Differences in scapular orientation,subacromial space and shoulder pain between the full can and empty can tests

Background

The empty and full can arm positions are used as diagnostic tests and in therapeutic exercise programs for patients with subacromial impingement syndrome. The adverse effects of these arm positions on the rotator cuff have not been fully described. The purpose of this investigation was to compare the acromio-humeral distance, three-dimensional scapular position, and shoulder pain during maximum isometric contractions in the empty and full can arm positions.

Methods

Subjects with subacromial impingement syndrome (n = 28) and a matched control group without shoulder pain (n = 28) participated. Acromio-humeral distance, scapular/clavicular positions and shoulder pain were measured during maximal isometric contractions in each position.

Findings

No difference was found in acromio-humeral distance (P = 0.314) between the arm positions or between the groups (P = 0.598). The empty can position resulted in greater scapular upward rotation (P < 0.001, difference = 4.9°), clavicular elevation (P < 0.001, difference = 2.7°), clavicular protraction (P = 0.001, difference = 2.5°) and less posterior tilt (P < 0.001, difference = 3.8°) than the full can position. No differences in the scapular positions were found between the groups. Positive correlations were seen between the scapular positions in the control and not in the subacromial impingement group.

Interpretation

Our results did not show a difference in acromio-humeral distance between the arm positions or groups, indicating that the kinematic differences between the positions are not associated with altered acromio-humeral distance. The increased pain in the EC position might be due to the lack of an association amongst the scapular positions rather than the deficiency of a single scapular motion.     

The potential role of upper extremity muscle fatigue in the generation of extrinsic subacromial impingement syndrome: a kinematic perspective

Abstract

Background:

Subacromial impingement syndrome (SAIS) of the shoulder has a multi-factorial aetiology which includes both intrinsic and extrinsic mechanisms. Upper extremity muscle fatigue has been proposed as a potential causative factor in extrinsic SAIS development.

Objectives:

This review summarises the current state of knowledge regarding fatigue-induced glenohumeral (GH) and scapulothoracic (ST) kinematic changes as they relate to subacromial space reduction and subsequent SAIS. It specifically addresses evidence for mechanisms including superior humeral head translation and scapular reorientation.

Major findings:

Global upper extremity muscle fatigue elicits GH kinematic changes that increase SAIS risk. Concurrent compensatory ST kinematic alterations, primarily scapular upward rotation (UR), lessen this risk. Additionally, fatiguing protocols aimed to selectively exhaust certain muscles or muscle groups without fatiguing the rotator cuff were unsuccessful, suggesting that rotator cuff fatigue is likely for a wide range of fatiguing upper extremity tasks.

Conclusions:

Despite the compensatory response of scapular reorientation in fatigued conditions, the dimensions of the subacromial space still pose increased risk for SAIS development, and the variability in kinematic responses produces highly differential risk, particularly for those exposed to tasks requiring increased rotator cuff muscle demand.     

肩峰下撞击综合征发病机制、诊断及治疗的研究进展

肩峰下撞击综合征(subacromial impingement syndrome,SAIS)是肩关节病变中较为常见的疾患,对其整体了解仍有所不足.多年来,多种假设提出来描述肩峰下撞击征的发病机制,但尚未找到明确的解释.近年来,否认撞击存在的内源性机制越来越受到大众的认可;多个不同的肩峰下撞击综合征的体格检查特异性较低...     

Physiotherapist survey: Increasing thoracic spine movement within the management of chronic subacromial impingement syndrome

AimsThis study's primary aim is to address two questions. Firstly; what evidence exists regarding the inclusion of increasing thoracic movement within the management of subacromial impingement syndrome SIS?; and secondly, what proportion of Society of Musculoskeletal Medicine (SOMM) physiotherapists use this form of treatment within SIS management?MethodsAn online survey was conducted using a questionnaire incorporating a vignette describing a patient with chronic SIS. The SOMM physiotherapy members were sampled using convenience sampling.FindingsThis study has identified some evidence supporting increasing movement of the thoracic spine in the management of patients with SIS. No study or guideline protocols have been identified that advocate the use of this form of treatment, nor research identified that investigates physiotherapists’ use of this form of treatment within SIS management. Of the 1340 physiotherapists surveyed, 52 responded of which 79% stated that they would use treatment aimed at increasing movement of the thoracic spine within SIS management. Chi Square analysis suggests no significant association between using this treatment and number of years experience (p value = 0.15) or courses attended (p = 0.62).ConclusionsEvidence suggests it is beneficial to include treatment to increase thoracic spine mobility within SIS management. This study highlights the need for the clinician to be aware of the role of the thoracic spine in relation to the biomechanics of the shoulder complex. Of the sample of SOMM physiotherapists obtained, the majority stated that they would use this form of treatment. Further research is recommended.     

肩峰下撞击综合征的经皮超声引导下肩峰下滑囊造影表现

目的 探讨肩峰下撞击综合征（SIS）的经皮超声引导下肩峰下滑囊造影（PUSB）表现。方法 对150例经临床诊断为SIS患者行PUSB检查,动态观察造影剂在滑囊内的弥散情况及是否进入肩袖、关节腔。结果 53例造影剂在滑囊内呈线状均匀分布,诊断为单纯性肩峰下滑囊炎。97例造影剂在滑囊内分布不均匀,诊断为粘连性肩峰下滑囊炎。40例可见造影剂由滑囊进入肩袖肌腱,但未达肱骨头表面;32例可见造影剂由滑囊进入肩袖肌腱,到达肱骨头表面;78例造影剂未进入肩袖肌腱。结论 PUSB可实时动态评估肩峰下滑囊炎、滑囊粘连、肩袖损伤等情况,对SIS的诊断具有较高的应用价值。     

MRI诊断肩峰下撞击综合征

目的 分析MRI征象Ⅲ型肩峰、肱肩间隙狭窄和肩袖撕裂对肩峰下撞击综合征（SAIS）的诊断价值。方法 对 92例肩关节MRI疑诊SAIS患者,以关节镜结果为诊断金标准,比较Ⅲ型肩峰、肱肩间隙狭窄和肩袖撕裂单一征象或联合征象诊断SAIS的效能。结果 Ⅲ型肩峰、肩峰下间隙变窄、肩袖撕裂和联合征象诊断SAIS的敏感度分别为51.06%（24/47）、72.34%（34/47）、80.85%（38/47）和85.11%（40/47）,单一肩袖撕裂诊断敏感度与联合征象比较差异无统计学意义（χ²=0.17,P=0.68）,特异度（64.44%,29/45）低于联合征象（84.44%,38/45）,差异有统计学意义（χ²=7.11,P=0.008）。结论 MRI可显示SAIS肩袖损伤、肩峰形态和最短肱肩间隙狭窄,根据以上三种征象联合诊断SAIS的效能较高。     

肩袖损伤合并肩峰下撞击综合征的MRI表现

目的探讨肩袖损伤合并肩峰下撞击综合征的MRI影像表现。材料与方法对33例X线片无骨折但临床怀疑肩袖损伤或肩峰下撞击综合征的患者,用1.5 T MRI机检查,观察肩袖损伤及肩峰下撞击综合征在MR上的影像特征,分析两者的相关性,并与手术结果对比,计算准确率。结果 33例中肩袖损伤20例(合并肩峰下撞击综合征10例),肩峰下撞击综合征15例(合并肩袖损伤10例)。肩袖损伤和肩峰下撞击综合征术前MR诊断准确率分别约为95.0%、71.3%。结论肩关节MRI扫描对肩袖损伤及肩峰下撞击综合征的诊断有较高的临床应用价值,肩袖损伤者中至少半数合并肩峰下撞击综合征,临床和影像应予重视。     

Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic review

Gebremariam L, Hay EM, Koes BW, Huisstede BM. Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic review.

Objective

To provide an evidence-based overview of the effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome.

Data Sources

The Cochrane Library, PubMed, Embase, PEDro, and CINAHL were searched.

Study Selection

Two reviewers independently selected relevant systematic reviews and randomized controlled trials (RCTs).

Data Extraction

Two reviewers independently extracted data and assessed the methodologic quality.

Data Synthesis

If pooling of data was not possible, a best-evidence synthesis was used to summarize the results.

Results

One review and 5 RCTs reporting on various surgical techniques, and postsurgical interventions were included. Moderate evidence was found in favor of adding platelet-leukocyte gel versus open subacromial decompression. No evidence was found for the superiority of subacromial decompression versus conservative treatment in the short, mid, and long term or in favor of 1 surgical technique when compared with another. Limited evidence was found in favor of early activation after arthroscopic decompression in the short and long term.

Conclusions

This review shows that there is no evidence that surgical treatment is superior to conservative treatment or that1 particular surgical technique is superior to another. Because of possibly lower risks for complications, conservative treatment may be preferred. When choosing for surgery, arthroscopic decompression may be preferred because of the less invasive character of the procedure.     

Interrater and intrarater reliability of the pectoralis minor muscle length measurement in subjects with and without shoulder impingement symptoms

Measuring the pectoralis minor muscle length (PML) is of clinical interest, as a short PML has been associated with a decrease of scapular posterior tilting and shoulder pain. However, as no reliability data are available at present, the objective of this study was to examine the inter- and intrarater reliability of the PML measurement in both subjects with and without shoulder impingement symptoms (SIS). Therefore, two assessors performed the PML measurement (3 times/shoulder) in 25 patients with SIS and 25 pain-free controls. Both assessors were blinded for each other's findings. For reliability testing, intra-class coefficients (ICCs; model 2,1) and standard errors of measurements were calculated. Intrarater reliability analysis resulted with ICCs ranging from 0.87 (Standard error of measurement (SEM) 0.21–0.27%) (symptomatic) to 0.93 (SEM 0.19–0.30%) (asymptomatic) in patients with SIS, representing excellent test-retest agreement. Healthy subjects presented with ICCs ranging from 0.76 (SEM 0.29–0.32%) (dominant side) to 0.87 (SEM 0.21–0.32%) (non-dominant side), representing good test-retest agreement. ICCs and SEMs on the symptomatic and asymptomatic side (0.48 and 0.46%; 0.56 and 0.61%) in SIS patients, and on the two sides (non-dominant; 0.47 and 0.45%, dominant; 0.53 and 0.38% respectively) in healthy subjects showed moderate interrater reliability and low dispersion of the measurement errors. We concluded that the PML measurement has good to excellent intrarater reliability and poor to moderate interrater reliability.     

肩峰下撞击综合征肩峰下滑囊骨形态发生蛋白-2及7表达及意义

目的探讨骨形态发生蛋白-2及7在肩峰下撞击综合征患者肩峰下滑囊中表达及临床意义。方法肩峰下撞击综合征患者12例为观察组,非肩峰下撞击综合征肱骨外科颈骨折10例为对照组,观察组采用肩关节镜微创手术方式取肩峰下滑囊标本,对照组采取开放手术方式取标本,采用ELISA法检测肩峰下滑囊骨形态发生蛋白-2及7含量。结果观察组骨形态发生蛋白-2及7表达水平（760．36士98．61）pg／mL及（620．34±101．43）pg／mL明显高于对照组（230．35±97．30）pg／mL及（320．42±98．51）pg／mL（P％0．05）。结论肩峰下撞击综合征肩峰下滑囊骨形态发生蛋白-2及-7表达水平明显增加,可能与肩峰下骨赘、肩袖退变等肩峰下间隙内病理变化有关。     

Comparison of the effect of two different types of dry-needling techniques on subacromial impingement syndrome

IntroductionInfraspinatus is one of the main muscles that is involved in the subacromial impingement syndrome. Dry needling and routine physical therapy can improve this syndrome. However, the dry needling technique is not well defined.Designrandomized controlled clinical trial, single-blind study.MethodSixty-six patients diagnosed with shoulder impingement syndrome were recruited and randomly divided into three groups.InterventionsIn 1st group; patients received deep dry needling technique in addition to routine physical therapy, in Hong's group; patients received Hong's dry needling technique in addition to routine physiotherapy and in third group; patient just received routine physical therapy.Main outcome measure(s)Before, immediately after and 4 weeks after the intervention, pain, disability and the pressure pain threshold were measured.ResultsThe findings of this study indicated that in DDN group, pain and disability reduction was significantly more than two other groups. Although, the pressure pain tolerance increased in all three groups after treatment, but the increase between groups was not significantly different. All study groups showed reduction in pain, while there was no significant difference between the three groups.ConclusionPain and disability reduction in the DDN group compared to the other two groups may reveal the treatment with deep dry needling technique along with routine physiotherapy is more effective than receiving dry needling with Hong's technique or routine physiotherapy alone. However, there was no significant difference between the three groups in pressure pain tolerance threshold and pain reduction.     

Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study

Objective

To investigate the effectiveness of a physiotherapy programme in patients with subacromial impingement syndrome.

Design

Prospective randomised study.

Setting

Orthopaedic department in a district general hospital.

Participants

Eighty-five patients who had been listed for surgery for subacromial impingement syndrome.

Interventions

Patients were allocated at random into one of two groups. One group containing 45 patients received physiotherapy while the other group containing 40 patients acted as controls.

Outcome measures

All patients entering the study underwent Constant score evaluation prior to being allocated to a group. This was repeated at 6 months, prior to surgical intervention.

Results

Seventy-three patients were able to complete the study. In the physiotherapy group, 11 patients no longer required surgery (26%). In this group, all patients improved their Constant score by a mean of 20 (range 4-45). In the control group, all patients required surgery. The mean improvement in the Constant score for the 31 control patients available for review was 0.65 (range −16 to 14).

Conclusion

All patients in this study improved with physiotherapy. Physiotherapy should be thought of as a first-line management for patients with subacromial impingement syndrome.     

肩峰下撞击综合征超声引导下介入治疗后复发危险因素

目的 探讨肩峰下撞击综合征（SIS）2型超声介入治疗后复发的危险因素。方法 回顾分析71例临床诊断SIS 2型,根据治疗方案分为单纯注射组（超声引导下肩峰下滑囊注射,n=16）及联合治疗组（超声引导下肩袖肌腱松解术+肩峰下滑囊注射,n=55）,采用Logistic多因素回归分析影响治疗后复发的因素。结果 联合治疗组治疗后1、3、6个月复发率明显低于单纯注射组（P均<0.001）。多因素回归分析显示,年龄、性别、SIS 2型病程均与复发无关,而治疗方法是治疗后复发的独立危险因素。结论 采用超声引导下肩袖肌腱松解术+肩峰下滑囊注射治疗SIS 2型患者可降低治疗后复发风险。     

Dry needling in addition to standard physical therapy treatment for sub-acromial pain syndrome: a randomized controlled trial protocol

BackgroundTrigger point dry needling interventions are utilized by physical therapists to manage shoulder pain. Observational studies have shown positive short-term outcomes in patients with subacromial pain syndrome receiving trigger point dry needling. However, little research has been done to evaluate the long-term effectiveness of trigger point dry needling specifically as it compares to other commonly utilized interventions such as exercise and manual therapy. The purpose of this study is to assess the additive short and long-term effectiveness of trigger point dry needling to a standard physical therapy approach of manual therapy and exercise for patients with subacromial pain syndrome.MethodsThis multicenter randomized trial with 3 arms was designed following the standard protocol items for randomized interventional trials. Results will be reported consistent with the consolidated standards of reporting trials guidelines. 130 participants will be randomized to receive standard PT interventions alone (manual therapy and exercise), standard PT and trigger point dry needling or standard PT and sham trigger point dry needling. The primary outcome measures will be the Shoulder Pain and Disability Index and Patient Reported Outcomes Measurement Information Systems (PROMIS-57) scores collected at baseline, 6-weeks, 6-months and one year. Healthcare utilization will be collected for 12 months following enrollment and groups analyzed for differences.DiscussionIt is not known if trigger point dry needling provides long-term benefit for individuals with subacromial pain syndrome. This study will help determine if this intervention provides additive benefits over those observed with the commonly applied interventions of exercise and manual therapy.Trial registrationIdentifier: NCT03442894 (https://clinicaltrials.gov/ct2/show/NCT03442894) on 22 February 2018.     

Kinematic patterns in normal and degenerative shoulders. Part II: Review of 3-D scapular kinematic patterns in patients with shoulder pain,and clinical implications

Background

The global range of motion of the arm is the result of a coordinated motion of the shoulder complex including glenohumeral (GH), scapulothoracic, sternoclavicular and acromioclavicular joints.

Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial

Hong JY, Yoon S-H, Moon DJ, Kwack K-S, Joen B, Lee HY. Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial.

Objective

To determine whether subacromial injection with high-dose corticosteroid in patients with periarticular shoulder disorders is better than low-dose corticosteroid or placebo in improving pain, function, and active range of motion (AROM).

Design

Multicenter, randomized, triple-blind, placebo-controlled trial.

Setting

Primary (n=2) and university-affiliated (n=1) tertiary-care hospitals.

Participants

Volunteers (N=79) with periarticular shoulder disorders with at least 1 month's duration of pain.

Intervention

Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone acetonide, 40 or 20mg, or placebo. After a single injection, participants were followed up for 8 weeks.

Main Outcome Measures

Visual analog scale (VAS) of average shoulder pain level during the past 1 week, Shoulder Disability Questionnaire (SDQ), and angles of shoulder AROM (including flexion, abduction, external rotation, internal rotation) pre- and posttreatment at weeks 2, 4, and 8.

Results

There were no significant differences among the 3 groups (triamcinolone acetonide, 40mg, group 1, n=27; triamcinolone acetonide, 20mg, group 2, n=25; placebo, group 3, n=27) in terms of demographic and clinical characteristics at baseline. (1) Within-group comparison: VAS score, SDQ score, and AROM for groups 1 and 2 significantly improved at weeks 2, 4, and 8 (P<.0167). However, there was no difference in VAS score, SDQ score, and AROM scores for group 3. (2) Between-group comparison: significant differences in VAS score, SDQ score, and abduction, external rotation, and internal rotation of AROM were shown between groups 1 and 2 and group 3 at weeks 2, 4, and 8 (P<.05).

Conclusions

This was the first study to assess the efficacy of corticosteroid according to 2 different doses, which are the most widely used in subacromial injection for participants with periarticular shoulder disorders. This study showed no significant differences between the high- (triamcinolone acetonide, 40mg) and low-dose (20mg) corticosteroid groups, indicating preferred use of a low dose at the initial stage.     

脑卒中患者躯干上部异常姿势与肩峰撞击综合征的相关性分析

目的 脑卒中患者常合并头前倾和胸椎后凸等异常姿势,通过颅颈角和上胸椎角测量,观察其与肩痛是否有相关性。 方法 将102例脑卒中患者分为肩痛组和对照组,肩痛组为脑卒中合并有肩峰撞击综合征且有肩痛症状的患者,对照组为物理检查阴性且无肩痛的脑卒中患者。通过坐位下矢状位头颈部及上胸部照片,分别进行颅颈角和上胸椎角测量,比较两组之间数据是否具有统计学意义。 结果 肩痛组患者颅颈角较对照组小,上胸椎角较对照组大,差异均有统计学意义（P<0.05）。经Speraman相关性分析,颅颈角与肩痛呈负相关（r=-0.29,P=0.04）,上胸椎角与肩痛呈正相关（r=0.58,P<0.01）。 结论 颅颈角及上胸椎角度可作为脑卒中后肩峰撞击综合征的一个预测因子,脑卒中患者合并有头前倾及胸椎后凸时应积极进行康复治疗。