico capacitado puede hacer la ecografía del hombro para el diagnóstico preciso de la patología del manguito rotador. Objetivo: determinar la concordancia entre ecografía-artroscopía de hombro en lesiones del mango rotador en la Unidad Médica Atención Ambulatoria No. 55 de León, Guanajuato, México. Material y métodos: estudio experimental de una muestra de 37 pacientes con diagnóstico de lesión del mango rotador, en los que se realizó ecografía preoperatoria y posteriormente artroscopía de hombro del mismo lado. Los datos se sometieron a concordancia con el Índice de Kappa de Cohen. Resultados: fueron 37 pacientes en los que se identificó la concordancia global de 81%. El Índice de Kappa de Cohen fue de 0.76, considerada una buena concordancia. De los 7 pacientes sin correlación, en un paciente la ecografía mostró rotura parcial y por artroscopía mostró rotura completa del supraespinoso. En 2 pacientes la ecografía mostró rotura completa de mango rotador; durante la artroscopía, ambos mostraron rotura masiva del mango rotador. Conclusiones: la ecografía preoperatoria de hombro realizada por traumatología presenta una buena concordancia en el diagnóstico de roturas del mango rotador confirmadas por artroscopía.

Glenohumeral versus subacromial steroid injections for impingement syndrome with mild stiffness: a randomized controlled trial.

BACKGROUND: The subacromial (SA) space is a commonly used injection site for treatment of impingement syndrome. For shoulder stiffness, glenohumeral (GH) injections are commonly performed. However, in cases of impingement syndrome with mild shoulder stiffness, the optimal site of steroid injection has yet to be identified. METHODS: This prospective, randomized study compared the short-term outcomes of ultrasound-guided GH and SA steroid injections in patients who were diagnosed with impingement syndrome and mild stiffness. Each group comprised 24 patients who received either a GH or SA injection of 40 mg of triamcinolone. Range of motion and clinical scores were assessed before and 3, 7, and 13 weeks after the injection. RESULTS: GH and SA injections significantly improved the range of motion and clinical scores after 13 weeks of follow-up. Notably, targeting the GH joint resulted in an earlier gain of forward elevation, external rotation, and internal rotation in 3 weeks (P<0.001, P=0.012, and P=0.002, respectively) and of internal rotation and a Constant-Murley score in 7 weeks (P<0.001 and P=0.046). Subsequent measurements were similar between the groups and showed a steady improvement in all ranges of motion and clinical scores. CONCLUSIONS: GH injections may be more favorable than SA injections for treatment of impingement syndrome with mild stiffness, especially in improving the range of motion in the early period. However, the procedures showed similar outcomes after 3 months. Level of evidence: I.

Physical and well-being effect of scapular kinesio taping combined with conventional physiotherapy in shoulder impingement syndrome: A randomized controlled study.

BACKGROUND: Kinesio taping (KT) is one of the treatment methods used on patients with shoulder impingement syndrome (SIS). There are different results regarding its effectiveness in the literature. OBJECTIVE: To investigate the effects of scapular KT combined with a conventional physiotherapy program on scapular dyskinesia, shoulder pain, upper extremity function, and well-being in patients with SIS. METHODS: The study was conducted with 60 outpatients diagnosed with SIS, aged 40-65 years. The patients were divided into two groups: KT [conventional physiotherapy program + scapular KT (targets scapular retraction and is applied along the inferior-medial edge of the scapula, starting from the processus coracoids), n= 30] and control [conventional physiotherapy program, n= 30]. In before- and after-treatment evaluations, the Lateral Scapular Slide Test (LSST) for scapular dyskinesia, a Visual Analogue Scale (VAS) for shoulder pain, and the Disabilities of the Arm, Shoulder, and Hand (DASH) for upper extremity function were used. In addition, at the end of treatment, a Kinesio taping Satisfaction Survey, created by the researchers, was filled out by the KT group for the assessment of well-being. RESULTS: The interaction effect of Group*Time was not statistically significant in all outcome measures (p> 0.05). However, the main effect of both group and time was statistically significant in the DASH-Function/Symptom, VAS-Rest, VAS-Activity, and VAS-Night (p< 0.05). Moreover, only the main effect of time was statistically significant in LSST-1 and LSST-3 (p< 0.05). In the KT group, the satisfaction level was 8.50 ± 1.69 and the recommendation level was 8.72 ± 1.81. CONCLUSION: Both conventional physiotherapy programs and additional scapular KT improved scapular dyskinesia, reduced pain, and increased the upper extremity function. Adding scapular KT to treatment did not change the results, but it had positive psychological effects and yielded a high satisfaction rate.

MRI is a Reliable Method for Measurement of Critical Shoulder Angle and Acromial Index / A ressonância magnética é um método confiável para medida do ângulo crítico do ombro e do índice acromial

Abstract Objective The objectives of this study are to compare absolute values of acromial index (AI) and critical shoulder angle (CSA) obtained in both radiographs and magnetic resonance image (MRI) of the shoulder; and to compare the interobserver and intra-observer agreement for AI and CSA values measured in these image modalities. Methods Patients who had medical indication of investigating shoulders conditions through radiographs and MRI were included. Images were taken to two fellowship-trained shoulder surgeons, which conducted measurements of AI and CSA in radiographs and in MRI. Twelve weeks after the first evaluation, a second evaluation was conducted. Inter- and intra-observer reliability was presented as an Intraclass Correlation Coefficient (ICC) and agreement was classified according to Landis & Koch criteria. The differences between two measurements were evaluated using Bland-Altman plots. Results 134 shoulders in 124 subjects were included. Mean intra-observer ICC for CSA in X-rays and in MRI were 0.936 and 0.940, respectively; for AI, 0.908 and 0.022. Mean inter-observer ICC for CSA were 0.892 and 0.752 in X-rays and MRI respectively; for AI, ICC values were 0.849 and 0.685. All individual analysis reached statistical power (p< 0.001). Mean difference for AI values measured in X-rays and in MRI was 0.01 and 0.03 for observers 1 and 2, respectively. Mean difference for CSA values obtained in X-rays and MRI was 0.16 and 0.58 for observers 1 and 2, respectively. Conclusion Both MRI and X-rays provided high intra- and interobserver agreement for measurement of AI and CSA. Absolute values found for AI and CSA were highly correlated in both image modalities. These findings suggest that MRI is a suitable method to measure AI and CSA. Level of Evidence II, Diagnostic Study.

Resumo Objetivo Os objetivos deste estudo foram comparar os valores absolutos do índice acromial (IA) e do ângulo crítico do ombro (ACO) obtidos em radiografias e ressonâncias magnéticas (RM) do ombro e comparar a concordância interobservador e intraobservador dos valores de IA e ACO medidos nessas modalidades de imagem. Métodos Pacientes com indicação médica de investigação de doenças dos ombros por meio de radiografias e RM foram incluídos no estudo. As imagens foram levadas para dois cirurgiões de ombro treinados que realizaram medidas de IA e ACO em radiografias e RM. Doze semanas após a primeira avaliação, uma segunda avaliação foi realizada. A confiabilidade inter e intraobservador foi apresentada como coeficiente de correlação intraclasse (CCI) e a concordância foi classificada segundo os critérios de Landis e Koch. As diferenças entre duas medidas foram avaliadas por meio de gráficos de Bland-Altman. Resultados Cento e trinta e quatro ombros de 124 indivíduos foram incluídos no estudo. O CCI intraobservador médio para ACO em radiografias e RM foi 0,936 e 0,940, respectivamente; para IA, foi 0,908 e 0,022. O CCI interobservador médio para ACO foi 0,892 e 0,752 em radiografias e RM, respectivamente; para IA, os valores de CCI foram 0,849 e 0,685. Todas as análises individuais apresentaram poder estatístico (p < 0,001). A diferença média dos valores de IA em radiografias e RM foi 0,01 e 0,03 para os observadores 1 e 2, respectivamente. A diferença média dos valores de ACO em radiografias e RM foi 0,16 e 0,58 para os observadores 1 e 2, respectivamente. Conclusão Tanto a RM quanto as radiografias tiveram alta concordância intra e interobservador para medida de IA e ACO. Os valores absolutos de IA e ACO foram altamente correlacionados em ambas as modalidades de imagem. Esses achados sugerem que a RM é um método adequado para determinação de IA e ACO. Nível de Evidência II, Estudo Diagnóstico.

[Evidence-based versus expertise-based medicine in orthopedic and trauma surgery : There is nothing more practical than a good theory]. / Evidenzbasierte Medizin versus Erfahrungsmedizin in Orthopädie und Unfallchirurgie : Es gibt nichts Praktischeres als eine gute Theorie.

About a quarter of a century after the introduction of the concept and principles of evidence-based medicine (EbM), some healthcare providers are still adamant that these are incompatible with knowledge gained through experience. Across the surgical disciplines, it is often argued EbM underestimates or neglects the importance of intuition and surgical skills. To put it bluntly, these assumptions are wrong and often characterized by a misunderstanding of the methodology of EbM. Even the best controlled trial cannot be properly interpreted or implemented without clinical reasoning; furthermore, clinicians of all disciplines are obligated to provide care according to the current state of scientific knowledge. In an era of revolutionary biomedical developments, exponential increase of research but incremental innovations, they must become familiar with pragmatic tools to appraise the validity and relevance of clinical study results, and to decide whether there is a need to adapt current beliefs and practices based on the new information. We herein use the recent example of a new medical device for the surgical treatment of rotator cuff tears and subacromial impingement syndrome to illustrate how important it is to interpret data in the context of a precise, answerable question and to combine clinical expertise with methodological principles offered by EbM.

Injection of autologous conditioned plasma combined with a collagen scaffold may improve the clinical outcome in shoulder impingement syndrome: a prospective study.

BACKGROUND: Shoulder impingement syndrome (SIS) is one of the most common diseases of the shoulder and can be addressed with various therapeutic concepts. Orthobiological agents such as platelet rich plasma with a low side effect rate gain importance in the conservative treatment of SIS. Currently, the knowledge about success rate influencing factors, such as the growth factors (GF) concentration or acromion type, is limited. The aim of this study was to analyze the clinical outcome in the therapy of external SIS using autologous conditioned plasma combined with recombinant human collagen scaffold (ACP/STR) injection in comparison with a corticosteroid-local anesthetic (CSA) injection. Additionally, the influence of potential limiting factors such as GF concentration, age and acromial morphology was proved. MATERIALS AND METHODS: This prospective pseudo-randomized trial recruited 58 patients with external SIS who received an ultrasound-guided subacromial injection either an ACP/STR or a CSA followed by physical therapy. Follow-up (FU) was performed at 6 weeks, 3 and 6 months. The outcome was assessed with Constant-Murley score, disability of arm, shoulder and hand score and simple shoulder test. The concentration of GF was measured using ELISA. RESULTS: During the FU, the improvement of outcome measures was observed with no differences between both groups. Shoulder force was significantly increased in the ACP/STR group (p < 0.01). We found no correlation between the amount of GF and age or gender in the ACP/STR patients. An acromion Bigliani type III predisposes for therapy failure (p < 0.001, OR = 56) in both treatment groups. CONCLUSIONS: Patients with SIS benefit regarding to PROMs after both ACP/STR and CSA injection and physical therapy. Patients who received ACP/STR obtained superior improvement in force. The quantity of GF did not vary depending on the age, so that ACP/STR can be a treatment option for SIS in elderly patients with multimorbidity. The presence of an acromion type III seems to be a predictive factor for limited effectivity of injections in the clinical management of SIS.

Effectiveness of scapular mobilization in people with subacromial impingement syndrome: A randomized controlled trial.

BACKGROUND: Scapular mobilization is a manual therapy technique widely used in the management of musculoskeletal disorders of the shoulder. OBJECTIVE: To determine the effects of scapular mobilization in addition to an exercise program in people with subacromial impingement syndrome (SIS). METHODS: Seventy-two adults with SIS were randomly allocated to 1 of 2 groups. The control group (n=36) participated in a 6-week exercise program, and the intervention group (n = 36) participated in the same exercise program plus passive manual scapular mobilization. Both groups were assessed at baseline and 6 weeks (end of treatment). The primary outcome measure was upper limb function assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Secondary outcome measures were the Constant-Murley questionnaire, pain (visual analog scale [VAS]), and scapular upward rotation. RESULTS: All participants completed the trial. The between-group difference in DASH was -1.1 points (Cohen d = 0.05; p = 0.911), Constant-Murley 2.1 points (Cohen d = 0.08; p = 0.841), VAS rating of pain at rest -0.1 cm (Cohen d = 0.05; p = 0.684), and VAS rating of pain during movement -0.2 cm (Cohen d = 0.09; p = 0.764); scapular upward rotation at rest (arm by the side) was 0.6° (Cohen d = 0.09; p = 0.237), at 45° shoulder abduction was 0.8° (Cohen d = 0.13; p = 0.096), at 90° was 0.1° (Cohen d = 0.04; p = 0.783), and at 135° was 0.1° (Cohen d = 0.07; p = 0.886). Most differences were in favor of the intervention group; however, the effect sizes were weak and not statistically significant. CONCLUSIONS: In the short-term, the addition of scapular mobilization did not provide significant clinical benefits in terms of function, pain or scapular motion in participants with SIS. TRIAL REGISTRATION: Brazilian registry of clinical trials UTN number U1111-1226-2081. Registered February 25, 2019.

Identifying Conservative Interventions for Individuals with Subacromial Pain Syndrome Prior to Undergoing a Subacromial Decompression: A Scoping Review.

Background: Subacromial decompression (SAD) surgery remains a common treatment for individuals suffering from subacromial pain syndrome (SAPS), despite numerous studies indicating that SAD provides no benefit over conservative care. Surgical protocols typically recommend surgery only after exhausting conservative measures; however, there is no consensus in the published literature detailing what constitutes conservative care "best practice" before undergoing surgery. Purpose: To describe conservative interventions received by individuals with SAPS prior to undergoing a SAD. Study Design: Scoping review. Methods: An electronic search using MEDLINE, CINAHL, PubMed, and Scopus databases was conducted. Peer-reviewed randomized controlled control trials and cohort studies published between January 2000 and February 2022 that included subjects diagnosed with SAPS who progressed to receive a SAD were eligible. Subjects who received previous or concurrent rotator cuff repair with SAPS were excluded. Conservative interventions and treatment details that subjects received prior to undergoing a SAD were extracted. Results: Forty-seven studies were included after screening 1,426 studies. Thirty-six studies (76.6%) provided physical therapy (PT) services, and six studies (12.8%) included only a home exercise program. Twelve studies (25.5%) specifically detailed the delivered PT services, and 20 studies (42.6%) stated who provided the PT interventions. Subacromial injections (SI) (55.3%, n=26) and non-steroidal anti-inflammatories (NSAIDs) (31.9%, n=15) were the next most frequently delivered interventions. Thirteen studies (27.7%) included combined PT and SI. The duration of conservative care varied from 1.5 months to 16 months. Conclusion: Conservative care that individuals with SAPS receive to prevent advancement to SAD appears inadequate based on the literature. Interventions, such as PT, SI, and NSAIDs, are either underreported or not offered to individuals with SAP prior to advancing to surgery. Many questions regarding optimal conservative management for SAPS persists. Level of Evidence: n/a.

Effects of thoracic spinal thrust manipulation for the management of shoulder impingement syndrome: Systematic review.

OBJECTIVE: To determine the effectiveness of thoracic spinal thrust manipulation for shoulder impingement syndrome in the improvement of pain, range of motion and functional outcomes. METHODS: The systematic review was conducted by 2 researchers independently using search strategy developed for different databases, including Cochrane Central register of control trials, PubMed, Pedro and MEDLINE, for relevant articles published between 2008 and 2020. The search strategy was designed for each database by combining the key terms and Boolean operators related to the review's objective. RESULTS: Of the 312 studies identified, 14(4.5%) were included. Of them, 4(28.6%) were in favour of thoracic thrust manipulation, 8(57.2%) did not support thoracic thrust manipulation as the sole treatment and 2(14.3%) favoured thoracic thrust manipulation along with exercises. CONCLUSIONS: Studies indicated immediate improvement in range of motion as well as pain after thrust manipulation, but others reported no such clinical difference. Manipulation should be combined with other exercise therapy to ensure some clinical improvement.

Peripheral sensitization is demonstrated in subacromial pain syndrome, with central sensitization found only in females.

The objective of this study was to explore whether hypersensitivity in patients with subacromial pain syndrome (SPS) manifests purely as localized peripheral sensitization or central sensitization, is influenced by the presence of subacromial pain, and presents similarly in male and female patients. Pressure pain threshold was assessed in both a patient cohort with unilateral SPS and an uninjured matched control group. Control subjects were assessed twice, with a 15 minute rest period between testing, while patients were assessed at baseline and after an almost instantaneous reduction in pain arising from an anesthetic injection in patients. Patients received a subacromial injection consisting of both anesthetics (3 cc of 2% lidocaine and 6 cc 0.5% Marcaine with Epinephrine) and a corticosteroid agent (1 cc DepoMedrol). Patients demonstrated hypersensitivity across the involved shoulder only, providing evidence for peripheral sensitization. There were trends for hypersensitivity across remote joints, however when separated by sex, only female patients demonstrated both peripheral and central sensitization. Immediate pain reduction had no influence on hypersensitivity in the short-term. Clinical Significance: Neuropathic components are likely present in some patients with subacromial pain syndrome, and female patients may be particularly at risk for presenting with neuropathic pain. These findings are applicable towards understanding the heterogeneous etiology underlying subacromial pain syndrome and informing clinical management.

Subacromial Motion Metrics in Painful Shoulder Impingement: A Dynamic Quantitative Ultrasonography Analysis.

OBJECTIVES: To explore the subacromial motion metrics in patients with and without subacromial impingement syndrome (SIS) and to investigate whether the abnormality was associated with rotator cuff pathologies. DESIGN: This cross-sectional observational study used dynamic quantitative ultrasonography imaging for shoulder joint assessment. SETTING: Outpatient rehabilitation clinic. PARTICIPANTS: Individuals with SIS on at least 1 shoulder (n=32) and asymptomatic controls (n=32) (N=64). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Frame-by-frame, the humeral greater tuberosity against the lateral edge of the acromion was traced to obtain the minimal vertical acromiohumeral distance (AHD). The rotation angle and radius of the humerus were computed using the least-squares curve fitting method. RESULTS: Approximately two-thirds of the shoulders with SIS did not have any sonographically identifiable rotator cuff pathologies. There was a consistent trend of nonsignificantly increased humeral rotation angles in painful shoulders. The generalized estimating equation demonstrated that the decreased minimal vertical AHD was associated with painful subacromial impingement (ß coefficient: -0.123cm, 95% confidence interval [CI], -0.199 to -0.047). The area under the curve for the minimal vertical AHD to discriminate painful or impinged shoulders ranged from 0.624-0.676. The increased rotation angle (ß coefficient: 10.516°; 95% CI, 3.103-17.929) and decreased rotation radius (ß coefficient: -2.903cm; 95% CI, -5.693 to -0.111) were shown to be significantly related to the presence of supraspinatus tendinopathy. CONCLUSIONS: Shoulders with SIS were characterized by a decreased minimal vertical AHD during dynamic examination. Abnormal subacromial metrics can develop in patients with mild (or no) rotator cuff pathologies. More prospective cohort studies are warranted to investigate the changes in subacromial motion metrics in populations at risk for painful or impinged shoulders.

Efectividad de adicionar elongación de la cápsula posterior a un programa de ejercicios en pacientes con síndrome de pinzamiento subacromial: estudio clínico aleatorizado / Effectiveness of adding posterior capsule stretching after an exercise program in patients with subacromial impingement syndrome: a randomized clinical study

Objetivo: Determinar la efectividad clínica de adicionar el ejercicio de elongación de “estiramiento acostado” a un programa de ejercicios específicos en pacientes con síndrome de pinzamiento subacromial (SPSA). Diseño: Estudio clínico aleatorizado ciego simple. Método: Se reclutaron en forma prospectiva 64 pacientes con diagnóstico clínico e imagenológico de SPSA, quienes fueron asignados a dos grupos al azar. El grupo control (n = 32) recibió un programa de ejercicios de 12 semanas, el grupo de intervención (n = 32) recibió el mismo programa más un ejercicio de elongación de la cápsula posterior. Ambos grupos fueron evaluados al inicio y al finalizar el tratamiento. La medida de resultado primaria fue la función del hombro con el cuestionario Constant-Murley, las medidas de resultado secundarias fueron la función de la extremidad superior con el cuestionario DASH y el dolor en reposo y al movimiento con la escala visual analógica (EVA).Resultados: Todos los pacientes completaron el estudio. Al finalizar el tratamiento el cuestionario Constant-Murley mostró una diferencia de 3 puntos (p = 0.864) y el cuestionario DASH una diferencia fue de 2 puntos (p = 0.941), ambas diferencias son a favor del grupo de intervención, pero no son ni clínica ni estadísticamente significativas. Para la EVA en reposo la diferencia fue de 0,2 cm (p = 0,096) y la EVA al movimiento fue de 0,4 cm (p = 0,378), en ambas la diferencia en la reducción del dolor fue mayor en el grupo control. Conclusión: A corto plazo, adicionar el ejercicio de “estiramiento acostado” no proporciona un beneficio clínico ni estadísticamente significativo con respecto a la mejora funcional o la reducción del dolor en pacientes con SPSA.(AU)

Objective: To determine the clinical effectiveness of adding the exercise of “sleep-stretch” to a specific exercise program in patients with subacromial impingement syndrome (SIS). Design: Randomized controlled trial, single-blinded. Methods: Sixty-four patients with clinical and imagenologic diagnosis of SIS were prospectively recruited, who were randomly allocated to two groups. The control group (n = 32) received a 12-week exercise program, and intervention group (n = 32) received the same program plus stretching of the posterior capsule. Both groups were assessed at baseline and at the end of the treatment. The primary outcome measure was shoulder function assessed with Constant-Murley questionnaire. Secondary outcomes measures were upper limb function assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and pain at rest and movement with visual analog scale (VAS). Results: All patients completed the trial. At the end of the treatment, Constant-Murley questionnaire showed a difference of 3 points (p = 0.864), and the DASH questionnaire a difference was 2 points (p = 0.941), both differences were in favor of the intervention group, but they are neither clinically or statistically significant. For the VAS at rest the difference was 0.2 cm (p = 0.096) and the VAS at movement was 0.4 cm (p = 0.378), both differences in pain reduction was greater in the control group.Conclusion: In the short term, the addition of a “sleep-stretch” exercise does not provide a clinically or statistically significant benefit with respect to functional improvement or pain reduction in patients with SIS.(AU)