Tuberoplasty reduces resistance force in dynamic shoulder abduction for irreparable rotator cuff tears: a cadaveric biomechanical study.

BACKGROUND: Arthroscopic tuberoplasty is an optional technique for managing irreparable rotator cuff tears. However, there is a lack of studies investigating the resistance force during shoulder abduction in cases of irreparable rotator cuff tears and tuberoplasty. HYPOTHESES: In shoulders with irreparable rotator cuff tears, impingement between the greater tuberosity (GT) and acromion increases the resistance force during dynamic shoulder abduction. Tuberoplasty is hypothesized to reduce this resistance force by mitigating impingement. STUDY DESIGN: Controlled laboratory study. METHODS: Eight cadaveric shoulders, with a mean age of 67.75 years (range, 63-72 years), were utilized. The testing sequence included intact rotator cuff condition, irreparable rotator cuff tears (IRCTs), burnishing tuberoplasty, and prosthesis tuberoplasty. Burnishing tuberoplasty refers to the process wherein osteophytes on the GT are removed using a bur, and the GT is subsequently trimmed to create a rounded surface that maintains continuity with the humeral head. Deltoid forces and actuator distances were recorded. The relationship between deltoid forces and actuator distance was graphically represented in an ascending curve. Data were collected at five points within each motion cycle, corresponding to actuator distances of 20 mm, 30 mm, 40 mm, 50 mm, and 60 mm. RESULTS: In the intact rotator cuff condition, resistance forces at the five points were 34.25 ± 7.73 N, 53.75 ± 7.44 N, 82.50 ± 14.88 N, 136.25 ± 30.21 N, and 203.75 ± 30.68 N. In the IRCT testing cycle, resistance forces were 46.13 ± 7.72 N, 63.75 ± 10.61 N, 101.25 ± 9.91 N, 152.5 ± 21.21 N, and 231.25 ± 40.16 N. Burnishing tuberoplasty resulted in resistance forces of 32.25 ± 3.54 N, 51.25 ± 3.54 N, 75.00 ± 10.69 N, 115.00 ± 10.69 N, and 183.75 ± 25.04 N. Prosthesis tuberoplasty showed resistance forces of 29.88 ± 1.55 N, 49.88 ± 1.36 N, 73.75 ± 7.44 N, 112.50 ± 7.07 N, and 182.50 ± 19.09 N. Both forms of tuberoplasty significantly reduced resistance force compared to IRCTs. Prosthesis tuberoplasty further decreased resistance force due to a smooth surface, although the difference was not significant compared to burnishing tuberoplasty. CONCLUSION: Tuberoplasty effectively reduces resistance force during dynamic shoulder abduction in irreparable rotator cuff tears. Prosthesis tuberoplasty does not offer a significant advantage over burnishing tuberoplasty in reducing resistance force. CLINICAL RELEVANCE: Tuberoplasty has the potential to decrease impingement, subsequently reducing resistance force during dynamic shoulder abduction, which may be beneficial in addressing conditions like pseudoparalysis.

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.

Health Care Utilization for Common Shoulder Disorders: Analysis of the 2010-2019 National Patient Sample Data from the Health Insurance Review and Assessment Service in Korea.

Background and Objective: The aim of this study was to analyze trends in surgical and non-surgical service utilization for common shoulder disorders in Korea from 2010 to 2019. Methods and Materials: This retrospective, cross-sectional, descriptive study utilized National Patient Sample data from the Health Insurance and Review Assessment Service (HIRA) of Korea. These data constitute a 2% sample out of the entire Korean population and include data for a variety of parameters instrumental for health care research. Patients with at least one medical service use for rotator cuff syndrome or tear, impingement syndrome, or adhesive capsulitis between January 2010 and December 2019 were included. Trends in healthcare utilization by disorder type, patient demographics, seasonal service use, and treatment details were examined. Results: There was an upward trend in the total number of patients and costs for shoulder disorders, from 35,798 patients and USD 5,485,196 in 2010 to 42,558 and USD 11,522,543 in 2019, respectively. The number of patients aged ≥60 and hospital visits increased. March had the highest number of claims. Physical therapy was the most common non-surgical procedure, while nerve block claims more than doubled. Opioid prescription rates also tripled. Surgical treatments were dominated by shoulder rotator cuff repair and acromioplasty. Conclusions: There was a significant increase in healthcare utilization for shoulder disorders, marked by rising costs and patient numbers. The use of nerve blocks and opioids notably increased. These data are valuable for clinicians, researchers, and policymakers.

Treatment of shoulder impingement syndrome: a survey of physical therapists in Saudi Arabia.

OBJECTIVE: Shoulder impingement syndrome (SIS) is one of the most frequent causes of shoulder pain. Evidence supported the use of conservative treatment for SIS. Clinical practice guidelines (CPGs) indicated that physical therapy interventions, including therapeutic exercises, manual therapy, patient education, and advice, were recommended for the treatment of SIS. This study's purpose was to investigate physical therapists' adherence to the CPGs for treating SIS. SUBJECTS AND METHODS: Physical therapists in Saudi Arabia were invited to participate in an online survey via the Saudi Physical Therapy Association between May and December 2022. The developed online survey consisted of 36 questions, divided into five sections: eligibility, demographics, clinical practice regarding the treatment of SIS, barriers, and facilitators for the use of CPGs. Descriptive and logistic regression analysis were employed to analyze study data. RESULTS: A total of 313 physical therapists completed the entire survey. In general, physical therapists were aligned with CPGs. Physical therapists advised their patients, utilized therapeutic exercises and manual therapy techniques, and used electrotherapy modalities despite being not recommended. Key challenges indicated by physical therapists for the use of CPGs include low patient adherence to therapists' instructions, lack of adequate knowledge, and limited clinical time. CONCLUSIONS: Overall, physical therapists in Saudi Arabia followed the CPGs for treating SIS. Therapeutic exercises combined with manual therapy were the most common treatment options. However, further research should consider exploring adherence to such guidelines over time.

Surgeon Factors and Trends Associated With the Use of Subacromial Decompression at the Time of Rotator Cuff Repair.

PURPOSE: Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use. METHODS: Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability. RESULTS: During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio = 3.04). CONCLUSIONS: Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use. CLINICAL RELEVANCE: These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.

Can coracoacromial ligament degeneration be evaluated with preoperative MRI?

BACKGROUND: Subacromial impingement syndrome is one of the most common causes of painful shoulder in the middle-aged and elderly population. Coracoacromial ligament (CAL) degeneration is a well-known indicator for subacromial impingement. PURPOSE: To examine the relationship between CAL thickness on preoperative magnetic resonance imaging (MRI), arthroscopic CAL degeneration and types of rotator cuff tears. MATERIAL AND METHODS: Video records of patients who underwent arthroscopic shoulder surgery between 2015 and 2021 were retrospectively scanned through the hospital information record system. In total, 560 patients were included in this study. Video records of the surgery were used to evaluate the grade of coracoacromial ligament degeneration and the type of cuff tear. Preoperative MRI was used to measure CAL thickness, acromiohumeral distance, critical shoulder angle, acromial index, and acromion angulation. RESULTS: Significant differences were observed between grades of CAL degeneration in terms of CAL thickness (P < 0.001). As CAL degeneration increases, the mean of CAL thickness decreases. According to the results of post-hoc analysis, the mean CAL thickness of normal patients was significantly higher than those of patients with full-thickness tears (P = 0.024) and massive tears (P <0.001). Patients with articular-side, bursal-side, and full-thickness tears had significantly higher CAL thickness averages than patients with massive tears. CONCLUSION: This study showed that the CAL thickness decreases on MRI as arthroscopic CAL degeneration increases. High-grade CAL degeneration and therefore subacromial impingement syndrome can be predicted by looking at the CAL thickness in MRI, which is a non-invasive method.

Patient Preferences and Their Effects on Rehabilitation Outcomes: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To assess the effect of aligning patients' preferences with specific rehabilitation delivery modes on rehabilitation outcomes. DESIGN: A secondary analysis of a randomized controlled trial. METHODS: The study cohort comprised 208 patients referred for physiotherapy rehabilitation after nonsurgical or surgical interventions for rotator cuff injury, shoulder impingement, or acromioclavicular osteoarthritis. Participants were randomly assigned to 1 of 3 rehabilitation modalities: (1) group-based exercise, (2) individual exercise, or (3) home exercise. In this study, participants were categorized into 2 groups: "matched preference" and "unmatched preference." The primary outcome measure was change in function, measured with the shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH). Secondary outcome measures were change in pain, assessed using the Numeric Rating Scale (NRS), mental well-being measured with the World Health Organization Five Well-Being Index (WHO-5), health-related quality of life assessed using the EuroQol-5 Domain questionnaire (EQ-5D), fear avoidance assessed using the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ), and overall treatment satisfaction. Outcomes were assessed at 3 and 6 months. RESULTS: The primary outcome measure, QuickDASH, showed no significant differences between groups at either 3 months (-3.0 [-8.2 to 2.3]) or 6 months (0.5 [-5.7 to 6.7]). Additionally, no significant differences were observed in the secondary outcome measures. CONCLUSION: Matching patients' preferences for specific rehabilitation delivery modes did not seem to effect rehabilitation outcomes. J Orthop Sports Phys Ther 2024;54(6):1-9. Epub 26 March 2024. doi:10.2519/jospt.2024.12314.

Distribution and analysis of subacromial spurs and the relationship with acromial classification and angle in healthy individuals.

BACKGROUND: Subacromial spurs are considered the one of the pathology underlying shoulder impingement syndrome. Furthermore, few studies have focused on the morphology of the subacromial spurs in normal Chinese people. This study aimed to study the spur distribution and to illustrate the morphology of spurs, which may help guide the extent of acromioplasty. METHODS: A total of 93 normal individuals were enrolled, and both shoulders of all enrolled individuals were analyzed. The subjects were divided and classified into three different groups by ages: group I = 18-40 years, group II = 41-60 years, and group III ≥ 61 years. The osteophyte distribution, osteophyte area, subacromial surface area and osteophyte area/subacromial surface area ratio were measured and illustrated using Mimics and 3-matic software. The shape of the acromion was classified according to the Bigliani and Morrison classification system. The acromial angle was also classified. Then, the relationship between osteophytes, acromial classification and acromial angle was analyzed. RESULTS: Type II (curved shape) was the most common type of acromion, and the hooked shape was a rare form. A significant increase in the left subacromial surface area in males was observed in group III compared with group I (P < 0.001) and group II (P = 0.004). The total spur/subacromial area ratio was significantly higher in group II than I. An obvious increase in the right subacromial area was observed in group III compared with group I (P = 0.004). Furthermore, there was a significant increase in the right spur area (P = 0.021) and total spur/subacromial area ratio (P = 0.006) in females in group II compared with group I. Fewer spurs were observed on the left than on the right side (p = 0.0482). One spur was most common among type II acromions (29/36) (80.56%) on the left side and the right side (34/52, 65.38%). CONCLUSIONS: Spurs osteophytes are mainly distributed with an irregular shape and mostly run through the medial and lateral sides of the subacromial surface in normal subjects. The characteristics of subacromial spurs are so diverse that a surgeon must conduct subacromial decompression completely based on the morphology of individual spurs.

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).

Lifestyle factors and subacromial impingement syndrome of the shoulder: potential associations in finnish participants.

BACKGROUND: Emerging evidence has indicated the associations between subacromial impingement syndrome (SIS) of shoulder and lifestyle factors. However, whether unhealthy lifestyle factors causally increase SIS risk is not determined. This study aims to evaluate whether lifestyle factors are the risk factors of SIS. METHODS: A two-sample Mendelian randomization (MR) study was designed to evaluate the effect of 11 lifestyle factors on SIS risk. Causality was determined using the inverse-variance weighted method to calculate the odds ratio (OR) and establish a 95% confidence interval (CI). Weighted median method, MR-Egger method and MR-PRESSO method were conducted as sensitivity analysis. RESULTS: Four lifestyle factors were identified causally associated with an increased risk of SIS using the IVW method: insomnia (OR: 1.66 95% CI 1.38, 2.00; P = 8.86 × 10- 8), short sleep duration (OR: 1.53 95% CI 1.14, 2.05: P = 0.0043), mobile phone usage (OR: 4.65, 95% CI 1.59, 13.64; P = 0.0051), and heavy manual or physical work (OR: 4.24, 95% CI 2.17, 8.26; P = 2.20 × 10- 5). Another causal but weak association was found between smoking initiation on SIS (OR: 1.17, 95% CI 1.01, 1.35; P = 3.50 × 10- 2). Alcohol, coffee consumption, physical activity, sedentary behavior, sleep duration and computer usage were not found to be causally associated with an increased risk of SIS. Sensitivity analyses indicated that the MR estimates were robust and no heterogeneity and pleiotropy were identified in these MR analyses. CONCLUSION: Sleep habits and shoulder usage were identified as causal factors for SIS. This evidence supports the development of strategies aimed at improving sleep behaviors and optimizing shoulder usage patterns as effective measures to prevent SIS.

Effect of Exergame on Pain, Function, and Quality of Life in Shoulder Impingement Syndrome: A Prospective Randomized Controlled Study.

Objective: This study aimed to investigate the effect of a virtual reality (VR)-mediated gamified rehabilitation program added to a home exercise program on pain, functionality, and quality of life in shoulder impingement syndrome. Methods: Forty-eight participants with shoulder impingement syndrome were included in this prospective, randomized, single-blind study between January and July 2022. The participants were randomized into two groups: the VR group (n = 24) and the control group (n = 24). All participants were given a home exercise program for 3 weeks, with five sessions per week. The participants in the VR group received 15 sessions (45 minutes each session) of a gamified shoulder exercise program with an immersive VR headset, while those in the control group received 15 sessions (45 minutes each session) of supervised therapeutic exercises. The participants were evaluated and compared before and after treatment using the 36-item Short Form Survey (SF-36), range-of-motion (ROM) measurements, the Visual Analog Scale (VAS), and the Shoulder Pain and Disability Scale (SPADI). Results: At the baseline assessment, the two groups were homogenous regarding demographic and clinical parameters. The post-treatment shoulder extension and adduction ROM was significantly greater in the VR group and the post-treatment pain subscales for SPADI and SF-36 were significantly lower in the VR group. Conclusion: In individuals with shoulder impingement syndrome, a VR-mediated gamified exercise program added to a home exercise program increased shoulder ROM and reduced pain scores. Further clinical studies are needed to prove the long-term efficacy of the addition of VR-mediated gamified exercises to the treatment of this condition in clinical settings.

Utilizing Scapula Retraction Exercises With or Without Glenohumeral Rotational Exercises With a Gradual Progression for Subacromial Pain Syndrome.

BACKGROUND: Although exercise interventions are recommended in the management of subacromial pain syndrome (SPS), there is a lack of data regarding the exercises focusing on the principal biomechanical deficiencies that cause symptoms. HYPOTHESIS: Utilizing progressive scapula retraction exercises (SRE) and glenohumeral rotation exercises (GRE) in the scapula stabilization program may lead to more reduction in symptoms and greater acromiohumeral distance (AHD) values. STUDY DESIGN: A double-blind, randomized controlled trial. LEVEL OF EVIDENCE: Level 2. METHODS: A total of 33 patients were assigned randomly to either SRE or SRE+GRE. Both groups received a 12-week supervised rehabilitation program, including manual therapy and exercises (stretching and progressive scapula stabilization exercises). In addition, the SRE+GRE group performed GRE exercises at gradual elevation angles. From 12 to 24 weeks, patients performed exercise programs less frequently (3 times per week). Disability (shoulder pain and disability index [SPADI]), AHD (at 5 active abduction angles), pain intensity (visual analogue scale [VAS]), and patient satisfaction were recorded at baseline, 12 weeks, and 24 weeks. A total of 16 healthy individuals were recruited as a control group to compare AHD values. Data were analyzed using mixed model analyses of variance. RESULTS: A statistically significant group-by-time interaction was found for AHD values (F4,92 = 6.38; P = 0.001), a significant group-by-time interaction for SPADI-disability (F1,33 = 5.148; P = 0.01), SPADI-total (F1,32 = 4.172; P = 0.03), and for pain during activity (F2,62 = 3.204; P = 0.05). However, no significant group-by-time interaction for SPADI-pain (F1,33 = 0.533; P = 0.48), for pain at rest (F1,31 < 0.001; P = 0.99), and at night (F1,32 = 2.166; P = 0.15). Yet, a significant time effect was observed. CONCLUSION: Progressive SRE and GRE in the scapula stabilization program lessens symptoms and improves AHD values in patients with SPS. Moreover, this program could preserve outcomes and further increase AHD when applied less frequently. CLINICAL RELEVANCE: Utilizing SRE and GRE in the scapula stabilization program at gradual shoulder abduction angles provides better rehabilitation outcomes.

The shoulder joint complex in the throwing motion.

The shoulder joint complex in the overhead athlete is organized to effectively transfer the proximally generated forces distally into the arm. The organization also protects the joints and anatomic structures against the repetitive high velocities, large ranges of motions, and compressive, shear, translational, and distraction loads in the overhead motion while placing the hand in the "launch window." Coupling of the movements of the scapula, clavicle, and humerus results in scapulohumeral rhythm (SHR). Effective SHR requires the clavicle and scapula-and, at times, the mechanically linked claviscapular segment-to move the arm into the task-specific position and motion and requires the humerus to move through the ranges of motion to achieve the specific task in the throwing motion. Alterations in SHR can negatively affect effective shoulder joint complex function in the overhead throwing motion and increase injury risk. There are 4 phases of clavicular, scapular, and claviscapular motion that are coupled with arm motion in SHR. The first 3 phases occur in arm elevation motions from 0°-90° and result in the claviscapula and humerus being placed in task-specific positions. The fourth phase is coupling of claviscapular motion with humeral motion to maintain ball-and-socket kinematics throughout the throwing motion. Alterations in this composite motion are termed "scapular dyskinesis." The dyskinesis is considered an impairment of the efficient mobility of the claviscapular segment of the shoulder complex. The most prevalent problem with scapular dyskinesis is the association of scapular protraction and consequent glenoid antetilt with alterations in humeral rotation and posterior humeral head translation to produce shoulder joint internal impingement. Task effectiveness in overhead throwing is also based on and determined by humeral range of motion, precision of humeral motion, and velocity of humeral motion, as well as humeral and arm position in 3-dimensional space. This activity requires maximum ball-and-socket kinematics to create the highest amount of concavity-compression that creates stability for the joint. There are bony and soft-tissue contributions to this stability. Injuries to the glenoid labrum are among the most common deficits that alter concavity-compression. Clinical evaluation of the shoulder joint complex in the injured throwing athlete should be comprehensive and systematic, following an evaluation pathway for proximal and distal causative factors and including observation of humeral motion. This type of evaluation can result in intervention protocols that address the pathoanatomic, pathophysiological, and pathomechanical deficits identified.

Novel Posterior Shoulder Stretching With Rapid Eccentric Contraction and Static Stretching in Patients With Subacromial Pain Syndrome: A Randomized Trial.

BACKGROUND: In subacromial pain syndrome (SPS), it is unknown whether posterior shoulder stretching exercises (PSSE) with rapid eccentric contraction, a muscle energy technique, improve clinical and ultrasonographic outcomes more than no stretching or static PSSE. HYPOTHESIS: PSSE with rapid eccentric contraction is superior to no stretching and static PSSE in improving clinical and ultrasonographic outcomes in SPS. STUDY DESIGN: Randomized controlled trial. LEVEL OF EVIDENCE: Level 1. METHODS: Seventy patients with SPS and glenohumeral internal rotation deficit were randomized into the modified cross-body stretching with rapid eccentric contraction group (EMCBS; n = 24), static MCBS group (SMCBS; n = 23), or control group (CG; n = 23). In addition to 4-week physical therapy, EMCBS received PSSE with rapid eccentric contraction, SMCBS static PSSE, and CG no PSSE. The primary outcome was internal rotation range of motion (ROM). Secondary outcomes were posterior shoulder tightness, external rotation ROM (ERROM), pain, modified Constant-Murley score, short form of the disabilities of the arm, shoulder, and hand questionnaire (QuickDASH), rotator cuff strength, acromiohumeral distance (AHD), supraspinatus tendon thickness, and supraspinatus tendon occupation ratio (STOR). RESULTS: Shoulder mobility, pain, function and disability, strength, AHD, and STOR improved in all groups (P < 0.05). CONCLUSION: In patients with SPS, PSSE with rapid eccentric contraction and static PSSE were superior to no stretching in improving clinical and ultrasonographic outcomes. Stretching with rapid eccentric contraction was not superior to static stretching, but improved ERROM compared with no stretching. CLINICAL RELEVANCE: In SPS, both PSSE with rapid eccentric contraction and static PSSE included in physical therapy program are beneficial to improve posterior shoulder mobility and other clinical and ultrasonographic outcomes. In the case of ERROM deficiency, rapid eccentric contraction might be preferred.

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.

Diagnostic Implications of Ultrasound Evaluation in Patients With Shoulder Impingement Syndrome.

OBJECTIVE: To evaluate the diagnostic value of musculoskeletal ultrasound measurements of subacromial bursa (SAB) thickness, supraspinatus tendon (SUP) thickness, acromiohumeral distance (AHD), and SUP-to-AHD ratio (AHD%) in patients with shoulder impingement syndrome (SIS). METHODS: This was a prospective cross-sectional observational study. Thirty patients with SIS (60 shoulders) admitted between January 2019 and January 2020 were enrolled. The SUP thickness, SAB thickness, AHD, and AHD% (calculated as AHD% = [(SUP / AHD) × 100%]) were measured in 60 shoulders using musculoskeletal ultrasound. RESULTS: The affected shoulder displayed thicker SUP and SAB (t = 7.838), narrower AHD (t = 2.324), and larger AHD% (t = 6.875) than the unaffected shoulder (P < .05). The SUP thickness showed a linear positive correlation with AHD (r = .503) and AHD% (r = .792) in the affected shoulder (P < .05). On receiver operating characteristic analysis, AHD*AHD% showed the best diagnostic performance in both measurements (area under the curve: 0.877). CONCLUSION: This study revealed that SIS symptoms may be related to a larger AHD% with SUP thickening. As diagnostic criteria, the cut-off values of AHD% (65.6%) and AHD*AHD% (0.504) have good sensitivity and specificity and can help improve the differential diagnosis of patients with SIS.

Comparative Analysis of Muscle Synergy between Patients with Shoulder Impingement Syndrome and Healthy Controls: A Preliminary Study.

Shoulder impingement syndrome can be caused by a muscle imbalance around the shoulder joint. It would be beneficial for therapy to implement rehabilitation exercises based on intermuscular coordination in order to achieve muscle balance. This study presents the muscle synergy characteristics of patients with shoulder impingement syndrome, which can be used to develop rehabilitation exercises. During pick and place task, the muscle synergy obtained from eight shoulder muscles in patients and healthy subjects was compared. The experimental results revealed that patients have low contributed muscle synergy structures for the serratus anterior and infraspinatus.Clinical relevance- This proposes that patients with shoulder impingement syndrome may have abnormal muscle synergy structure which can be used for assessment.

The role of bone morphology of the greater tuberosity and lateral acromion on subacromial space during scaption: a three-dimensional dynamic simulation analysis.

BACKGROUND: The bone morphology of the greater tuberosity and lateral acromion plays a central role in subacromial impingement syndrome. The critical shoulder angle (CSA) and greater tuberosity angle (GTA) are two-dimensional measurement parameters that have been validated to evaluate it radiologically. These markers are, however, static and don't consider the dynamic effect of glenohumeral motion. OBJECTIVES: This study aimed to better understand the biomechanics in subacromial impingement with a dynamic simulation based on a validated 3D biomechanical model coupling joint kinematics and 3D reconstructed computed tomography. STUDY DESIGN & METHODS: Sixty-one patients were included in this study: a case group of 44 patients with degenerative rotator cuff tears involving only the supraspinatus, and a control group of 17 without a rotator cuff tear. Patients with previous surgeries, traumatic cuff tears, and cuff tear arthropathy were excluded. CSA, GTA, and impingement-free range of motion (IF-ROM) of the glenohumeral joint in scaption were calculated. Correlation tests were used to determine the relationship between ROM and CSA, GTA, and combined CSA and GTA values. RESULTS: CSA and GTA were significantly higher in the rotator cuff tear group (p = 0.001 and < 0.001), while IF-ROM was significantly higher in the control group (p = 0.001). There was no overall correlation between CSA and GTA (R = 0.02, p = 0.8). Individual correlation between both angles with IF-ROM was negatively weak for CSA (R = -0.4, p < 0.001) and negatively moderate for GTA and IF-ROM (R = -0.5, p < 0.001). However, combining both angles resulted in a negatively high correlation with IF-ROM (R = -0.7, p < 0.001). CONCLUSION: Subacromial space narrowing during scaption is highly correlated to the cumulative values of GTA and CSA. These findings suggest that the combined bony morphology of the lateral acromion and greater tuberosity plays an important role in subacromial impingement. LEVEL OF EVIDENCE: III.

Comparison of the efficacy of manual treatment according to fascial distortion model versus joint mobilization in patients with shoulder impingement: A randomized clinical trial.

BACKGROUND: The Fascial Distortion Model (FDM) is a relatively new manual therapy approach in the field of musculoskeletal physical therapy, but to date no study has been conducted to compare its' effect in comparison with joint mobilization on patients with shoulder impingement syndrome. OBJECTIVE: The present study aims to compare the efficacy of the FDM versus joint mobilization in pain intensity, pain-free abduction range of motion and function of patients with shoulder impingement syndrome. DESIGN: single-blind, parallel-arm randomized controlled trial. METHODS: 26 patients diagnosed with shoulder impingement syndrome were equally randomized into 2 groups: manual treatment according to the FDM, and joint mobilization of the shoulder complex. All patients received 3 intervention sessions every other day. Pain intensity (by visual analogue scale), pain-free abduction range of motion (by goniometry) and function (by Persian version of shoulder pain and disability index) were measured before and after every session and at follow-up 2 weeks later. Patients' satisfaction with treatment was also measured (by a 4-point Likert scale) at follow-up. RESULTS: FDM therapy group showed statistically significant greater pain reduction (P = 0.014) and range of motion increment (P = 0.044) than joint mobilization group after intervention, while only range of motion maintained the difference at follow-up (P = 0.034). Function improvement was not statistically different after the intervention (P = 0.582) and at follow-up (P = 0.094). There was no difference in patients' satisfaction with treatment between groups (P > 0.05). CONCLUSION: The FDM is a safe and effective treatment approach with comparable results to joint mobilization in patients with shoulder impingement syndrome.

Comparison of Manual Therapy Technique to Therapeutic Exercise in the Treatment of Patients With Subacromial Impingement Syndrome: A Randomized Clinical Trial.

OBJECTIVE: The purpose of this study was to compare the effects of manual therapy to therapeutic exercise on shoulder pain, disability, and range of motion (ROM) in patients with subacromial impingement syndrome (SAIS). METHODS: Sixty patients with SAIS were randomly assigned into the manual therapy (MT) and therapeutic exercise (TE) groups. Patients in the MT group were treated with joint mobilization, which was applied to the glenohumeral, acromioclavicular, sternoclavicular and scapulothoracic joints, and trigger point (TrP) inactivation using ischemic compression. Patients in the TE group performed therapeutic exercises. Shoulder pain, disability and active ROM (elevation, external rotation, and internal rotation) were assessed by the visual analog scale, the Shoulder Pain and Disability Index, and a goniometer, respectively. The outcomes were measured at baseline, after the intervention, and 1 month after the intervention. RESULTS: After the treatment, both groups had significant improvements in shoulder pain, disability, and ROM (P < .05). The MT group experienced a greater reduction in shoulder pain than the TE group (P < .001). However, in disability and ROM, both groups exhibited similar improvements in post-treatment and follow-up periods. CONCLUSION: Both MT and TE were effective in improving shoulder pain, disability, and ROM in patients with SAIS. Greater improvement in shoulder pain was observed in the MT group.