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

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.

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.

EFFECTS OF THORACIC SPINAL MANIPULATIVE THERAPY ON THORACIC SPINE AND SHOULDER KINEMATICS, THORACIC SPINE FLEXION/EXTENSION EXCURSION, AND PRESSURE PAIN SENSITIVITY IN PATIENTS WITH SUBACROMIAL PAIN SYNDROME By Joseph R. Kardouni, Ph.D., PT A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, at Virginia Commonwealth University. Virginia Commonwealth University, 2013. Major Director: Lori A. Michener, PhD, PT, ATC, Professor, Department of Physical Therapy In patients with shoulder pain, the use of manual therapy directed at the spine and shoulder have been reported to provide superior outcomes to exercise based interventions or usual care without the use of manual therapy. Clinical trials have also reported improved pain and disability after thoracic spinal manipulative therapy (SMT) as a stand-alone treatment for shoulder pain. Although clinical efficacy is reported for the use of thoracic SMT for the treatment of shoulder pain, the mechanisms underlying the clinical benefits are not well understood. This limits the directed use of SMT. The benefits could be due to changes in spine or shoulder motion or neurophysiologic mechanisms of pain modulation. Elucidating the mechanism of manual therapy will aid the directed use of thoracic SMT for treating patients with shoulder pain. The research described in chapters 3 and 4 was performed to assess the effects of thoracic SMT in patients with subacromial pain syndrome with regard to biomechanical changes at the thoracic spine and shoulder and effects on central and peripheral pain sensitivity. Subjects with shoulder impingement pain symptoms were randomly assigned to receive 1 visit of thoracic SMT or sham SMT, applied to the lower, middle, and upper (cervicothoracic junction) thoracic spine. A 3-dimensional electromagnetic tracking system was used to measure thoracic and scapular kinematics during active arm elevation, and thoracic excursion at end-range of flexion and extension pre- post-treatment. Pressure pain threshold (PPT) was measured at the painful shoulder (deltoid) and unaffected regions (contralateral deltoid and bilateral lower trapezius areas) immediately pre- and post-treatment. PPT measures at the painful shoulder were used to assess peripheral and/or central pain sensitivity, and PPT at unaffected regions measured central pain sensitivity. Patient-rated outcomes measures of pain (Numeric Pain Rating Scale-NPRS), function (Pennsylvania Shoulder Score-Penn), and global rating of change (GROC) were used to assess changes in clinical symptoms following treatment. No significant differences were found between treatment groups for the thoracic kinematics or excursion, shoulder kinematics, PPT measures, or patient-rated outcomes. No differences were noted pre- to post-treatment in either group for thoracic kinematics or excursion or PPT measures. In both groups, there was a decrease in mean scapular external rotation over time during ascending arm elevation, but the change was less than measurement error. Outcome measures of NPRS, Penn and GROC indicated clinical improvements in both groups following treatment, but there were no differences between the thoracic SMT or sham SMT groups. There were no meaningful correlations between thoracic and scapular kinematics or thoracic excursion with the outcome measures of NPRS, Penn, or GROC. There was a significant positive correlation (r=0.52 , p=0.009) between change in PPT at the lower trapezius on the unaffected side and baseline Penn scores. Biomechanically, thoracic spine extension and excursion did not change following thoracic SMT, and the SMT group had no greater changes in shoulder kinematics or patient-rated pain and function than the sham SMT group. Additionally, thoracic SMT did not improve peripheral or central pain sensitivity as measured by PPT. Furthermore, improvements in patient-rated outcomes were not found to be related to changes in thoracic spine mobility, or shoulder kinematics with SMT. The single correlation between change in PPT and baseline Penn may indicate a neurophyciologic effect of SMT in patients with higher baseline function scores, but the since no other significant relationships between PPT and outcome were seen, the implications of this finding are limited. Overall, alterations in thoracic spine mobility and pressure pain sensitivity do not appear to be responsible for improved outcomes in patients with subacromial pain syndrome. Future studies should explore the effects of SMT using other measures of thoracic spine motion and experimental pain modalities, as well as greater dosing of SMT over a longer follow-up.

Title: The effect of shoulder girdle stabilization exercises on muscle activity during direct impact in rugby players with sub-acromial impingement syndrome Objectives: Comparison of muscle activity during direct impact while performing the rugby tackle to tackle bag and to player using amplitude analysis of electromyographic signal (EMG) before and after intervention programme for players with subacromial impingement syndrome (SIS). Application of intervention programme consisting stabilization excercises for shoulder complex and activation of deep stabilization muscles of the spine. Methods: Theoretical part contains topics about shoulder girdle, rugby and rugby injuries, mainly subacromial impingement syndrome and electromyography. Mentioned issues are included into the thesis due to the research of current literature from international sources and studies. Practical part regards the aplication of three- months long intervention programme for eight rugby players at junior national level with diagnosis of SIS, when pre-testing a post-testing is realized by clinical tests and EMG measurement. Results: Intervention programme was sufficient for changes of EMG amplitude values expressed as percentage of maximal voluntary isometric contraction (MVIC) in some of rugby players with SIS only for some...

Title: The effect of shoulder girdle stabilization exercises on muscle activity during direct impact in rugby players with sub-acromial impingement syndrome Objectives: Comparison of muscle activity during direct impact while performing the rugby tackle to tackle bag and to player using electromyographic amplitude analysis before and after intervention programme for players with subacromial impingement syndrome (SIS). Application of intervention programme consisting stabilization excercises for shoulder complex and activation of deep stabilization muscles of the spine. Methods: Theoretical part contains topics about shoulder girdle, rugby and rugby injuries, mainly subacromial impingement syndrome. Mentioned issues are included into the thesis due to the research of current literature from international sources and studies. Practical part regards the aplication of three-months long intervention programme for eight players at junior national level with diagnosis of SIS, when pre-testing a post-testing is realized by clinical tests and EMG measurement. Assessment of enter and control examination is realized with analysis of variance ANOVA. Results: Intervention programme was sufficient for changes in EMG amplitude for two muscle groups in rugby players with SIS. Hypothesis comparing the EMG measure...

This diploma thesis is focused on the observation of influence of Vojta's reflex locomotion on the activity of shoulder girdle's muscles at patients with the subacromial impingement syndrome. We examined ten patients with the subacromial impingement syndrome as well as twenty asymptomatic individuals. We evaluated the impact of just one Vojta's reflex locomotion therapy on the activity of muscles using the Method of the Surface Electromyography. At the same time we evaluated if the reaction on the therapy had some impact on measured values. The therapy always took at least time necessary to obtain any reaction of each of the individuals, although the maximum limit of the therapy was 32 minutes. The impact of Vojta's reflex locomotion therapy had not statistical importance with regard on changes of muscle activity after and before the therapy, with regard on the symmetry of muscle activity, as well as the difference of beginning of activation of every muscle before and after the therapy. The statistical importance was influenced just by the corporeal disposition of every measured individual, which was observed on the timing. The influence of the corporeal disposition on the average measured values with regard of the left - right side symmetry has no statistical importance. The statistical...

Les troubles musculo-squelettiques de l’épaule constituent un problème majeur de santé au travail. Le principal mécanisme à l’origine de ces pathologies est le conflit sous-acromial, dont le développement est intimement lié à la qualité du contrôle neuromusculaire de l’épaule. Nos données montrent que les tâches expérimentales classiquement utilisées pour l’exploration des facteurs de développement du conflit sous-acromial sont insuffisantes pour rendre compte de la complexité du contrôle neuromusculaire mis en jeu lors des tâches industrielles. Il semble primordial que les actions de lutte contre les TMS considèrent la réalité de l’organisation motrice à l’origine de leur développement. L’application dans ce travail de la technique d’enregistrement électromyographique au secteur industriel met en évidence la pertinence de cet outil afin d’orienter et d’évaluer les actions ergonomiques qui visent à réduire la charge musculo-squelettique. Un moyen complémentaire de lutte contre les TMS a été proposé afin de pallier aux limites propres à la démarche ergonomique. Il s’agit d’un exercice de recentrage dynamique de la tête humérale exécuté en chaîne cinétique fermée, déployé lors d’un programme d’intervention destiné aux opérateurs ayant des symptômes de conflit sous-acromial. Nos données mettent en évidence une diminution de la douleur et une amélioration de la fonction de l’épaule suite à cette intervention. Les bénéfices associés à cette démarche répondent au double enjeu de santé et de performance, essentiel pour les individus comme pour l’entreprise. Finalement, l’ensemble des contributions expérimentales et des applications industrielles présentées dans ce travail de thèse souligne le rôle central que peuvent jouer les spécialistes de la motricité humaine dans la démarche de lutte contre les TMS. Leur intégration dans les équipes pluridisciplinaires de prévention constitue un réel enjeu pour la réduction de ce risque professionnel majeur / Shoulder disorders represent a major health problem at the workplace. The most common shoulder disorder is the subacromial impingement syndrome. Shoulder neuromuscular control has a critical role in the development of shoulder disorders. Our data show that the experimental tasks generally use to investigate subacromial impingement causative factors are insufficient to represent the complexity of shoulder neuromuscular control involved during industrial tasks. It is essential that workplace interventions take into consideration the actual motor control associated with the development of work-related musculoskeletal disorders. The use of the electromyography in the industrial context, during this thesis work, highlights the interest of this tool in order to conduct and evaluate ergonomic interventions that aimed to reduce exposure to physical risk factors. Another work-related musculoskeletal disorder management way was proposed as a supplement to ergonomic interventions. It is about a dynamic closed chain humeral head centering exercise performed by assembly line workers with clinical signs of subacromial impingement syndrome. Our data demonstrated that the intervention program was effective in decreasing shoulder pain as well as improving shoulder function. This study underlined the relevance of therapeutic exercises for shoulder disorders management at the workplace. Finally, the whole of this thesis work highlights the decisive role of specialists in human motor analysis for work-related musculoskeletal disorders management