Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings

OBJECTIVE: Although there has been much research about imaging methods for shoulder impingement syndrome, the clinical information and upper limb level of disability have been generally ignored. The purpose of this study was to detect the relationships between clinical, functional, and radiologic variables in patients with shoulder impingement syndrome. DESIGN: A cross-sectional, clinical, and radiologic study was planned and 59 shoulders of 58 consecutive patients waiting for physical therapy because of a clinically suspected shoulder impingement syndrome were included into this study. Comprehensive clinical examination, radiography, shoulder ultrasonography, and magnetic resonance imaging were performed in the same month. RESULTS: Despite the high sensitivities of ultrasonography for diagnosing rotator cuff tears (98.1%) and biceps pathologies (100%), magnetic resonance imaging was superior to ultrasonography in many important shoulder structures such as a glenoid labral tear and subacromial bursal effusion/hypertrophy (P < 0.01). These structures were the determinants of the shoulder's disability measured by disabilities of the arm, shoulder, and hand questionnaire. CONCLUSION: Ultrasonography and magnetic resonance imaging had comparable high accuracy for identifying the biceps pathologies and rotator cuff tears. The basic clinical tests had modest accuracy in both disorders. The choice of which imaging test to perform should be based on the patient's clinical information (regarding lesion of glenoid labrum, joint capsule, muscle, and bone), cost, and imaging experience of the radiology department.     

Diagnosing suprascapular neuropathy in patients with shoulder dysfunction: a report of 5 cases

BACKGROUND AND PURPOSE: Suprascapular neuropathy, resulting in shoulder pain and weakness, is frequently misdiagnosed. The consequences of misdiagnosis can include inappropriate physical rehabilitation or surgical procedures. The purpose of this case report is to describe the differential diagnosis of suprascapular neuropathy. CASE DESCRIPTIONS: Five patients were initially diagnosed with subacromial impingement syndrome and referred for physical therapy. Physical therapist examination findings were consistent with subacromial impingement syndrome and suprascapular neuropathy. Subsequent electrophysiologic testing confirmed the diagnosis of suprascapular neuropathy in all 5 patients. DISCUSSION: The differential diagnosis of patients with suprascapular neuropathy includes subacromial impingement syndrome, rotator cuff pathology, C5-6 radiculopathy, and upper trunk brachial plexopathy. The diagnostic process and a table with key findings based on evidence and clinical experience is presented for differential diagnosis.     

肩袖损伤合并肩峰下撞击综合征的MRI表现

目的探讨肩袖损伤合并肩峰下撞击综合征的MRI影像表现。材料与方法对33例X线片无骨折但临床怀疑肩袖损伤或肩峰下撞击综合征的患者,用1.5 T MRI机检查,观察肩袖损伤及肩峰下撞击综合征在MR上的影像特征,分析两者的相关性,并与手术结果对比,计算准确率。结果 33例中肩袖损伤20例(合并肩峰下撞击综合征10例),肩峰下撞击综合征15例(合并肩袖损伤10例)。肩袖损伤和肩峰下撞击综合征术前MR诊断准确率分别约为95.0%、71.3%。结论肩关节MRI扫描对肩袖损伤及肩峰下撞击综合征的诊断有较高的临床应用价值,肩袖损伤者中至少半数合并肩峰下撞击综合征,临床和影像应予重视。     

脑卒中后肩痛患者肩关节前方撞击综合征的磁共振成像表现

目的 采用磁共振成像（MRI）分析脑卒中后肩痛（PSSP）患者并发肩关节前方撞击综合征的影像学特点,并探讨其发病机制和分型。 方法 将脑卒中后肩痛合并肩关节前方撞击综合征的患者15例作为研究对象,对其进行肩关节查体、MRI影像学分析,并对肩关节前方撞击综合征进行分型。 结果 MRI影像学表现提示,PSSP合并肩关节前方撞击综合征的患者中,4例患者为Ⅰ型,即肩胛下肌前方撞击型;7例患者为Ⅱ型,即肩胛下肌后方撞击型;1例患者为Ⅲ型,即肱二头肌长头肌腱下方撞击型;2例患者为Ⅳ型,即肩胛下肌上缘撞击型;1例患者为Ⅴ型,即混合型,这一类型主要是由Ⅰ、Ⅱ、Ⅲ型撞击混合而成。 结论 PSSP合并肩关节前方撞击综合征患者的撞击类型并不相同,且不同类型的肩关节前方撞击综合征,其撞击部位和特点也不同,MRI是诊断肩关节前方撞击症不同分型的重要方法。     

Shoulder strengthening exercises adapted to specific shoulder pathologies can be selected using new simulation techniques: a pilot study

Purpose

Shoulder strength training exercises represent a major component of rehabilitation protocols designed for conservative or postsurgical management of shoulder pathologies. Numerous methods are described for exercising each shoulder muscle or muscle group. Limited information is available to assess potential deleterious effects of individual methods with respect to specific shoulder pathologies. Thus, the goal of this pilot study was to use a patient-specific 3D measurement technique coupling medical imaging and optical motion capture for evaluation of a set of shoulder strength training exercises regarding glenohumeral, labral and subacromial compression, as well as elongation of the rotator cuff muscles.

Methods

One volunteer underwent magnetic resonance imaging (MRI) and motion capture of the shoulder. Motion data from the volunteer were recorded during three passive rehabilitation exercises and twenty-nine strengthening exercises targeting eleven of the most frequently trained shoulder muscles or muscle groups and using four different techniques when available. For each exercise, glenohumeral and labral compression, subacromial space height and rotator cuff muscles elongation were measured on the entire range of motion.

Results

Significant differences in glenohumeral, subacromial and labral compressions were observed between sets of exercises targeting individual shoulder muscles. Muscle lengths computed by simulation compared to MRI measurements showed differences of 0–5%.

Conclusions

This study represents the first screening of shoulder strengthening exercises to identify potential deleterious effects on the shoulder joint. Motion capture combined with medical imaging allows for reliable assessment of glenohumeral, labral and subacromial compression, as well as muscle-tendon elongation during shoulder strength training exercises.

     

肩部撞击综合征的发生机制和影像学表现

肩部撞击综合征是临床上常见的引起肩关节疼痛和活动障碍的一组疾病,以肩袖、肱二头肌肌腱等结构的炎症及损伤为主要病理改变.广义的肩部撞击综合征包括肩峰下撞击、喙突下撞击和内撞击三型,对其发生机制尚存在争议,本文就肩部撞击的发生机制和影像学表现进行综述.     

The painful shoulder: Part II. Intrinsic disorders and impingement syndrome

Intrinsic disorders that can cause shoulder pain include arthritis, gout, pseudogout and osteonecrosis. In its mildest form, impingement syndrome may cause only minimal discomfort. At its worst, impingement syndrome may lead to rotator cuff tear. Bicipital tendinitis and rupture of the biceps tendon may also be associated with impingement. Early rehabilitative intervention is important. Physical therapy is directed toward restoring range of motion and muscle strength.     

Rotator cuff pathology and subacromial impingement

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.     

Interobserver variation in sonography of the painful shoulder

PURPOSE: This study was conducted as a prospective assessment of interobserver variability in the sonographic evaluation of the rotator cuff. METHODS: Three musculoskeletal radiologists who had different levels of scanning experience each performed shoulder sonography on 24 consecutive patients during 1 patient visit. The diagnostic criteria full-thickness rotator cuff tear, tendon calcification, tendinosis of the supraspinatus, subacromial fluid, subacromial synovial/bursal thickening, dynamic signs of impingement, and abnormality in the long head of biceps tendon were scored, with independent observers recording the data. Statistical analysis was performed using Cohen's kappa test, with significance assessed at p values of less than 0.05. RESULTS: There was good agreement (kappa >0.60, p <0.01) between the experienced operators for full-thickness rotator cuff tear, tendon calcification, dynamic signs of impingement, and abnormality of the long head of biceps tendon. There was no significant agreement between the experienced operators and the less experienced operator in several categories, including (and importantly) full-thickness rotator cuff tears (kappa=0.18-0.21). CONCLUSIONS: In experienced hands sonography of the rotator cuff is a reproducible diagnostic test, but agreement is poor when there is marked disparity between the operators' experience levels. Our findings suggest a need for a more clearly defined training curriculum for sonography of the shoulder in radiology training programs.     

肩胛动力障碍及康复治疗的进展

目的 了解肩胛动力障碍的病因、临床评估和分型,以及肩胛动力障碍康复方法。方法 调查近10年国内外相关文献,总结相关内容。结果和结论 总结了肩胛动力障碍的临床评估和分型。肩胛动力障碍可继发于肩袖损伤、肩峰下撞击综合征、盂肱关节不稳、肩锁关节损伤、投掷肩、冻结肩等,肩胛运动训练可进一步改善康复效果。     

Segmental zoster paresis of the upper extremity: a case report

Segmental zoster paresis, a rare complication of herpes zoster, is characterized by focal, asymmetric motor weakness in the myotome that corresponds to the dermatome of the rash. The pathogenesis of segmental zoster paresis is inflammation caused by the spread of the herpes virus. Motor damage may affect the root, plexus, or peripheral nerve. A woman in her early seventies with right shoulder pain and shoulder girdle muscle weakness was diagnosed with involvement of the C5-7 motor roots and upper truncus of the brachial plexus as a complication of herpes zoster. Recognition of herpes zoster as a cause of acute motor weakness is important in avoiding unnecessary interventions as well as in determining the treatment and outcome of the patient. This case is presented to emphasize that herpes zoster infection may be complicated by segmental paresis, which should be considered in the differential diagnosis of acute painful motor weakness of the upper extremity.     

The Swimmer’s Shoulder: Multi-directional Instability

Purpose of Review

Swimmer’s shoulder is the term used to describe the problem of shoulder pain in swimmers. Originally described as supraspinatus tendon impingement under the coracoacromial arch, it is now understood that several different pathologies can cause shoulder pain in competitive swimmers, including subacromial impingement syndrome, overuse and subsequent muscle fatigue, scapular dyskinesis, and laxity and instability.

Recent Findings

Swimmers may develop increased shoulder laxity over time due to repetitive use. Such excessive laxity can decrease passive shoulder stability and lead to rotator cuff muscle overload, fatigue, and subsequent injury in order to properly control the translation of the humeral head. Generalized laxity can be present up to 62% of swimmers, while a moderate degree of multi-directional instability can be present in the majority. Laxity in swimmers can be due to a combination of underlying inherent anatomical factors as well as from repetitive overhead activity.

Summary

The role of excessive laxity and muscle imbalance are crucial in the swimmer’s shoulder and should be well understood since they are the primary target of the training and rehabilitation program.

     

Anatomical and biomechanical mechanisms of subacromial impingement syndrome

Subacromial impingement syndrome is the most common disorder of the shoulder, resulting in functional loss and disability in the patients that it affects. This musculoskeletal disorder affects the structures of the subacromial space, which are the tendons of the rotator cuff and the subacromial bursa. Subacromial impingement syndrome appears to result from a variety of factors. Evidence exists to support the presence of the anatomical factors of inflammation of the tendons and bursa, degeneration of the tendons, weak or dysfunctional rotator cuff musculature, weak or dysfunctional scapular musculature, posterior glenohumeral capsule tightness, postural dysfunctions of the spinal column and scapula and bony or soft tissue abnormalities of the borders of the subacromial outlet. These entities may lead to or cause dysfunctional glenohumeral and scapulothoracic movement patterns. These various mechanisms, singularly or in combination may cause subacromial impingement syndrome.     

Ursachen und Therapiemöglichkeiten bei sekundären Impingementläsionen der Schulter

Secondary impingement lesions can be caused by e.g. posterior-superior (PSI) and more rarely anterior-superior impingement (ASI). Impingement of the supraspinatus/infraspinatus tendon during overhead athletics with the arm abducted and externally rotated or impingement of the subscapularis tendon with the arm internally rotated is per se not pathologic. Overuse with excessive and repetitive movements, however, can cause force disequilibrium of the shoulder, glenohumeral instability and scapular dyskinesis. Finally, typical injuries such as articular-sided rotator cuff lesions, lesions of the biceps tendon anchor and the labrum can occur. Preventive measures should focus on early detection of functional disorders such as muscle imbalance, scapular dyskinesis and capsular contracture to integrate regular preventive exercises into the training. Capsular contracture and scapular dyskinesis respond particularly well to conservative treatment. In cases of persistent symptoms magnetic resonance imaging e.g. with intra-articular contrast media allow detection of intra-articular pathologies. Articular-sided rotator cuff lesions with less than 50% thickness can usually be debrided and lesions of the biceps anchor should be treated depending on the stage. In the case of a massive anterior instability an anterior capsular plication and in the case of a massive posterior capsular contraction a capsular release can be considered.     

Trapezius muscle activation levels and ratios during scapular retraction exercises: A comparative study between patients with subacromial impingement syndrome and healthy controls

BackgroundLittle is known about trapezius muscle activities during scapular retraction exercises in patients with subacromial impingement syndrome. The aim of this study was to compare upper trapezius, middle trapezius and lower trapezius muscle activity and upper/middle and upper/lower trapezius ratios between patients with subacromial impingement syndrome and healthy individuals during six scapular retraction exercises.MethodsTwenty-two patients with subacromial impingement syndrome and 22 healthy individuals participated. Upper, middle, and lower trapezius activities were measured by surface electromyography, while the participants performed six scapular retraction exercises at different shoulder abduction angles in a standing position. Upper/middle and upper/lower trapezius ratios were also calculated. Repeated-measures analyses of variance were performed to determine whether muscle activation levels and ratios differed between groups during exercises.FindingsThere was no significant exercise × group interactions for upper, middle, and lower trapezius activation levels and upper/middle and upper/lower trapezius ratios (P > .05). A main effect for the exercise was observed for the upper/middle and upper/lower trapezius ratios (P < .05).InterpretationCompared to healthy individuals, patients with subacromial impingement syndrome did not exhibit different upper, middle, and lower trapezius activity and had similar upper/middle and upper/lower trapezius ratios during the various scapular retraction exercises. Therefore, scapular retraction exercises with various shoulder abduction could be safely offered for the patients with subacromial impingement syndrome since it does not lead to abnormal compensatory trapezius muscle activity. If the goal is to minimize upper/middle and upper/lower trapezius ratios, the scapular retraction exercises at 0° shoulder abduction may be used in early stage of shoulder rehabilitation.     

Ultrasound‐guided Prolotherapy with Polydeoxyribonucleotide Sodium in Ischiofemoral Impingement Syndrome

Ischiofemoral impingement syndrome is an uncommon disorder defined by hip pain caused by the narrowing of the space between the ischial tuberosity and lesser trochanter with associated entrapment of the quadratus femoris muscle. We effectively treated two male patients using ultrasound‐guided prolotherapy with polydeoxyribonucleotide sodium mixed with local anesthetics. A 24‐year‐old male patient with no history of trauma or surgery complained of bilateral hip and groin pain; magnetic resonance imaging demonstrated slight narrowing of the bilateral ischiofemoral spaces with mild enhancement of the left quadratus femoris muscle. A 23‐year‐old male patient with a history of iliotibial band release and iliopsoas tendon release complained of left hip and groin pain; magnetic resonance imaging revealed swelling of the left quadratus femoris muscle. After the fifth treatment session of prolotherapy, the pain severity score using the visual analog scale was found to be minimal (0–1/10), and follow‐up magnetic resonance imaging revealed a slightly decreased enhancement of the quadratus femoris muscle compared with that on previous images. Prolotherapy with polydeoxyribonucleotide sodium was an efficacious treatment for two patients with ischiofemoral impingement syndrome who were not candidates for surgery.     

Coracoid impingement syndrome: a literature review

Coracoid impingement syndrome is a less common cause of shoulder pain. Symptoms are presumed to occur when the subscapularis tendon impinges between the coracoid and lesser tuberosity of the humerus. Coracoid impingement should be included in the differential diagnosis when evaluating a patient with activity-related anterior shoulder pain. It is not thought to be as common as subacromial impingement, and the possibility of the coexistence of the two conditions must be taken into consideration before treatment of either as an isolated process. If nonoperative treatment fails to relieve symptoms, surgical decompression can be offered as an option.     

Mechanisms of rotator cuff tendinopathy: Intrinsic,extrinsic, or both?

The etiology of rotator cuff tendinopathy is multi-factorial, and has been attributed to both extrinsic and intrinsic mechanisms. Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder. A unique extrinsic mechanism, internal impingement, is attributed to compression of the posterior articular surface of the tendons between the humeral head and glenoid and is not related to subacromial space narrowing. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes.     

Subacromial Motion Metrics in Painful Shoulder Impingement: A Dynamic Quantitative Ultrasonography Analysis

ObjectivesTo explore the subacromial motion metrics in patients with and without subacromial impingement syndrome (SIS) and to investigate whether the abnormality was associated with rotator cuff pathologies.DesignThis cross-sectional observational study used dynamic quantitative ultrasonography imaging for shoulder joint assessment.SettingOutpatient rehabilitation clinic.ParticipantsIndividuals with SIS on at least 1 shoulder (n=32) and asymptomatic controls (n=32) (N=64).InterventionsNot applicable.Main Outcome MeasuresFrame-by-frame, the humeral greater tuberosity against the lateral edge of the acromion was traced to obtain the minimal vertical acromiohumeral distance (AHD). The rotation angle and radius of the humerus were computed using the least-squares curve fitting method.ResultsApproximately two-thirds of the shoulders with SIS did not have any sonographically identifiable rotator cuff pathologies. There was a consistent trend of nonsignificantly increased humeral rotation angles in painful shoulders. The generalized estimating equation demonstrated that the decreased minimal vertical AHD was associated with painful subacromial impingement (β coefficient: ?0.123cm, 95% confidence interval [CI], ?0.199 to ?0.047). The area under the curve for the minimal vertical AHD to discriminate painful or impinged shoulders ranged from 0.624-0.676. The increased rotation angle (β coefficient: 10.516°; 95% CI, 3.103-17.929) and decreased rotation radius (β coefficient: ?2.903cm; 95% CI, ?5.693 to ?0.111) were shown to be significantly related to the presence of supraspinatus tendinopathy.ConclusionsShoulders with SIS were characterized by a decreased minimal vertical AHD during dynamic examination. Abnormal subacromial metrics can develop in patients with mild (or no) rotator cuff pathologies. More prospective cohort studies are warranted to investigate the changes in subacromial motion metrics in populations at risk for painful or impinged shoulders.     

肩峰下撞击综合征发病机制、诊断及治疗的研究进展

肩峰下撞击综合征(subacromial impingement syndrome,SAIS)是肩关节病变中较为常见的疾患,对其整体了解仍有所不足.多年来,多种假设提出来描述肩峰下撞击征的发病机制,但尚未找到明确的解释.近年来,否认撞击存在的内源性机制越来越受到大众的认可;多个不同的肩峰下撞击综合征的体格检查特异性较低...