Diagnosing shoulder pain conditions is a challenging area of musculoskeletal practice. Subacromial impingement syndrome (SIS) is a clinical syndrome that indicates pain and pathology involving the subacromial bursa and rotator cuff tendons within the subacromial space. The three stages of SIS are subacromial bursitis, partial thickness and full thickness rotator cuff tears. The cause of SIS is believed to be multi-factorial with both extrinsic and intrinsic factors involved in its pathogenesis. Clinicians have traditionally diagnosed SIS using a clinical examination including a subjective history followed by confirmatory clinical tests. A review of the evidence for diagnostic accuracy of clinical tests highlights that individual tests have poor diagnostic accuracy. A combination of clinical tests or a clinical examination per se may be useful at ruling out rotator cuff tears, but is less accurate at detecting rotator cuff tears when it is present. There is consensus in the literature that particular combinations of signs and clinical features may be useful in diagnosing rotator cuff tears but not for diagnosing SIS. The vast majority of research to date examining the clinical diagnosis of SIS has been focused on individual clinical tests carried out by medical practitioners in specialist and tertiary care settings. This review has established that the majority of diagnostic accuracy studies for SIS and rotator cuff tears have had poor methodological design. This exploratory study was conducted with subjects undergoing a standardized clinical examination (index test) by a physiotherapist. The decision as to which specific tests were chosen for this research was based on supporting research within the literature and the test’s actual use within the New Zealand clinical setting. This included subjective history questions, active and passive shoulder movement tests and eleven SIS tests. Subjects were referred for a diagnostic ultrasound scan immediately following the clinical examination and results from the scan stood as the criterion reference standard. Thirty eight individuals (males n=23, females n=15) with new onset shoulder pain, who met the inclusion criteria, were assessed by a participating physiotherapist. Sensitivity, specificity, positive likelihood ratios, negative likelihood ratios and respective 95% confidence intervals were calculated for all variables of the examination. Individual variables from the clinical examination were tested for their association with the diagnostic ultrasound scan reference criterion using Pearson Chi-Squared Exact test. Potential predictor variables were retained as potential predictors for use in the logistic regression analysis to determine the most accurate set of clinical examination variables for diagnosing SIS and the individual pathological stages of SIS. The results indicate that no historical, subjective or objective features from the clinical examination are accurate in diagnosing SIS or rotator cuff tears. The presence of night pain demonstrated a significant correlation (P<0.02) with the criterion reference standard for the presence of subacromial bursa fluid/bunching. Night pain and pain with overhead activity has a high sensitivity for subacromial bursa fluid/bunching being present. The absence of night pain and the absence of pain with overhead activity are two subjective phenomena from a clinical examination that are useful in ruling out subacromial bursa fluid/bunching being present. Night pain was also found to be the best predictor of subacromial bursa fluid/bunching being present (P<0.012). Male gender (P<0.034) was the best predictor of partial thickness rotator cuff tears while being 60 years of age or older (P<0.01) significantly correlated with full thickness rotator cuff tears. The Drop Arm Sign (P<0.01) and External Rotation Lag Sign (P<0.01) were significantly correlated with SIS and full thickness rotator cuff tears. Clinical tests for all three pathological stages of SIS and subacromial bursa fluid/bunching being present, had equivalent or if not greater diagnostic accuracy than previous report studies in the literature. The Hawkins-Kennedy Test and Neer Sign can be used in the primary care setting to rule out the presence of subacromial bursa fluid/bunching or SIS if the tests are negative. For mid to end stage SIS (rotator cuff tears) the Empty Can Test and Drop Arm Sign with their high sensitivity can be used to rule out rotator cuff tears especially to the supraspinatus tendon when the tests are negative. Despite the small sample size and other limitations of this study, the findings are an important addition to the current literature surrounding the diagnostic accuracy of clinical tests for SIS and rotator cuff tears. This is the first study to use physiotherapists as examiners and to be set in a primary care setting. The study is also the first to examine the diagnostic accuracy of a range of historical and subjective features from the clinical examination. The results found in the current study could be used by future studies as a starting point in the development of a clinical decision or prediction rule to assist clinicians in the diagnosis of SIS and rotator cuff tears.

Diagnosing shoulder pain conditions is a challenging area of musculoskeletal practice. Subacromial impingement syndrome (SIS) is a clinical syndrome that indicates pain and pathology involving the subacromial bursa and rotator cuff tendons within the subacromial space. The three stages of SIS are subacromial bursitis, partial thickness and full thickness rotator cuff tears. The cause of SIS is believed to be multi-factorial with both extrinsic and intrinsic factors involved in its pathogenesis. Clinicians have traditionally diagnosed SIS using a clinical examination including a subjective history followed by confirmatory clinical tests. A review of the evidence for diagnostic accuracy of clinical tests highlights that individual tests have poor diagnostic accuracy. A combination of clinical tests or a clinical examination per se may be useful at ruling out rotator cuff tears, but is less accurate at detecting rotator cuff tears when it is present. There is consensus in the literature that particular combinations of signs and clinical features may be useful in diagnosing rotator cuff tears but not for diagnosing SIS. The vast majority of research to date examining the clinical diagnosis of SIS has been focused on individual clinical tests carried out by medical practitioners in specialist and tertiary care settings. This review has established that the majority of diagnostic accuracy studies for SIS and rotator cuff tears have had poor methodological design. This exploratory study was conducted with subjects undergoing a standardized clinical examination (index test) by a physiotherapist. The decision as to which specific tests were chosen for this research was based on supporting research within the literature and the test’s actual use within the New Zealand clinical setting. This included subjective history questions, active and passive shoulder movement tests and eleven SIS tests. Subjects were referred for a diagnostic ultrasound scan immediately following the clinical examination and results from the scan stood as the criterion reference standard. Thirty eight individuals (males n=23, females n=15) with new onset shoulder pain, who met the inclusion criteria, were assessed by a participating physiotherapist. Sensitivity, specificity, positive likelihood ratios, negative likelihood ratios and respective 95% confidence intervals were calculated for all variables of the examination. Individual variables from the clinical examination were tested for their association with the diagnostic ultrasound scan reference criterion using Pearson Chi-Squared Exact test. Potential predictor variables were retained as potential predictors for use in the logistic regression analysis to determine the most accurate set of clinical examination variables for diagnosing SIS and the individual pathological stages of SIS. The results indicate that no historical, subjective or objective features from the clinical examination are accurate in diagnosing SIS or rotator cuff tears. The presence of night pain demonstrated a significant correlation (P<0.02) with the criterion reference standard for the presence of subacromial bursa fluid/bunching. Night pain and pain with overhead activity has a high sensitivity for subacromial bursa fluid/bunching being present. The absence of night pain and the absence of pain with overhead activity are two subjective phenomena from a clinical examination that are useful in ruling out subacromial bursa fluid/bunching being present. Night pain was also found to be the best predictor of subacromial bursa fluid/bunching being present (P<0.012). Male gender (P<0.034) was the best predictor of partial thickness rotator cuff tears while being 60 years of age or older (P<0.01) significantly correlated with full thickness rotator cuff tears. The Drop Arm Sign (P<0.01) and External Rotation Lag Sign (P<0.01) were significantly correlated with SIS and full thickness rotator cuff tears. Clinical tests for all three pathological stages of SIS and subacromial bursa fluid/bunching being present, had equivalent or if not greater diagnostic accuracy than previous report studies in the literature. The Hawkins-Kennedy Test and Neer Sign can be used in the primary care setting to rule out the presence of subacromial bursa fluid/bunching or SIS if the tests are negative. For mid to end stage SIS (rotator cuff tears) the Empty Can Test and Drop Arm Sign with their high sensitivity can be used to rule out rotator cuff tears especially to the supraspinatus tendon when the tests are negative. Despite the small sample size and other limitations of this study, the findings are an important addition to the current literature surrounding the diagnostic accuracy of clinical tests for SIS and rotator cuff tears. This is the first study to use physiotherapists as examiners and to be set in a primary care setting. The study is also the first to examine the diagnostic accuracy of a range of historical and subjective features from the clinical examination. The results found in the current study could be used by future studies as a starting point in the development of a clinical decision or prediction rule to assist clinicians in the diagnosis of SIS and rotator cuff tears.

Abstract The pathomechanism of the shoulder impingement syndrome has been under debat. Two main theories of the pathogenesis of the disease exists; mechanical (extrinsic) and degenerative (intrinsic) theory. The purpose of this work was to evaluate the pathogenesis of impingement syndrome with five studies that consentrate to aspects related to ethiopathology as outcome and recovery after surgery, radiological diagnosis, immunohisto- and histopathology of subacromial bursa, and subacromial mechanical pressures. The good results of 14 shoulders of 96 operated with an open acromioplasty turned painful after an average of 5 (2 - 10) years postoperatively and had developed 6 full-thickness and 4 partial rotator cuff tears. Initially good result is not permanent in all cases, suggesting that a degenerative process is involved in the pathogenesis of impingement syndrome. Shoulder muscle strengths of 48 patients, who had undergone an open acromioplasty, restored to near normal within one year after open acromioplasty, suggesting that mechanical compression plays a role in the pathogenesis of impingement syndrome. Variation in the shape of the acromion, evaluated in 111 patients and their matched controls by a routine supraspinatus outlet view, is associated with impingement syndrome, but this association is weak. Validity of this radiograph in the diagnosis of impingement syndrome is therefore a minor adjunct to the other diagnostic methods. The role of subacromial bursa in impingement syndrome was studied in 62 patients (33 tendinitis, 11 partial and 18 full-thickness RC tear) suffering from a unilateral impingement syndrome and 24 controls. Tenascin-C proved to be a more general indicator of bursal reaction compared to the conventional histological markers, being especially pronounced at the more advanced stages of impingement. The local subacromial contact pressures measured in 14 patients and 8 controls with a piezoelectric probe were elevated in the impingement syndrome, supporting the mechanical theory. On the basis of this study, both mechanical and degenerative factors are involved in the pathogenesis of impingement syndrome.

Thesis (MHSc--Health Science) -- AUT University, 2009. / Includes bibliographical references. Also held in print ( leaves : ill. ; 30 cm.) in the Archive at the City Campus (T 617.572044 HAR)

STUDY DESIGN: Block-counterbalanced, repeated-measures crossover study. OBJECTIVES: To assess scapular upward rotation positional adaptations to experimentally induced subacromial pain. BACKGROUND: Existing subacromial pathology is often related to altered scapular kinematics during humeral elevation, such as decreased upward rotation and posterior tilting. These changes have the potential to limit subacromial space and mechanically impinge subacromial structures. Yet, it is unknown whether these changes are the cause or result of injury and what the acute effects of subacromial pain on scapular upward rotation may be. METHODS: Subacromial pain was induced via hypertonic saline injection in 20 participants, aged 18 to 31 years. Scapular upward rotation was measured with a digital inclinometer at rest and at 30°, 60°, 90°, and 120° of humeral elevation during a painful condition and a pain-free condition. Repeated-measures analyses of variance were conducted for scapular upward rotation position, based on condition (pain or control) and humeral position. Post hoc testing was conducted with paired t tests as appropriate. RESULTS: Scapular upward rotation during the pain condition was significantly increased (range of average increase, 3.5°-7.7°) compared to the control condition at all angles of humeral elevation tested. CONCLUSION: Acute subacromial pain elicited an increase in scapular upward rotation at all angles of humeral elevation tested. This adaptation to acute experimental pain may provide protective compensation to subacromial structures during humeral elevation.

STUDY DESIGN: Block-counterbalanced, repeated-measures crossover study. OBJECTIVES: To assess scapular upward rotation positional adaptations to experimentally induced subacromial pain. BACKGROUND: Existing subacromial pathology is often related to altered scapular kinematics during humeral elevation, such as decreased upward rotation and posterior tilting. These changes have the potential to limit subacromial space and mechanically impinge subacromial structures. Yet, it is unknown whether these changes are the cause or result of injury and what the acute effects of subacromial pain on scapular upward rotation may be. METHODS: Subacromial pain was induced via hypertonic saline injection in 20 participants, aged 18 to 31 years. Scapular upward rotation was measured with a digital inclinometer at rest and at 30°, 60°, 90°, and 120° of humeral elevation during a painful condition and a pain-free condition. Repeated-measures analyses of variance were conducted for scapular upward rotation position, based on condition (pain or control) and humeral position. Post hoc testing was conducted with paired t tests as appropriate. RESULTS: Scapular upward rotation during the pain condition was significantly increased (range of average increase, 3.5°-7.7°) compared to the control condition at all angles of humeral elevation tested. CONCLUSION: Acute subacromial pain elicited an increase in scapular upward rotation at all angles of humeral elevation tested. This adaptation to acute experimental pain may provide protective compensation to subacromial structures during humeral elevation.

Objectives: To determine the subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder non-thrust plus exercise in patients with subacromial pathology. Methods: This was a randomized, single blinded controlled trial pilot study. This trial was registered at ClinicalTrials.gov (NCT01753271) and reported according to Consolidated Standards of Reporting Trials requirements. Patients were randomly assigned to either shoulder treatment plus cervicothoracic spinal thrust/non-thrust or shoulder treatment-only group. Primary outcomes were average pain intensity (Numeric Pain Rating Scale) and physical function (Shoulder Pain and Disability Index) at 2 weeks, 4 weeks, and patient discharge. Results: 18 patients, mean age 43.1(15.8) years satisfied the eligibility criteria and were analyzed for follow-up data. Both groups showed statistically significant improvements in both pain and function at 2 weeks, 4 weeks, and discharge. The between-group differences for changes in pain or physical function were not significant at any time point. Discussion: The addition of cervicothoracic spinal thrust/non-thrust to the shoulder treatment-only group did not significantly alter improvement in pain or function in patients with subacromial pathology. Both approaches appeared to provide an equally notable benefit. Both groups improved on all outcomes and met the criteria for clinical relevance for both pain and function. Level of Evidence: 2b.

No description available.

The supraspinatus tendon is an important structure of the rotator cuff. Subacromial impingement is a common reason for shoulder pain. Despite extensive scientific work in this field, the cause of impingement syndrome is still not fully understood. The general aim of the present thesis was to generate new knowledge with respect to pathogenesis and treatment of impingement syndrome. A combination of animal and clinical studies were performed. Different methods were used such as histology, immunohistochemistry, development and assessment of a novel measuring device and clinical and radiological assessment. Thirty rats were injected with triamcinolone or saline into the subacromial bursa. After five corticosteroid injections, we found focal inflammation, degradation and fragmentation of collagen bundles in the supraspinatus tendon, whereas the control specimens were normal (p=0.035). Subacromial bursitis was induced by injections of carrageenan into the subacromial space (n=28). Fibrocartilaginous metaplasia and bony metaplasia were found in the supraspinatus tendon. Even in specimens with no histologic changes of the collagen bundles the staining for fibronectin was significantly increased. The distance between the anterolateral acromion and the supraspinatus tendon was measured in patients with impingement syndrome intraoperatively (n=30) and in controls (instability, n=15). The mean value of the subacromial distance in controls was 16 mm, the 95% mean confidence limits between 14 and 18 mm. The mean value in the group of patients with impingement syndrome was 8 mm before and 16 mm after the decompression. Fifty patients were reviewed after arthroscopic subacromial decompression. Twenty-five showed calcific deposits in the rotator cuff on radiographs preoperatively. In 13 patients the calcific deposits totally disappeared postoperatively. In another six patients the calcifications had decreased in size. Four patients still showed calcifications, which were 5 mm or greater in size. The postoperative results measured by the Constant score were almost identical in the calcific and the non-calcific groups. Tillander 010916 8 Human surgical supraspinatus tendon specimens were studied from patients with impingement (n=16), ruptured supraspinatus tendons (n=7) and controls (n=10). Degradation of tendinous tissue and fibrin were found only in some specimens from ruptures. The difference in fibronectin staining was significant between controls and patients with a rupture (p=0.002). Fibrosis and thinning of fascicles seemed to be a more non-specific finding, appearing in control, impingement and rupture specimens. In conclusion, subacromial corticosteroid injections may cause rupture of the supraspinatus tendon. Metaplasia of the supraspinatus tendon may play a role in the pathogenesis of impingement and rupture of the supraspinatus tendon. The subacromial distance can be measured intraoperatively and was shown to be lower in patients with impingement than in patients with instability. Calcifications disappear or decrease in size after arthroscopic subacromial decompression and do not seem to influence the postoperative outcome in patients with impingement. Degradation of tendon tissue, fibrin and fibronectin appear to be signs of tendon degeneration, whereas fibrosis and thinning of fascicles were found also in controls.

Syftet med avhandlingen var att beskriva diagnostiken och utvärdera handläggningen i primärvård av patienter med subacromial smärta. Avhandlingen omfattar fyra studier. I den första studien användes ett frågeformulär och resultaten beskriver hur distriktsläkare och distriktssjukgymnaster i ett svenskt län diagnosticerar och handlägger primärvårdspatienter med subacromial smärta. Den andra studien beskriver distriktsläkares och distriktssjukgymnasters tilltro till effekten av olika behandlingsmetoder för dessa patienter. Med utgångspunkt från de tilltrodda behandlingsmetoderna genomfördes en systematisk litteraturöversikt. Den tredje studien utvärderar intra- och interbedömar reliabilitet för ett styrketest som ingår i ett utvärderingsinstrument ‘the Constant-Murley shoulder assessment’. Den avslutande studien är en randomiserad klinisk studie som utvärderar och jämför effekten av två behandlingsstrategier, akupunktur och ultraljud, båda i kombination med hemträning. Distriktsläkare och distriktssjukgymnaster visade sig använda en likartad diagnostik. Det troligaste valet av behandling för distriktsläkare var antiinflammatoriska läkemedel och kortisoninjektion i den subacromiala bursan och för distriktssjukgymnaster rörelseträning samt ergonomiska åtgärder. Dock var de flesta behandlingsalternativen troliga val, vilket tolkas som en osäkerhet om behandlingarnas effekt. Med utgångspunkt från de behandlingsmetoder som distriktsläkare och distriktssjukgymnaster tilltrodde som effektiva för patienter med subacromial smärta, genomfördes en systematisk kritisk litteraturöversikt. Fyrtio studier inkluderades och deras evidensnivå utvärderades. Endast kortisoninjektion i den subacromiala bursan visade sig ha definitiva bevis för effekt. Akupunktur visade sig ha troliga bevis för effekt och ultraljudsbehandling konkluderades som ineffektivt för patienter med subacromial smärta. Det förelåg en låg grad av samstämmighet mellan tilltro och tillgängliga vetenskapliga bevis. En digital dynamometer kan ersätta den konventionella fjädervågen i det standardiserade styrketestet. En nästan perfekt överensstämmelse vad gäller både intra- och interbedömarreliabilitet vid test av unga skulderfriska personer, oberoende av om en ”håll emot-” eller ”dragteknik” användes eller om medel- eller maxvärden användes vid beräkningen av överensstämmelse. I den randomiserade kliniska studien inkluderades 85 patienter. Tre utvärderingsinstrument, kombinerade i resultatanalysen, utvärderade förändringen under en uppföljningsperiod på 12 månader tillsammans med patienternas subjektiva skattning av resultatet. Resultaten visade att akupunktur i kombination med hemträning är att föredra. Båda behandlingsgrupperna förbättrades signifikant och fortsatte förbättras över tid oberoende av behandling. De flesta patienter uppnådde ett tillfredställande behandlingsresultat efter 12 månader. Åtminstone tre fjärdedelar i varje behandlingsgrupp skattade sig mycket förbättrade eller helt återställda. Detta tolkas som en behandlingseffekt i kombination med naturalförloppet. Avhandlingen har beskrivit handläggningen i primärvård av patienter med subacromial smärta och har bidragit med vetenskapliga bevis för distriktsläkare att behandla med kortisoninjektion i subacromiala bursan och för distriktssjukgymnaster att behandla med akupunktur kombinerat med hemträning. / The aim of the thesis was to describe the diagnostic approach and evaluate primary care management of patients with subacromial pain. The thesis includes four different studies, a questionnaire study describing attitudes among general practitioners and physiotherapists in a Swedish county toward the diagnostic approach and management of primary care patients with subacromial pain; a combination of a systematic review and general practitioners and physiotherapists beliefs in interventions for patients with subacromial pain; a study of intra- and inter-observer reliability for the strength test in the Constant-Murley shoulder assessment; and a randomised clinical trial to evaluate and compare the efficacy of two treatment strategies for patients with subacromial pain, acupuncture combined with home exercises and continuous ultrasound combined with home exercises. In the questionnaire study we described that general practitioners and physiotherapists have a uniform diagnostic approach. The most probable choice of treatment was non-steroidal anti-inflammatory drugs and corticosteroid injection into the subacromial bursa for general practitioners and movement exercises together with ergonomics/adjustments at work for physiotherapists, but most treatments were probable choices, reflecting an uncertainty about their effectiveness. The treatments trusted by general practitioners and physiotherapists were systematically reviewed. Forty studies were included and the level of evidence was summarised. Only corticosteroid injections into the subacromial bursa, had definitive evidence for efficacy. Acupuncture had tentative evidence for efficacy and therapeutic ultrasound was concluded as ineffective for patients with subacromial pain. The association between trusted treatments and available scientific evidence was weak. A digital dynamometer can replace the conventional spring-balance in the standardised strength test. An almost perfect agreement was found for intra- and inter-observer reliability in young shoulder-healthy persons, regardless of whether a 'resisted-force' or a 'pull-force' was used or if calculated with mean or maximum values. Eighty-five patients were included in the randomised clinical trial. Three shoulder scores, combined in the analysis, measure change during a 12 months follow-up together with a ‘patient self-evaluation’ of the experienced result. The results favoured acupuncture combined with home exercises. Both groups improved significantly and continued to improve over time independent of treatment and most of the patients reached a satisfactory result at 12 months. At least three fourths of the patients, in each treatment group, reported large improvements or felt completely recovered. This is interpreted as a combination of treatment effect and the natural course. This thesis has described the primary care management of patients with subacromial pain and provided scientific evidence for general practitioners to use corticosteroid injection and for physiotherapists to use acupuncture combined with home exercises, when treating these patients. / On the day of the defence date the status on article III was Accepted and article IV was Submitted.