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.

xiii, 79 p. : ill. A print copy of this thesis is available through the UO Libraries. Search the library catalog for the location and call number. / Subacromial impingement syndrome is the most common disorder of the shoulder. Abnormal superior translation of the humeral head is believed to be one of the major causes of this pathology. The overall purpose of this study was to better understand glenohumeral kinematics in normal healthy individuals using fluoroscopy to help comprehend the mechanism of shoulder impingement. This research was divided into three sections: a validation study to measure humeral head translation, a comparison between dynamic and static arm elevation and lastly, humeral head translation after a suprascapular nerve block. In the first study, fluoroscopy was used to take images of human cadaver shoulders. Scapular orientation was manipulated in different positions while the humerus was at 90 degrees of elevation. Humeral head translation was measured using two methods and was compared to the known translation. Additionally, the accuracy of the contour registration method to measure 2-D scapular rotations was assessed. For the second study, subjects elevated their dominant arm while fluoroscopic images were taken. An edge detection software was utilized to digitize points on both the humeral head and glenoid. Humeral head translation and scapular upward rotation were measured using a contour registration method with respect to the glenoid during arm elevation. Five different arm elevation angles were investigated to measure differences in humeral head translation between trials. There was no difference found between humeral head translation and scapular upward rotation between static and dynamic shoulder elevation. For the third study, humeral head translation was measured before and after a suprascapular never block. The humeral head was superiorly located and the scapula was more upwardly rotated after the block. The differences were observed during mid range of motion. This result showed that there was a compensatory increase in both humeral head translation and scapular upward rotation due to the nerve block. These results suggest that increasing muscular strength and endurance of the supraspinatus and infraspinatus muscle could prevent any increased superior humeral head translation. This may be beneficial in preventing shoulder impingement or rotator cuff tear over time. This dissertation includes unpublished co-authored materials. / Committee in charge: Andrew Karduna, Chairperson, Human Physiology; Li-Shan Chou, Member, Human Physiology; Louis Osternig, Member, Human Physiology; Stephen Frost, Outside Member, Anthropology

Made available in DSpace on 2016-06-02T20:18:11Z (GMT). No. of bitstreams: 1 2780.pdf: 1030621 bytes, checksum: f3e052fa6f2410523f393a152522d580 (MD5) Previous issue date: 2010-02-05 / Financiadora de Estudos e Projetos / There is lack of studies with approach on the evaluation of torque steadiness in subjects with shoulder impingement, as well as studies evaluating the eccentric phase of elevation of the arm in these subjects. As such, the purpose of this study was to evaluate torque steadiness during isometric abduction and muscle performance during concentric and eccentric abduction of the shoulder in subjects with subacromial impingement syndrome (SIS) and healthy subjects. The SIS group consisted of 27 subjects (33.48&#61617;9.94 years) with unilateral SIS and it was divided into two groups: 1) SIS with the dominant involved side; 2) SIS with the nondominant involved side. The control group consisted of 23 healthy subjects (32.26&#61617;9.04 years). Peak torque and torque steadiness were measured during isometric abduction (80º in the scapular plane) of the shoulder. Standard deviation, coefficient of variation, stability time, median frequency, and relative power were measured from the steadiness trials. The target torque was 35% of peak torque. There were neither significant interactions between group and side (P > 0.05), nor were there significant main effects of group and side (P > 0.05) for all variables analyzed. Peak torque, total work and acceleration time were measured, bilaterally, during isokinetic concentric and eccentric abduction at 60°/s and 180°/s. No significant interactions were found between group and side (P>0.05), as well as no significant main effects of group and side (P>0.05) for all variables during concentric abduction of the shoulder at both tested speeds. During the eccentric contractions, lower total work (P<0.05) was demonstrated by the nondominant uninvolved side of SIS group at 60°/s, and by the uninvolved sides of the SIS groups at 180°/s compared to the dominant side of the controls. At 180°/s, the nondominant uninvolved side of the SIS group demonstrated slower acceleration time (P<0.05) compared to the dominant side of the control group, as well as the nondominant involved side of the SIS group compared to the nondominant side of the controls. The results of this study showed that steadiness is preserved by SIS during isometric abduction of the shoulder. No alterations were also shown in the measured parameters during concentric and eccentric phases of isokinetic abduction in subjects with SIS when compared to a control group. However, alterations may be observed in the contralateral side during the eccentric phase of abduction in subjects with unilateral conditions of SIS. / Além da escassez de estudos com abordagem na avaliação da manutenção do torque em portadores da síndrome do impacto do ombro, estudos sobre a fase excêntrica da elevação do braço também são bastante escassos. Desta forma, o objetivo deste estudo foi avaliar a manutenção do torque submáximo durante a abdução isométrica e o desempenho muscular durante abdução concêntrica e excêntrica em sujeitos com síndrome do impacto subacromial (SIS) e sujeitos saudáveis. O grupo SIS consistiu de 27 sujeitos (33,48 &#61617; 9,94 anos) com SIS unilateral e foi divido em dois grupos: 1) SIS com lado dominante acometido; 2) SIS com lado não-dominante acometido. O grupo controle consistiu de 23 sujeitos saudáveis (32,26 &#61617; 9,04 anos). O pico de torque e a manutenção do torque foram registrados durante a abdução isométrica (80º no plano escapular) do ombro. Desvio-padrão, coeficiente de variação, tempo de estabilidade, freqüência mediana e potência relativa foram calculados para cada repetição da avaliação de manutenção do torque. O torque alvo foi 35% do pico de torque. Não foram identificadas interações significativas entre grupo e lado (P>0,05), assim como não houve diferenças significativas entre grupos e lados (P>0,05) para todas as variáveis analisadas. Pico de torque, trabalho total e tempo de aceleração foram avaliados durante abdução isocinética concêntrica e excêntrica do ombro, bilateralmente, a 60°/s e 180°/s. Também não foram encontradas interações significativas entre grupos e lado (P>0,05), assim como não foram encontrados efeitos de grupo e lado (P>0,05) para todas as variáveis analisadas durante a abdução concêntrica do ombro para ambas as velocidades testadas. Durante as contrações excêntricas, menor trabalho total (P<0,05) foi demonstrado no lado não-dominante não-acometido do grupo SIS a 60°/s, e no lado não-acometido dos grupos SIS a 180°/s quando comparado com o lado dominante do grupo controle. A 180°/s, o lado não-dominante não-acometido do grupo SIS demonstrou maior tempo de aceleração (P<0,05) quando comparado com o lado dominante do grupo controle, assim como o lado não-dominante acometido do grupo SIS quando comparado com o lado nãodominante do grupo controle. Os resultados do presente estudo mostraram que a manutenção do torque está preservada na SIS durante a abdução isométrica do ombro. Também não foram demonstradas alterações nos parâmetros avaliados durante as fases concêntrica e excêntrica da abdução isocinética em sujeitos com SIS quando comparados com um grupo controle. No entanto, alterações podem ser observadas no lado contralateral durante a fase excêntrica em sujeitos com SIS unilateral.

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.

Objetivos del estudio: establecer los efectos de ultrasonidos y ondas de choque radiales en el síndrome subacromial, determinar la posible influencia del sexo y analizar la rentabilidad de ambas técnicas. Realizamos un estudio en veinticuatro pacientes repartidos en dos grupos: un grupo recibió ondas de choque y el otro ultrasonidos. Los pacientes fueron evaluados mediante la escala DASH, Constant&Murley, UCLA, SF-36 y EVA, antes del tratamiento, al mes, a los tres meses y a los seis meses. El estudio no mostró diferencias entre ultrasonidos y ondas de choque, aunque ambos tratamientos mostraron eficacia. Dicha mejoría fue mayor en los varones. Obtuvimos un coste por paciente menor con las ondas de choque. Conclusiones: ambas técnicas son eficaces en el tratamiento del síndrome subacromial, aunque no encontramos diferencias estadísticamente significativas entre ellas. Los resultados fueron mejores en los varones. En dichas condiciones, el abordaje con ondas de choque radiales es más rentable. / Objectives: To set the utility of ultrasound and radial shock waves in subacromial syndrome; to determinate the possible influence of sex; to analyse the profitability of both techniques. We did a clinical trial in twenty-four patients, divided in two groups: one of them received shock waves treatment, the other group received ultrasounds. The patients were evaluated using DASH scale, Constant&Murley, UCLA, SF-36 and VAE scales before treatment, one month, three months and six months later. No significant differences were found between the two techniques, although both treatments improved symptoms and function. That improvement was better in males. We obtained a patients’ cost in shock waves group lower than in ultrasounds one. Conclusions: both techniques are effective in the treatment of subacromial syndrome, although we couldn’t find relevant differences. The results were better in males. Thus, radial shock waves treatment is more profitable than ultrasounds one.

Bakgrund: Subacromial smärta är en av de tre vanligaste förekommande orsakerna till att patienter söker hjälp inom primärvården. En definition på subacromial smärta är att det är en icke-traumatisk smärta, oftast lokaliserad enbart i ena axeln, som skapar smärta i strukturer i och kring axelleden. Orsaken till subacromial smärta sägs vara multifaktoriell och de strukturer som kan vara involverade är många. Vid behandling av subacromial smärta är konservativ behandling förstahandsvalet, evidensen för vilka övningar som är effektiva och hur dessa ska doseras är dock begränsad. Syfte: Syftet med studien var att mäta effekten av behandling med passivt hängande med avseende på axelrörlighet, funktion samt smärta hos patienter med subacromial smärta. Frågeställningar: - Ökar passivt hängande axelrörligheten samt minskar smärtan hos patienter med subacromial smärta? - Minskar passivt hängande förekomsten av störd nattsömn hos patienter med subacromial smärta? - Förbättrar passivt hängande axelfunktionen hos patienter med subacromial smärta? Metod: Studien var av kvasiexperimentell design vilket bestod av två mättillfällen. En mätning innan behandlingen och en mätning efter att interventionen genomförts, en så kallad pretest – posttest design. Samtliga deltagare utförde passivt hängande från en pull up-stång sammanlagt sju minuter per dag (tre minuter på morgonen och fyra minuter på kvällen) under en åtta veckors period. Övningen utfördes i 30 sekunders intervaller. Studiens huvudsakliga data var insamlat genom Constant-Murley shoulder outcome score. Totalt sex patienter genomförde studien. Resultat: Enligt Constant-Murley shoulder outcome score förbättrade samtliga sex deltagare sin rörlighet och funktionsförmåga efter åtta veckors passivt hängande. Förekomsten av störd nattsömn och smärta vid ADL minskade också hos samtliga deltagare. Den smärtfria rörligheten minskade med 61 % på gruppnivå (p=0,028). Smärta vid aktivitet minskade med 75 % på gruppnivå, (p=0,027). Förekomsten av störd nattsömn minskade med 76% på gruppnivå (p=0,027). Och deltagarnas axelfunktion förbättrades med 94% på gruppnivå (p=0,028). Slutsats: Denna pilotstudie indikerar att åtta veckors passivt hängande kan förbättra rörligheten och funktionen hos patienter med subacromial smärta. Förekomsten av störd nattsömn och smärta vid ADL minskade också hos samtliga deltagare efter åtta veckors träning. Trots låga p-värden och stora skillnader på individnivå kan man dock inte uttala sig om signifikanta skillnader eller generaliserbarhet av resultaten på grund av låg power och avsaknad av kontrollgrupp. / Background: Subacromial pain is one of the three most common causes of patients seeking help in primary care. A definition of subacromial pain is that it is a non-traumatic pain, usually located only in one shoulder, which creates pain in structures in and around the shoulder joint. The cause of subacromial pain is proposed to be multifactorial and the structures that may be involved are many. Conservative treatmens is the first choice when treating shoulder injuries, however, the evidence for which exercises are effective and how these should be dosed is limited. Purpose: The purpose of the study was to measure the effect of passive hanging on shoulder mobility, function and pain in patients with subacromial pain. Questions: - Does passive hanging increase mobility and reduce pain in patients with subacromial pain? - Does passive hanging reduce the incidence of disturbed night sleep in patients with subacromial pain? - Does passive hanging improve shoulder function in patients with subacromial pain? Method: The study used a quasi-experimental design, which consisted of two measurement occasions. A measurement before the treatment and a measurement after the intervention, a so-called pretest - post-test design. All participants performed passively hanging from a pull-up bar for a total of seven minutes a day (three minutes in the morning and four minutes in the evening) during an eight-week period. The exercise was performed at 30 second intervals. The main data of the study is collected through the Constant-Murley shoulder outcome score. A total of six patients completed the study. Results: According to the Constant-Murley shoulder outcome score all six participants improved their mobility and shoulder function after eight weeks of passive hanging. The presence of disturbed night sleep and pain in ADL also decreased among all participants. Participants improved their painless mobility by 61 % at group level (p-value 0.028). Pain during activity decreased by 75 % at group level (p-value 0.027). The presence of disturbed night sleep decreased by 76 % at group level (p-value 0.027). And the participants shoulder function improved by 94 % at group level (p-value 0.028). Conclusion: This pilot study indicates that eight weeks of passive hanging can improve the mobility and shoulder function in patients with subacromial pain. The incidence of disturbed night sleep and pain in ADL also decreased in all participants after eight weeks of training. Despite low p-values and large differences at the individual level one cannot comment on significant differences or generalisability of the results due to low power and lack of control group.

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.

L’ultrasò és un dels agents físics de fisioteràpia més utilitzats en el tractament de la síndrome subacromial. La fonoforesi i la iontoforesi són agents físics que, a diferència dels ultrasons, utilitzen un fàrmac com a conductor del corrent. Per valorar si l’ús del dexketoprofèn com a conductor en la fonoforesi i la iontoforesi provoca més millora clínica que l’ultrasò es va realitzar un assaig clínic aleatoritzat amb tres grups de tractament, sent l’agent físic diferent en cada grup. Les variables principals de l’estudi van ser l’escala visual analògica (EVA), el qüestionari DASH i l’escala de Constant-Murley. Es van trobar diferències significatives entre l’ultrasò i la iontoforesi en l’EVA i el Constant, i entre la fonoforesi i la iontoforesi en el Constant. Tots els pacients van millorar significativament les tres variables després del tractament. Per tant, els tres agents físics són eficaços però l’ús del dexketoprofèn no millora els resultats. / Ultrasound is of the most widely used techniques in physiotherapy to treat subacromial syndrome. Phonophoresis and iontophoresis are physical agents that, in contrast to ultrasound, use a drug as an electrical conductor. To evaluate whether the use of dexketoprofen as a conductor in phonophoresis and iontophoresis leads to a greater improvement than the use of ultrasound, a randomized clinical trial was carried out on three treatment groups, each of which was administered a different technique. The main variables in the study were the visual analog scale (VAS), the DASH questionnaire and the Constant-Murley scale. The Constant-Murley scale and the VAS found significant differences between the ultrasound and iontophoresis, and the Constant-Murley scale found significant differences between phonophoresis and iontophoresis. All the patients significantly improved in terms of the three variables after the treatment. Consequently, the three physical agents are effective but the use of dexketoprofen does not improve the results.

Background Persistent musculoskeletal pain is a multi-factorial entity, influenced by biological, genetic and psychosocial factors. Psychosocial factors, such as individuals' beliefs and experiences, need to be considered in the management of such pain. While extensive research has explored beliefs of individuals with spinal pain, less is known about individuals' beliefs regarding shoulder pain. Objectives To explore beliefs about the cause of pain in individuals with persistent rotator cuff-related pain, as well as the experiences of the effect of pain on their daily lives. Design A mixed methods design, using semi-structured interviews and validated outcome questionnaires. Method Five men and five women, aged 47–68 years, with shoulder pain for at least three months were recruited. Individual semi-structured interviews were audio-recorded, transcribed verbatim and analysed using the general inductive approach. Results/findings Four key themes emerged. The cause of pain, ‘Understanding the pain’, was described in terms of anatomical factors within the context of the participants' lives. The pain impacted all areas of life, creating another theme, ‘It affects everything’. Participants responded to their pain by adopting certain, ‘Pain-associated behaviours’ and sought information for diagnosis, general management and exercise prescription, ‘Emotional responses and the future’. Conclusions The participants with rotator cuff-related pain believed the cause of their pain to be local to the shoulder region. However, they also described various stressors in their work-, sports- and family-related lives. Rehabilitation may need to include educating the individual, expanding their understanding regarding pain mechanisms and appropriate interventions, based on individual goal-setting.