Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. Is ultrasound-guided injection more effective in chronic subacromial bursitis? The targeting accuracy of subacromial injection to the shoulder: an arthrographic evaluation. Contributions of myofascial pain in diagnosis and treatment of shoulder pain. A randomized control trial Thoracic Spine Manipulation in Individuals With Subacromial Impingement Syndrome Does Not Immediately Alter Thoracic Spine Kinematics, Thoracic Excursion, or Scapular Kinematics: A Randomized Controlled Trial. Treatment of shoulder complaints in general practice: long term results of a randomised, single blind study comparing physiotherapy, manipulation, and corticosteroid injection Ultrasound-Guided Versus Blind Subacromial Corticosteroid Injections for Subacromial Impingement Syndrome Clinical predictors of a positive response to guided diagnostic block into the subacromial bursa. Additive effects of low-level laser therapy with exercise on subacromial syndrome: a randomised, double-blind, controlled trial Clinical and MRI findings after high dosage medical exercise therapy in patients with long lasting subacromial pain syndrome: a case series on six patients. Acupuncture and electro‐acupuncture for people diagnosed with subacromial pain syndrome: A multicentre randomized trial Effectiveness of individualized physiotherapy on pain and functioning compared to a standard exercise protocol in patients presenting with clinical signs of subacromial impingement syndrome. A randomized controlled trial The role of radiological subacromial distance measurements in the subacromial impingement syndrome Incidence of full-thickness rotator cuff tear after subacromial corticosteroid injection: A 12-week prospective study The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement. Exercise therapy after ultrasound-guided corticosteroid injections in patients with subacromial pain syndrome: a randomized controlled trial MRI changes of cervical spine in asymptomatic and symptomatic young adults One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome The clinical and sonographic effects of kinesiotaping and exercise in comparison with manual therapy and exercise for patients with subacromial impingement syndrome: a preliminary trial. Supervised Exercises Compared With Radial Extracorporeal Shock-Wave Therapy for Subacromial Shoulder Pain: 1-Year Results of a Single-Blind Randomized Controlled Trial Differences in scapular orientation, subacromial space and shoulder pain between the full can and empty can tests. Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: a single-blind randomized trial.
Generalized shoulder pain is a common problem that is difficult to treat and frequently recurrent . The asymptomatic cervical spine must be ruled out as a cause of any shoulder pain , as it can have a similar presentation to an isolated shoulder disorder . Previous studies have shown that lateral cervical glide mobilizations to the asymptomatic cervical spine at C5/6 can affect peripheral pain , but none have examined shoulder pain . A r and omized , blinded , placebo-controlled , cross-over trial was used to examine the immediate effects of cervical lateral glide mobilizations on pain intensity and shoulder abduction painful arc in subjects with shoulder pain . Twenty-one subjects received interventions of both cervical mobilization and placebo over two sessions . Pain intensity using a visual analog scale ( VAS ) and painful arc were assessed prior to and following application of cervical mobilization or placebo intervention . Evaluation of cervical mobilization revealed the shoulder abduction painful arc ( 12.5 degrees + /-15.6 degrees , p=0.002 ) and shoulder pain intensity ( 1.3+/-1.1 cm , p<0.001 ) were significantly decreased . The results of this study suggest that any immediate change in shoulder pain or active shoulder range of motion following cervical mobilizations indicate that treatment directed toward the asymptomatic cervical spine may expedite recovery PURPOSE Although ultrasound (US)-guided subacromial injection has shown increased accuracy in needle placement , whether US-guided injection produces better clinical outcome is still controversial . Therefore , this study aim ed to compare the efficacy of subacromial corticosteroid injection under US guidance with palpation-guided subacromial injection in patients with chronic subacromial bursitis . METHODS Patients with chronic subacromial bursitis were r and omized to a US-guided injection group and a palpation-guided injection group . The subjects in each group were injected with a mixture of 0.5 mL dexamethasone suspension and 3 mL lidocaine into the subacromial bursa . The primary outcome measures were the visual analog scale for pain and active and passive ranges of motion of the affected shoulder . Secondary outcome measures were the Shoulder Pain and Disability Index , the Shoulder Disability Question naire , and the 36-item Short-Form Health Survey ( SF-36 ) . The primary outcome measures were evaluated before , immediately , 1 wk , and 1 month after the injection ; the secondary outcome measures were evaluated before , 1 wk , and 1 month after the injection . RESULTS Of the 145 subjects screened , 46 in each group completed the study . Significantly greater improvement in passive shoulder abduction and in physical functioning and vitality scores on the SF-36 were observed in the US-guided group . The pre- and postinjection within-group comparison revealed significant improvement in the visual analog scale for pain and range of motion , as well as in the Shoulder Pain and Disability Index , Shoulder Disability Question naire , and SF-36 scores , in both groups . CONCLUSIONS The US-guided subacromial injection technique produced significantly greater improvements in passive shoulder abduction and in some items of the SF-36 . US is effective in guiding the needle into the subacromial bursa in patients with chronic subacromial bursitis PURPOSE The study goal was to examine the targeting accuracy of subacromial injection to the shoulder and the influence of the location of the injected structure . TYPE OF STUDY A prospect i ve nonr and omized study . METHODS Fifty-three patients ( 56 shoulders ; 34 women and 19 men ; mean age , 74.5 years ; range , 49 to 91 ) with impingement signs ( Neer , Hawkins ) of at least 2 months ' duration received a subacromial injection of a mixture of 0.5 mL ( 2.5 mg ) betamethasone acetate and 3 mL of radiographic contrast material ( iotrolan ) and 7 mL of 1 % lidocaine using a lateral approach . Radiographs of the shoulder joint were taken immediately after the injection to determine the structure reached by the injection . Details of pain expressed as Neer and Hawkins impingement signs were obtained before and 15 minutes after the injection , and subjectively assessed using a 4-point self-administered pain score . Pain reduction result ing from subacromial and intradeltoid injection was compared . RESULTS Thirty-nine of the 56 injections ( 70 % ) were judged to have reached the subacromial bursa . Twelve ( 21 % ) were seen to have entered the deltoid muscle ; 2 ( 4 % ) were in the glenohumeral joint ; and 3 ( 5 % ) were subcutaneous . A comparison of subacromial bursal with intradeltoid injection showed no significant differences in pain reduction expressed as impingement signs ( 1.5 vs 1.7 in the Neer impingement sign and 1.6 vs 1.6 in the Hawkins impingement sign , respectively ) . CONCLUSIONS This study showed that subacromial injection was a relatively difficult procedure . A high incidence of injections that missed the subacromial bursa would be a sufficient reason to refrain from repeated usage of corticosteroids . These results also suggest that pain relief could be attained whether the injected material reached the subacromial bursa or the deltoid muscle . Successful pain relief after intradeltoid injection seems to call into question the diagnostic value of a positive Neer impingement test Background Rotator cuff tendinopathy and subacromial impingement syndrome present complex patomechanical situations , frequent difficulties in clinical diagnosis and lack of effectiveness in treatment . Based on clinical experience , we have therefore considered the existence of another pathological entity as the possible origin of pain and dysfunction . The hypothesis of this study is to relate subacromial impingement syndrome ( SIS ) with myofascial pain syndrome ( MPS ) , since myofascial trigger points ( MTrPs ) cause pain , functional limitation , lack of coordination and alterations in quality of movement , even prior to a tendinopathy . MTrPs can coexist with any degenerative subacromial condition . If they are not taken into consideration , they could perpetuate and aggravate the problem , hindering diagnosis and making the applied treatments ineffective . The aims and methods of this study are related with providing evidence of the relationship that may exist between this condition and MPS in the diagnosis and treatment of rotator cuff tendonitis and /or SIS . Method / design A descriptive transversal study will be made to find the correlation between the diagnosis of SIS and rotator cuff tendonitis , positive provocation test responses , the existence of active MTrPs and the results obtained with ultrasonography ( US ) and Magnetic Renonance Imaging ( MRI ) . A r and omized double blinded clinical trial will be carried out in experimental conditions : A Protocol ized treatment based on active and passive joint repositioning , stabilization exercises , stretching of the periarticular shoulder muscles and postural reeducation . B. The previously described protocol ized treatment , with the addition of dry needling applied to active MTrPs with the purpose of isolating the efficacy of dry needling in treatment . Discussion This study aims to provide a new vision of shoulder pain , from the perspective of MPS . This syndrome can , by itself , account for shoulder pain and dysfunction , although it can coexist with real conditions involving the tendons . Trail Registration IS RCT N Number : STUDY DESIGN R and omized controlled trial . OBJECTIVES To determine if thoracic spinal manipulative therapy ( SMT ) alters thoracic kinematics , thoracic excursion , and scapular kinematics compared to a sham SMT in individuals with subacromial impingement syndrome , and also to compare changes in patient-reported outcomes between treatment groups . BACKGROUND Prior studies indicate that thoracic SMT can improve pain and disability in individuals with subacromial impingment syndrome . However , the mechanisms underlying these benefits are not well understood . METHODS Participants with shoulder impingement symptoms ( n = 52 ) were r and omly assigned to receive a single session of thoracic SMT or sham SMT . Thoracic and scapular kinematics during active arm elevation and overall thoracic excursion were measured before and after the intervention . Patient-reported outcomes measured were pain ( numeric pain-rating scale ) , function ( Penn Shoulder Score ) , and global rating of change . RESULTS Following the intervention , there were no significant differences in changes between groups for thoracic kinematics or excursion , scapular kinematics , and patient-reported outcomes ( P>.05 ) . Both groups showed an increase in scapular internal rotation during arm raising ( mean , 0.9 ° ; 95 % confidence interval [ CI ] : 0.3 ° , 1.6 ° ; P = .003 ) and lowering ( 0.8 ° ; 95 % CI : 0.0 ° , 1.5 ° ; P = .041 ) , as well as improved pain reported on the numeric pain-rating scale ( 1.2 points ; 95 % CI : 0.3 , 1.8 ; P<.001 ) and function on the Penn Shoulder Score ( 9.1 points ; 95 % CI : 6.5 , 11.7 ; P<.001 ) . CONCLUSION Thoracic spine extension and excursion did not change significantly following thoracic SMT . There were small but likely not clinical ly meaningful changes in scapular internal rotation in both groups . Patient-reported pain and function improved in both groups ; however , there were no significant differences in the changes between the SMT and the sham SMT groups . Overall , patient-reported outcomes improved in both groups without meaningful changes to thoracic or scapular motion . LEVEL OF EVIDENCE Therapy , level 1b- Descriptive studies have shown that shoulder complaints  can be persistent and recurrent , requiring long term evaluation of treatment.1 Unfortunately , in most r and omised studies comparing treatments for shoulder complaints the study period varies from a few weeks ( trials of non-steroidal anti-inflammatory drugs ) to 3 - 6 months ( injection therapy and physiotherapy trials).2–4 ) In a trial in 1994 - 5 of treatment of shoulder complaints in general practice we showed that in a study period of 11 weeks , injection therapy with a corticosteroid was superior to  physiotherapy  and manipulative therapy in the patients whose complaints originated from the structures of the glenohumeral joint , the subacromial space , or the acromioclavicular joint ( synovial group).5 In the patients whose complaints related to functional disorders of the cervical spine , the upper thoracic spine , or the adjoining ribs ( shoulder girdle group ) , manipulation was superior to physiotherapy . To assess the various treatments in Background : Subacromial corticosteroid injections are frequently performed for impingement syndrome of the shoulder . To improve the accuracy of injections , ultrasound can be used . Purpose : To assess the clinical outcome of ultrasound-guided subacromial injections compared with blind subacromial injections for subacromial impingement syndrome . Study Design : R and omized controlled clinical trial ; Level of evidence , 1 . Methods : A total of 56 shoulders with subacromial impingement syndrome were r and omized into 2 groups : 28 shoulders received a subacromial corticosteroid injection with ultrasound guidance ( ultrasound group ) , and 28 shoulders received a subacromial corticosteroid injection without ultrasound guidance ( blind group ) . The visual analog scale ( VAS ) for pain with overhead activities and the American Shoulder and Elbow Surgeons ( ASES ) score were obtained before the injection and at 6 weeks after the injection . Results : The VAS score for pain with overhead activities decreased from 59 ± 5 mm ( mean ± SEM ) before the injection to 33 ± 6 mm at 6 weeks after the injection in the ultrasound group ( P < .001 ) and from 63 ± 4 mm to 39 ± 6 mm , respectively , in the blind group ( P < .001 ) . The decrease in the VAS score was not significantly different between the groups ( P > .999 ) . The ASES score increased from 57 ± 2 before the injection to 68 ± 3 at 6 weeks after the injection in the ultrasound group ( P < .01 ) and from 54 ± 3 before the injection to 65 ± 4 after the injection in the blind group ( P < .01 ) , with no significant difference between the groups ( P = .7 ) . Four shoulders ( 14 % ) in the ultrasound group and 6 shoulders ( 21 % ) in the blind group eventually needed surgery ( P = .7 ) . Conclusion : No significant differences were found in the clinical outcome when comparing ultrasound-guided subacromial injections to blind subacromial injections for subacromial impingement syndrome . Clinical Trial Registration : Australian New Zeal and Clinical Trials Registry : OBJECTIVE To compare the accuracy of combinations of clinical examination findings for predicting a positive response to injection of local anaesthetic into the subacromial bursa . DESIGN Prospect i ve , cohort , diagnostic validity design . SUBJECTS Consecutive patients with shoulder pain recruited from primary care physiotherapy and general medical practice s. METHODS All subjects underwent a st and ardised clinical examination ( index test ) followed by a diagnostic injection of xylocaineTM into the subacromial bursa ( reference st and ard test ) performed under ultrasound guidance . Clinical examination variables associated with a positive anaesthetic response ( ≥ 80 % post-injection reduction in pain intensity ) were identified ( p < 0.20 ) and diagnostic accuracy was calculated . RESULTS Of the 196 subjects who received a subacromial bursa injection , 66 subjects ( 34 % ) reported a positive anaesthetic response . Strain injury ( adjusted odds ratio ( AOR ) 2.3 ) , anterior shoulder pain ( AOR 2.3 ) and absence of pain with external rotation at 90º abduction ( AOR 3.9 ) were the strongest clinical predictors of positive anaesthetic response . Clinical prediction model variables demonstrated 100 % specificity ( 3 positive tests ) but low sensitivity ( maximum 40 % ) for a positive anaesthetic response . Combinations of 9 other clinical variables also demonstrated 100 % specificity ( 7 or more positive tests ) , and improved sensitivity ( 95 to 100 % ) for a PAR compared with clinical prediction model variables when less than two findings were present . CONCLUSION Combinations of these clinical tests may assist the clinician to differentiate subacromial pain from other shoulder conditions and guide selection of targeted pain management interventions . Additional diagnostic tests may be required when clinical criteria are not satisfied The subacromial syndrome is the most common source of shoulder pain . The mainstays of conservative treatment are non-steroidal anti-inflammatory drugs and exercise therapy . Recently , low-level laser therapy ( LLLT ) has been popularized in the treatment of various musculoskeletal disorders . The aim of this study is to evaluate the additive effects of LLLT with exercise in comparison with exercise therapy alone in treatment of the subacromial syndrome . We conducted a r and omised clinical study of 80 patients who presented to clinic with subacromial syndrome ( rotator cuff and biceps tendinitis ) . Patients were r and omly allocated into two groups . In group I ( n = 40 ) , patients were given laser treatment ( pulsed infrared laser ) and exercise therapy for ten sessions during a period of 2 weeks . In group II ( n = 40 ) , placebo laser and the same exercise therapy were given for the same period . Patients were evaluated for the pain with visual analogue scale ( VAS ) and shoulder range of motion ( ROM ) in an active and passive movement of flexion , abduction and external rotation before and after treatment . In both groups , significant post-treatment improvements were achieved in all parameters ( P = 0.00 ) . In comparison between the two groups , a significant improvement was noted in all movements in group I ( P = 0.00 ) . Also , there was a substantial difference between the groups in VAS scores ( P = 0.00 ) which showed significant pain reduction in group I. This study indicates that LLLT combined exercise is more effective than exercise therapy alone in relieving pain and in improving the shoulder ROM in patients with subacromial syndrome UNLABELLED SUMMARY BACKGROUND AND PURPOSE : The primary aim of this case series was to investigate the effect of a high dosage medical exercise therapy program on shoulder pain in patients with subacromial pain syndrome . SUBJECTS Six subjects were assigned to a medical exercise therapy group . METHODS They received three treatments a week over three months . Outcome measures were descriptions of the subacromial space including supraspinatus tendon diameter , function , pain , and active range of motion in the shoulder girdle . RESULTS The subjects showed improvement posttest compared to pretest with respect to pain , function , range of motion , and isometric strength . An MRI demonstrated no change in tendon thickness after the treatment . Inflammatory signs such as fluid in the subacromial bursa decreased in some patients . DISCUSSION AND CONCLUSION In patients with uncomplicated subacromial pain syndrome , high dosage medical exercise therapy might be an efficient treatment approach . The clinical effects might be explained by morphological changes in the subacromial space BACKGROUND Musculoskeletal disorders have been identified globally as the second most common healthcare problem for ' years lived with disability ' , and of these shoulder conditions are amongst the most common , frequently associated with substantial pain and morbidity . Exercise and acupuncture are often provided as initial treatments for musculoskeletal shoulder conditions but their clinical effectiveness is uncertain . This study compared group exercise with group exercise plus either acupuncture or electro-acupuncture in patients with subacromial pain syndrome . METHODS Two hundred and twenty-seven participants were recruited to a three-arm parallel-group r and omized clinical trial . The primary outcome measure was the Oxford Shoulder Score . Follow-up was post treatment , and at 6 and 12 months . Between-group differences ( two comparisons : the exercise group versus each of the acupuncture groups ) were analysed at 6 months . A similar comparison across all follow-up time points was also conducted . Data were analysed on intention-to-treat principles with imputation of missing values . RESULTS Treatment groups were similar at baseline , and all treatment groups demonstrated an improvement over time . Between-group estimates at 6 months were , however , small and non-significant , for both of the comparisons . The analyses across all follow-up time points yielded similar conclusions . There was a high rate of missing values ( 22 % for the Oxford Shoulder Score ) . A sensitivity analysis using complete data gave similar conclusions to the analysis with missing values imputed . CONCLUSIONS In the current investigation , neither acupuncture nor electro-acupuncture were found to be more beneficial than exercise alone in the treatment of subacromial pain syndrome . These findings may support clinicians with treatment planning . SIGNIFICANCE Shoulder pain is common and associated with substantial morbidity . Acupuncture is a popular treatment for shoulder pain . The findings suggest that acupuncture and electro-acupuncture offer no additional benefit over exercise in the treatment of shoulder pain of musculoskeletal origin Background Shoulder impingement syndrome is a common musculoskeletal complaint leading to significant reduction of health and disability .  Physiotherapy is often the first choice of treatment although its effectiveness is still under debate . Systematic review s in this field highlight the need for more high quality trials to investigate the effectiveness of physiotherapy interventions in patients with subacromial impingement syndrome . Methods / Design This r and omized controlled trial will investigate the effectiveness of individualized physiotherapy in patients presenting with clinical signs and symptoms of subacromial impingement , involving 90 participants aged 18 - 75 . Participants are recruited from outpatient physiotherapy clinics , general practitioners , and orthopaedic surgeons in Germany . Eligible participants will be r and omly allocated to either individualized physiotherapy or to a st and ard exercise protocol using central r and omization . The control group will perform the st and ard exercise protocol aim ing to restore muscular deficits in strength , mobility , and coordination of the rotator cuff and the shoulder girdle muscles to unload the subacromial space during active movements . Participants of the intervention group will perform the st and ard exercise protocol as a home program , and will additionally be treated with individualized physiotherapy based on clinical examination results , and guided by a decision tree . After the intervention phase both groups will continue their home program for another 7 weeks . Outcome will be measured at 5 weeks and at 3 and 12 months after inclusion using the shoulder pain and disability index and patients ' global impression of change , the generic patient-specific scale , the average weekly pain score , and patient satisfaction with treatment . Additionally , the fear avoidance beliefs question naire , the pain catastrophizing scale , and patients ' expectancies of treatment effect are assessed . Participants ' adherence to the protocol , use of additional treatments for the shoulder , direct and indirect costs , and sick leave due to shoulder complaints will be recorded in a shoulder log-book . Discussion To our knowledge this is the first trial comparing individualized physiotherapy based on a defined decision making process to a st and ardized exercise protocol . Using high- quality method ologies , this trial will add evidence to the limited body of knowledge about the effect of physiotherapy in patients with SIS.Trial registration Current Controlled Trials IS RCT Subacromial impingement is one of the most common causes of painful shoulder in the middle aged and elderly population . Since Neer ’s first description of the process , many investigators have research ed this condition in an effort to gain a better underst and ing of the disease etiology . The aim of this study was to investigate the relationship between the  radiological subacromial distance measurements  and the subacromial impingement syndrome in a series of patients from our institution . For this purpose , 44 patients scheduled for a unilateral shoulder arthroscopy were investigated prospect ively . The acromio-glenoid angle , supraspinatus-glenoid angle ( from coronal MR images ) and acromial index ( from true anterior-posterior shoulder X-ray images ) were measured as the implication s of the subacromial distance , and the degree of subacromial impingement was grade d according to intraoperative findings . Statistical data analysis revealed no significant correlations between the radiological measurements and the severity of subacromial impingement ( p > 0.05 ) . On the other h and , there was a significant correlation ( p = 0.0049 ) between the patient age and subacromial impingement . These results suggest that the radiological subacromial distance measurements do not have enough clinical significance as predictive markers in the subacromial impingement syndrome Abstract Introduction . Rotator cuff tears ( RCT ) are a common source of shoulder pain , with an incidence ranging between 5 % and 40 % . The influence of corticosteroid injections on the incidence of RCT remains unknown . The aim of this study was to estimate the incidence of full-thickness RCT 12 weeks after a subacromial corticosteroid injection in patients with shoulder pain . Patients and method . We made a prospect i ve , open-label study in patients with unilateral painful shoulder without previous local corticosteroid injection .  Ultrasound assessment s were made at the first ( baseline ) and last ( Week 12 ) visits by an experienced radiologist . A rheumatologist did the clinical examination . Patients with full-thickness RCT at the first visit were excluded . All patients received a subacromial injection of triamcinolone acetate 40 mg . Results . One hundred and two patients with shoulder pain were initially evaluated : 49 ( 48 % ) were excluded due to full-thickness RCT on ultrasound assessment . Therefore , 53 patients completed the study ( 34 female , mean age 60.8 years , mean time of evolution 9.6 months ) . In the first ultrasound evaluation , 24 patients ( 45.3 % ) had a partial-thickness tear . At 12 weeks after the corticosteroid injection , 9 ( 17 % ) patients developed full-thickness RCT , 66.6 % of which occurred in patients with previous partial-thickness RCT . Corticosteroid injection significantly improved symptoms ( p = 0.0001 for pain VAS score ) and range of motion ( p = 0.002 for forward elevation and external rotation ) . Conclusions . Seventeen percent of patients with shoulder pain suffered a full-thickness RCT 12 weeks after subacromial corticosteroid injection . Corticosteroid injection is highly effective in improving clinical symptoms of rotator cuff tendinopathy at 12 weeks Primary shoulder impingement syndrome is a common shoulder problem which , if treated ineffectively , can lead to more serious pathology and expensive treatment . This study examined whether subjects receiving joint mobilization and comprehensive treatment ( hot packs , active range of motion , physiologic stretching , muscle strengthening , soft tissue mobilization , and patient education ) would have improved pain , mobility , and function compared with similar patients receiving comprehensive treatment alone . Subjects were eight men and six women ( mean age = 52.9 years ) with primary shoulder impingement syndrome ( superolateral shoulder pain , decreased active humeral elevation , limited overhead function ) . Following r and om assignment to experimental ( N = 7 ) and control groups ( N = 7 ) , three blinded evaluators tested 24-hour pain ( visual analog scale ) , pain with subacromial compression test ( visual analog scale ) , active range of motion ( goniometry ) , and function ( reaching forward , behind the head , and across the body in an overhead position ) before and after nine treatments . One-tailed analyses of covariance ( baseline values as covariates ) showed that the experimental group had less 24-hour pain and pain with subacromial compression test but no differences in range of motion and function ( Mann-Whitney U ) compared with controls . The experimental group improved on all variables , while the control group improved only on mobility and function ( one-tailed , paired t tests ; Wilcoxon matched pairs ) . Age , side of dominance , duration of symptoms , treatment attendance , exercise quality , and adherence had no effect on the outcomes . Results may be affected by inadequate sample size , minimal capsular tightness , insensitive functional scale , nonspecific motion measurements , position at which mobilization treatment was given , or a strong effect of comprehensive treatment . Mobilization decreased 24-hour pain and pain with subacromial compression test in patients with primary shoulder impingement syndrome , but larger replication studies are needed to assess more clearly mobilization 's influence on motion and function STUDY DESIGN R and om allocation of subjects into a placebo-controlled , crossover study . OBJECTIVES To investigate the effect of changing thoracic and scapular posture on shoulder flexion and scapular plane abduction range of motion in asymptomatic subjects , and in subjects with subacromial impingement syndrome . BACKGROUND Changes in upper body posture and concomitant imbalance of the muscle system have been proposed as one of the etiological mechanisms leading to subacromial impingement syndrome . Although clinicians commonly assess posture and devise rehabilitation programs to correct posture , there is little evidence to support this practice . METHODS AND MATERIAL S Selected postural , range of movement , and pain measurements were investigated in 60 asymptomatic subjects and 60 subjects with subacromial impingement syndrome , prior to and following thoracic and scapular taping intended to change their posture .  RESULTS Changing posture had an effect on all components of posture measured ( P<.001 ) and these changes were associated with a significant increase ( P<.001 ) in the range of motion in shoulder flexion and abduction in the plane of the scapula . Changing posture was not found to have a significant effect on the intensity of pain experienced by the symptomatic subjects , although the point in the range of shoulder elevation at which they experienced their pain was significantly higher ( P<.001 ) . CONCLUSIONS The findings of this investigation suggest that changing 1 or more of the components of posture may have a positive effect on shoulder range of movement and the point at which pain is experienced Background Subacromial pain syndrome ( SAPS ) accounts for around 50 % of all cases of shoulder pain . The most commonly used treatments are glucocorticosteroid ( steroid ) injections and exercise therapy ; however , despite treatment SAPS patients often experience relapse of their symptoms . Therefore the clinical effect of combining steroid and exercise therapy is highly relevant to clarify . The aim of this r and omized controlled trial was to investigate if exercise therapy added to steroid injection in patients with SAPS will improve the effect of the injection therapy on shoulder pain . Methods In this two-arm r and omized trial running over 26 weeks , patients with unilateral shoulder pain ( > 4 weeks ) and thickened subacromial bursa ( > 2 mm on US ) were included . At baseline all participants received two steroid injections into the painful shoulder with an interval of one week . Subsequently they were r and omized ( 1:1 ) to either 10 weeks exercise of the involved shoulder ( intervention group ) or exercise of the uninvolved shoulder ( control group ) . The patients were re-examined after the exercise program ( at week 13 ) and again at week 26 . The primary outcome assessed after 26 weeks was change in shoulder pain analyzed using the intention-to-treat principle ( non-responder imputation ) . Results Ninety-nine SAPS patients ( 58 female ) participated ( 49 intervention/50 control ) . At both follow up visits ( week 13 and 26 ) no statistically significant between-group differences in pain changes on a visual analog scale ( mm ) were seen ( 13 weeks : pain at rest 1.7 ( 95 % CI –3.6 to 7.0 ; P = 0.53 ) ; pain in activity 2.2 ( 95 % CI –6.5 to 10.9 ; P = 0.61 ) , 26 weeks : rest 5.6 ( 95 % CI –0.9 to 12.1 ; P = 0.09 ) ; activity 2.2 ( 95 % CI –6.8 to 11.2 ; P = 0.62 ) . The reduction in pain was most evident in the control group at all four pain measurements . The only difference between groups was seen by US examination at week 13 , where fewer participants with impingement were observed in the intervention group compared with the controls ( 9 vs. 19 participants ; P = 0.03 ) . Conclusion Exercise therapy in the painful shoulder in SAPS patients did not improve the effectiveness of steroid injections for shoulder pain in patients with unilateral SAPS and enlarged subacromial bursa on US examination . Trial registration Clinical Trials.gov ( NCT01506804 ) . Registration date 5 May 2011 Abstract . Several work-related , psychosocial and individual factors have been verified as being related to neck and shoulder pain , but the role of pathology visualized by magnetic resonance imaging ( MRI ) remains unclear . In this study , the relationship between neck and shoulder pain and cervical high-field MRI findings was investigated in a sample of persons in a longitudinal survey . The study aim ed to determine whether subjects with persistent or recurrent neck and shoulder pain were more likely to have abnormal MRI findings of cervical spine than those without neck and shoulder pain . A r and om sample of 826 high-school students was investigated initially when the students were 17–19 years , and again when they had reached 24–26 years of age . Eighty-seven percent participated in the first survey in 1989 , of whom 76 % took part in the second survey , in 1996 . The vali date d Nordic Musculoskeletal Question naire was used to collect data about neck and shoulder symptoms . Two groups were chosen for the MRI study : the first group ( n=15 ) consisted of the participants who had reported no neck and shoulder symptoms in either of the inquiries , while the second group ( n=16 ) comprised those who were suffering from neck and shoulder symptoms once a week or more often at the time of both surveys . The degrees of disc degeneration , anular tear , disc herniation and protrusion were assessed by two radiologists . The differences between the two study groups were evaluated . The study found that abnormal MRI findings were common in both study groups . Disc herniation was the only MRI finding that was significantly associated with neck pain . These findings indicate that pathophysiological changes of cervical spine verified on MRI seem to explain only part of the occurrence of neck and shoulder pain in young adults Context The shoulder impingement syndrome includes conditions , such as rotator cuff tendinosis and shoulder bursitis . Conservative management may include corticosteroid injections ( CSIs ) or manual physical therapy ( MPT ) . Contribution In this r and omized , controlled trial , groups of patients with the shoulder impingement syndrome receiving CSI or MPT  showed similar symptom improvements that did not differ significantly . Compared with the MPT group , the CSI group used more health care re sources during the 1-year follow-up . Caution The trial recruited only patients referred to MPT . Implication Manual physical therapy and CSI produced similar clinical outcomes in patients with the shoulder impingement syndrome . The Editors The shoulder impingement syndrome ( SIS ) is a generic term used for patients with shoulder pain that encompasses the rotator cuff syndrome , tendinosis of the rotator cuff muscles , and bursitis in the shoulder area ( 1 ) . It has a cumulative incidence between 5 and 30 per 1000 person-years ( 2 , 3 ) . Conservative treatment options include corticosteroid injections ( CSIs ) and physical therapy . Subacromial CSI is one of the most common procedures used by orthopedists , rheumatologists , and general practitioners ( 4 , 5 ) . However , evidence to support long-term efficacy is conflicting ( 610 ) . Clinical practice guidelines can not recommend for or against CSI for rotator cuff pathology without evidence of tears ( 11 ) . Four recent systematic review s have differing conclusions on the efficacy of CSI for SIS ( 6 , 8 , 9 , 12 ) , but the consensus suggests that any benefit may only be short-term . Although manual physical therapy ( MPT ) may be effective for SIS management ( 1321 ) , 2 recent systematic review s found no clear evidence to suggest additional benefits of MPT to other interventions ( 22 , 23 ) , indicating the need for further research . Data are also lacking about the patterns and timing of CSI and MPT use for patients with SIS . Studies suggest that a CSI is often considered initially ( 4 , 5 ) , whereas a referral to physical therapy may occur only 24 % of the time ( 24 ) . Other studies introduced CSI only after 6 weeks of physical therapy was unsuccessful ( 5 ) . Some investigations evaluated the effect of providing CSI before , or in conjunction with , MPT or shoulder exercises ( 14 , 25 , 26 ) , but CSI and MPT have not been directly compared . The objective of this study was to compare the 1-year effectiveness of CSI and MPT  for SIS management . Methods Design Overview This pragmatic , r and omized , controlled trial compared 2 treatments for patients with SIS : subacromial CSI and MPT . The primary end point was 1-year improvement on the Shoulder Pain and Disability Index ( SPADI ) . Secondary outcomes included changes in Global Rating of Change ( GRC ) scale and Numeric Pain Rating Scale ( NPRS ) scores and shoulder-related health care use . We followed the SPIRIT ( St and ard Protocol Items : Recommendations for Interventional Trials ) statement at the time of protocol development ( 27 ) , and our reporting followed the CONSORT ( Consoli date d St and ards of Reporting Trials ) extension for pragmatic clinical trials ( 28 ) . The study was approved by the Madigan Army Medical Center Institutional Review Board , the trial was registered ( Clinical Trials.gov : NCT01190891 ) , and the protocol was published with open access ( 29 ) . Setting and Participants Consecutive patients aged 18 to 65 years with a primary symptom of unilateral shoulder pain referred from family practice and orthopedic clinics to the physical therapy department at Madigan Army Medical Center were screened for eligibility during their initial visit in the physical therapy clinic . Exclusion criteria included a history of shoulder dislocation , fracture , or adhesive capsulitis ; history of CSI or physical therapy for the shoulder pain in the past 3 months ; baseline SPADI score less than 20 % ; reproduction of shoulder symptoms with cervical spine examination ; history of systemic or neurologic disease affecting the shoulder ; positive rotator cuff lag sign or history of full-thickness rotator cuff tear ; pending litigation ; or inability to attend physical therapy for 3 consecutive weeks . Patients at this medical center included a mix of active-duty and retired military service members and their families . Copayments were not required for care . R and omization and Interventions The r and omization schedule was computer-generated , with assignments placed in opaque , sequentially numbered envelopes by an off-site investigator not involved with patient care or follow-up . Treatment allocation was revealed after collection of baseline outcomes . Patients and treating clinicians were not blind to the intervention . The research assistant who collected outcome assessment s at each time point was blind to group assignment . Two physical therapists provided the MPT , and 1 physician administered all of the injections . Patients were allowed to continue any current medications prescribed by their primary care providers ( PCPs ) . MPT Group At the first session , the physical therapists performed a st and ardized clinical examination to identify relevant impairments ( weakness , mobility , or pain ) . The MPT intervention consisted of a combination of joint and soft-tissue mobilizations ; manual stretches ; contractrelax techniques ; and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine . Specific details of the treatment are published ( 29 ) . Patients did not receive identical treatments , but the MPT techniques were matched to individual impairments identified on examination . Patients were treated twice weekly over a 3-week period , a typical episode of care for SIS , by the same physical therapy in most cases . Home exercises were prescribed to reinforce clinic interventions ( 29 ) . The physical therapists were fellowship-trained in MPT from an American Physical Therapy Associationcredentialed program . CSI Group A credentialed family practice physician with sports medicine fellowship training injected 40 mg of triamcinolone acetonide to the subacromial space of the symptomatic shoulder ( 29 ) . Each participant received a h and out explaining the effects of the steroid injection and how to manage potential side effects . As many as 3 total injections could be administered by the study physician ( > 1 month apart ) during the 1-year period . Patients received printed instructions to perform a gentle gravity-assisted distraction and oscillatory pendulum exercise . Patients were discouraged , but not prohibited , from seeking additional care for at least the first month ( study -related treatment period ) . At the 1- , 3- , and 6-month follow-up periods , patients were also given written instructions and a number to call if they believed that they were not improving and needed additional care . A study coordinator , who was not involved with data collection or treatment , fielded these calls . She advised patients in the MPT group to return to their PCP for additional care and facilitated contact with the physician providing the injection for patients in the CSI group . Each case was managed individually , and another CSI was administered if the patient and physician mutually agreed that it was appropriate . Patients in either group could return to their PCP if they felt the need , and the PCP would manage the patient as they thought best , potentially including a CSI or referral to physical therapy . These patients would not see the same physical therapist or physician who administered the initial study intervention . Outcomes and Follow-up Outcome measurements were administered at baseline , 1 month , 3 months , 6 months , and 1 year . The SPADI is a 100-point , 13-item , self-administered question naire that is divided into 2 subscales : a 5-item pain subscale and an 8-item disability subscale . It is valid , is responsive to change , and accurately discriminates between improving and worsening status ( 30 , 31 ) . The minimal clinical ly important difference for the SPADI is a change between 8 and 13 points ( 6 % to 10 % ) ( 32 ) . The GRC is an instrument that measures overall perceived changes in the participant 's quality of life ( 33 ) . It provides a valid measurement of change in patients ' perceived status ( 34 ) . A GRC score of 3 rating points or greater is clinical ly meaningful ( 35 ) . An 11-point NPRS ranging from 0 ( no pain ) to 10 ( worst imaginable pain ) was used to assess pain intensity ( 36 ) . This scale has been demonstrated to be a reliable , generalizable , and internally consistent measure of clinical and experimental pain intensity ( 37 , 38 ) . The suggested minimal clinical ly important difference for the NPRS is a change of 2 points ( 39 ) . A research assistant blinded to treatment allocation collected health care use information from electronic health records at the 1-year follow-up using an established process ( 40 , 41 ) . This included additional use after completion of the study interventions . We identified shoulder-related visits to physical therapists , PCPs , rheumatologists , and orthopedists , as well as frequency and types of procedures , including additional steroid injections , magnetic resonance imaging , and radiography , similar to other studies ( 42 ) . A second clinician manually verified the electronic health record information to ensure that the care was related to the same shoulder condition . Statistical Analysis The sample size estimated to achieve 80 % power to detect a 12-point difference ( or a 9.2 % change ) in the SPADI , based on a reported minimal clinical ly important difference range of 8 to 13 points ( 32 ) , with an SD of 10 points , a 2-tailed test , and an level of 0.05 was 43 participants per group . To allow for a conservative withdrawal rate of approximately 20 % , we recruited 104 participants . The primary analyses of effectiveness included all available data from patients who received their assigned treatment ( that is , the CSI or at least 1 session of MPT ) . We used a linear mixed-effects model , which is flexible in accommodating data assumed to be missing at OBJECTIVE The purpose of this study was to compare the effects of manual therapy with exercise to kinesiotaping with exercise for patients with subacromial impingement syndrome . METHODS R and omized clinical before and after trial was used . Fifty-four patients diagnosed as having subacromial impingement syndrome who were referred for outpatient treatment were included . Eligible patients ( between 30 and 60 years old , with unilateral shoulder pain ) were r and omly allocated to 2 study groups : kinesiotaping with exercise ( n = 28 ) or manual therapy with exercise ( n = 26 ) . In addition , patients were advised to use cold packs 5 times per day to control for pain . Visual analog scale for pain , Disability of Arm and Shoulder Question naire for function , and diagnostic ultrasound assessment for supraspinatus tendon thickness were used as main outcome measures . Assessment s were applied at the baseline and after completing 6 weeks of related interventions . RESULTS At the baseline , there was no difference between the 2 group characteristics ( P > .05 ) . There were significant differences in both groups before and after treatment in terms of pain decrease and improvement of Disability of Arm and Shoulder Question naire scores ( P < .05 ) . No difference was observed on ultrasound for tendon thickness after treatment in both groups ( P > .05 ) . The only difference between the groups was at night pain , result ing in favor of the kinesiotaping with exercise group ( P < .05 ) . CONCLUSION For the group of subjects studied , no differences were found between kinesiotaping with exercise and manual therapy with exercise . Both treatments may have similar results in reducing pain and disability in subacromial impingement in 6 weeks Background Evidence from a recent r and omized controlled trial indicated that supervised exercises ( SE ) were more effective than radial extracorporeal shock-wave therapy ( rESWT ) for the treatment of subacromial shoulder pain in the short to medium term . Little knowledge exists about the long-term results of rESWT for subacromial pain . Objective The aim of this study was to evaluate the results of rESWT and SE provided to patients with subacromial shoulder pain after 1 year . Design This was a single-blind r and omized controlled trial . Setting The study was conducted in the outpatient clinic of the Physical Medicine and Rehabilitation Department at Oslo University Hospital , Ullevaal , Norway . Patients One hundred four patients with subacromial shoulder pain lasting at least 3 months participated . Patients were r and omly assigned to either an rESWT group ( n=52 ) or an SE group ( n=52 ) . Intervention The rESWT intervention consisted of one session weekly for 4 to 6 weeks . The SE intervention consisted of two 45-minute sessions per week for up to 12 weeks . Measurements The primary outcome measure was the Shoulder Pain and Disability Index . Secondary outcome measures were questions regarding pain and function and work status . Results After 1 year , an intention-to-treat analysis showed no significant differences between the 2 groups for the primary outcome measure ( −7.6 points , 95 % confidence interval=−16.6 to 0.5 ) and pain , function , and medication use . Twenty-nine participants ( 60 % ) in the SE group versus 24 participants ( 52 % ) in the rESWT group were categorized as clinical ly improved . Thirty-eight participants in the SE group were at work compared with 30 participants in the rESWT group ( odds ratio=1.1 , 95 % confidence interval=1.0 to 1.2 ) . Fewer patients in the SE group had received additional treatments between 18 weeks and 1 year . Limitations The lack of a placebo control group , the lack of a cost-benefit analysis , and the small sample size were limitations of the study . Conclusion No significant difference was found between the SE and rESWT groups at the 1-year follow-up . More participants in the SE group had returned to work BACKGROUND The empty and full can arm positions are used as diagnostic tests and in therapeutic exercise programs for patients with subacromial impingement syndrome . The adverse effects of these arm positions on the rotator cuff have not been fully described . The purpose of this investigation was to compare the acromio-humeral distance , three-dimensional scapular position , and shoulder pain during maximum isometric contractions in the empty and full can arm positions . METHODS Subjects with subacromial impingement syndrome ( n=28 ) and a matched control group without shoulder pain ( n=28 ) participated .  Acromio-humeral distance , scapular/clavicular positions and shoulder pain  were measured during maximal isometric contractions in each position . FINDINGS No difference was found in acromio-humeral distance ( P=0.314 ) between the arm positions or between the groups ( P=0.598 ) . The empty can position result ed in greater scapular upward rotation ( P<0.001 , difference=4.9 ° ) , clavicular elevation ( P<0.001 , difference=2.7 ° ) , clavicular protraction ( P=0.001 , difference=2.5 ° ) and less posterior tilt ( P<0.001 , difference=3.8 ° ) than the full can position . No differences in the scapular positions were found between the groups . Positive correlations were seen between the scapular positions in the control and not in the subacromial impingement group . INTERPRETATION Our results did not show a difference in acromio-humeral distance between the arm positions or groups , indicating that the kinematic differences between the positions are not associated with altered acromio-humeral distance . The increased pain in the EC position might be due to the lack of an association amongst the scapular positions rather than the deficiency of a single scapular motion STUDY DESIGN Single-blind r and omized clinical trial , with a follow-up of 24 weeks . OBJECTIVE To determine the effects of hyperthermia via localized microwave diathermy on pain and disability in comparison to subacromial corticosteroid injections in patients with rotator cuff tendinopathy . BACKGROUND Hyperthermia improves symptoms and function in several painful musculoskeletal disorders . However , the effects of microwave diathermy in rotator cuff tendinopathy have not yet been established . METHODS Ninety-two patients with rotator cuff tendinopathy and pain lasting for at least 3 months were recruited from the outpatient clinic of the Department of Orthopaedics and Traumatology , University Hospital , Rome , Italy . Participants were r and omly allocated to either local microwave diathermy or subacromial corticosteroids . The primary outcome measure was the short form of the Disabilities of the Arm , Shoulder and H and Question naire ( QuickDASH ) . Secondary outcome measures were the Constant-Murley shoulder outcome score and a visual analog scale for pain assessment . RESULTS At the end of treatment and at follow-up , both treatment groups experienced improvements in all outcome measures relative to baseline values . Changes over time in QuickDASH , Constant-Murley , and visual analog scale scores were not different between treatment arms . CONCLUSION In patients with rotator cuff tendinopathy , the effects of localized microwave diathermy on disability , shoulder function , and pain are equivalent to those elicited by subacromial corticosteroid injections
In many instances , no or minimal attempts to screen were undertaken or reported .
Background Subacromial shoulder pain is a common clinical presentation with much diagnostic uncertainty .
Some of this uncertainty relates to the involvement of the cervical spine as a source or contribution to subacromial shoulder pain .
Currently , there is no accepted method of screening of the cervical spine in the presence of subacromial shoulder pain , which risks patients receiving misguided and /or ineffective interventions .
Objective To evaluate approaches used to screen the cervical spine in patients with subacromial shoulder pain .