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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. 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Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial The addition of cervical unilateral posterior-anterior mobilisation in the treatment of patients with shoulder impingement syndrome: a randomised clinical trial. The relationship between subacromial bursa thickness on ultrasound and shoulder pain in open water endurance swimmers over time. Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression. [Effect of a sensorimotor training program on patients with subacromial pain syndrome]. 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A new interdisciplinary treatment strategy versus usual medical care for the treatment of subacromial impingement syndrome: a randomized controlled trial Objective outcome evaluation using inertial sensors in subacromial impingement syndrome: a five-year follow-up study. Efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy Imaging-guided subacromial therapeutic injections: prospective study comparing abnormalities on conventional radiography with patient outcomes. A comparison of functional, patient-based scores in subacromial impingement. High-dosage medical exercise therapy in patients with long-term subacromial shoulder pain: a randomized controlled trial. Sclerosing polidocanol injections to treat chronic painful shoulder impingement syndrome-results of a two-centre collaborative pilot study The accuracy of subacromial injections: a prospective randomized magnetic resonance imaging study. Are ultrasound, laser and exercise superior to each other in the treatment of subacromial impingement syndrome? A randomized clinical trial. A comparison of work absence periods and the associated costs for two different modes of exercise therapies for patients with longstanding subacromial pain Pain, depression and the postoperative stiff shoulder Is local subacromial corticosteroid injection beneficial in subacromial impingement syndrome? Effectiveness of microwave diathermy on pain, functional capacity, muscle strength, quality of life, and depression in patients with subacromial impingement syndrome: a randomized placebo-controlled clinical study Does Kinesio taping in addition to exercise therapy improve the outcomes in subacromial impingement syndrome? A randomized, double-blind, controlled clinical trial. Does acromioplasty result in favorable clinical and radiologic outcomes in the management of chronic subacromial pain syndrome? A double-blinded randomized clinical trial with 9 to 14 years' follow-up. Shoulder ultrasonography in the diagnosis of polymyalgia rheumatica: a case-control study. The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome Efficacy of Proprioceptive Exercises in Patients with Subacromial Impingement Syndrome: A Single-Blinded Randomized Controlled Study Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study Is radiofrequency treatment effective for shoulder impingement syndrome? A prospective randomized controlled study. Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. A double-blind randomised controlled study comparing subacromial injection of tenoxicam or methylprednisolone in patients with subacromial impingement. Arthroscopic subacromial decompression: results and factors affecting outcome. Ultrasound-Guided Shoulder Injections in the Treatment of Subacromial Bursitis Muscle shortening manoeuvre reduces pain and functional impairment in shoulder impingement syndrome: clinical and ultrasonographic evidence. Evaluation of an exercise concept focusing on eccentric strength training of the rotator cuff for patients with subacromial impingement syndrome Interobserver variation in sonography of the painful shoulder. Cost-effectiveness of exercise therapy after corticosteroid injection for moderate to severe shoulder pain due to subacromial impingement syndrome: a trial-based analysis. A Comparison of Fear-Avoidance Beliefs in Patients With Lumbar Spine Pain and Cervical Spine Pain Management of rotator cuff tears: A comparison of arthroscopic debridement and surgical repair. The Dose-Response Effect of Medical Exercise Therapy on Impairment in Patients with Unilateral Longstanding Subacromial Pain Administration of analgesics after rotator cuff repair: a prospective clinical trial comparing glenohumeral, subacromial, and a combination of glenohumeral and subacromial injections. Open versus arthroscopic subacromial decompressionA prospective, randomized study of 34 patients followed for 8 years Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study. Efficacy of Injections of Corticosteroids for Subacromial Impingement Syndrome* Effect of treatment with low-intensity and extremely low-frequency electrostatic fields (Deep Oscillation) on breast tissue and pain in patients with secondary breast lymphoedema. A comparison of isometric, isotonic concentric and isotonic eccentric exercises in the physiotherapy management of subacromial pain syndrome/rotator cuff tendinopathy: study protocol for a pilot randomised controlled trial Does hyaluronate injection work in shoulder disease in early stage? A multicenter, randomized, single blind and open comparative clinical study. Exercise therapy for shoulder pain aimed at restoring neuromuscular control: a randomized comparative clinical trial. Comparison of efficacy of kinesiological taping and subacromial injection therapy in subacromial impingement syndrome A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study. Effects of a movement training oriented rehabilitation program on symptoms, functional limitations and acromiohumeral distance in individuals with subacromial pain syndrome. Corticosteroid injections in adhesive capsulitis: investigation of their value and site. Assessment of calcific tendonitis of rotator cuff by ultrasonography: comparison between symptomatic and asymptomatic shoulders. The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: a three-arm randomised controlled trial. Randomized, double-blind, placebo-controlled study of the treatment of the painful shoulder. A pilot randomized, controlled trial of treatment for painful arc of the shoulder. A double-blind trial comparing subacromial methylprednisolone and lignocaine in acute rotator cuff tendinitis. Immediate and Short-Term Effects of Upper Thoracic Manipulation on Myoelectric Activity of Sternocleidomastoid Muscles in Young Women With Chronic Neck Pain: A Randomized Blind Clinical Trial. Manipulation of the cervical spine--a pilot study. The Safety and Efficacy of Intrabursal Oxycodone and Bupivacaine in Analgesia After Shoulder Surgery Comparison of the analgesic effects of intrabursal oxycodone and bupivacaine after acromioplasty. Comparision of Ultrasound Therapy of Various Durations in the Treatment of Subacromial Impingement Syndrome Short-term Effects of High-Intensity Laser Therapy Versus Ultrasound Therapy in the Treatment of People With Subacromial Impingement Syndrome: A Randomized Clinical Trial Comparison of subacromial tenoxicam and steroid injections in the treatment of impingement syndrome. Are Psychologic Factors Associated With Shoulder Scores After Rotator Cuff Surgery? Low-level laser therapy versus ultrasound therapy in the treatment of subacromial impingement syndrome: a randomized clinical trial. The effectiveness of scapular stabilization exercise in the patients with subacromial impingement syndrome. Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon Do anatomic variants of the acromion shape in the frontal plane influence pain and function in calcifying tendinitis of the shoulder? Self-training versus physiotherapist-supervised rehabilitation of the shoulder in patients treated with arthroscopic subacromial decompression: a clinical randomized study. Patients with shoulder impingement remain satisfied 6 years after arthroscopic subacromial decompression Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: a randomized clinical trial. Scapular kinematics and impairment features for classifying patients with subacromial impingement syndrome. Does adding heavy load eccentric training to rehabilitation of patients with unilateral subacromial impingement result in better outcome? A randomized, clinical trial COMPARISON OF ECCENTRIC AND CONCENTRIC EXERCISE INTERVENTIONS IN ADULTS WITH SUBACROMIAL IMPINGEMENT SYNDROME. Short-Term Effectiveness of Precut Kinesiology Tape Versus an NSAID as Adjuvant Treatment to Exercise for Subacromial Impingement: A Randomized Controlled Trial Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial. Low-level laser therapy in subacromial impingement syndrome. Effects of methylprednisolone and betamethasone injections on the rotator cuff: An experimental study in rats Validation of a sham comparator for thoracic spinal manipulation in patients with shoulder pain. The effectiveness of low laser therapy in subacromial impingement syndrome: a randomized placebo controlled double‐blind prospective study
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 Purpose Rotator cuff tears are one of the most common causes of shoulder malfunction and pain , which lead to a significant reduction in the quality of life . This present study investigated the effects of subacromial platelet-rich plasma injections [ i.e. autologous conditioned plasma ( ACP ) injections ] as compared to st and ard subacromial cortisone injection therapy in 50 patients with partial rotator cuff tears . Methods Before injection , and 6 weeks , 12 weeks and 6 months thereafter , the patients were assessed by the Constant – Murley score ( CMS ) , the American Shoulder and Elbow Surgeons St and ardized Shoulder Assessment Form ( ASES ) , the simple shoulder test ( SST ) and a pain visual analogue scale ( VAS ) . An MRI was also performed before and 6 months after injection . Results Both patient groups had statistically significant better shoulder score outcomes over time . ASES , SST and CMS outcomes after 12 versus 6 weeks were better in the ACP group as compared to the cortisone group . VAS , ASES and CMS outcomes after 12 weeks versus baseline in the ACP group were better as compared to the cortisone group . There was a statistically significant difference between ACP group and cortisone group 12 weeks after injection regarding VAS , ASES , SST and CMS in favour of the ACP group . The MRI showed an improvement in grade of tendinopathy in both groups , however , without statistically significant differences between the two groups . Conclusion Compared with cortisone injections , ACP injections show earlier benefit as compared to cortisone injections although a statistically significant difference after 6 months could not be found . Therefore , subacromial ACP injections are a good alternative to subacromial cortisone injections , especially in patients with contraindication to cortisone . Level of evidence Therapeutic study , Level III Objective . To compare effects of ultrasound- ( US- ) guided percutaneous electrolysis combined with an eccentric exercise program of the rotator cuff muscles in subacromial pain syndrome . Methods . Thirty-six patients were r and omized and assigned into US-guided percutaneous electrolysis ( n = 17 ) group or exercise ( n = 19 ) group . Patients were asked to perform an eccentric exercise program of the rotator cuff muscles twice every day for 4 weeks . Participants assigned to US-guided percutaneous electrolysis group also received the application of galvanic current through acupuncture needle on each session once a week ( total 4 sessions ) . Shoulder pain ( NPRS ) and disability ( DASH ) were assessed at baseline , after 2 sessions , and 1 week after the last session . Results . The ANOVA revealed significant Group∗Time interactions for shoulder pain and disability ( all , P < 0.01 ) : individuals receiving US-guided percutaneous electrolysis combined with the eccentric exercises experienced greater improvement than those receiving eccentric exercise alone . Conclusions . US-guided percutaneous electrolysis combined with eccentric exercises result ed in small better outcomes at short term compared to when only eccentric exercises were applied in subacromial pain syndrome . The effect was statistically and clinical ly significant for shoulder pain but below minimal clinical difference for function . Future studies should investigate the long-term effects and potential placebo effect of this intervention Introduction Arthroscopic subacromial decompression ( ASD ) is the most commonly performed surgical intervention for shoulder pain , yet evidence on its efficacy is limited . The rationale for the surgery rests on the tenet that symptom relief is achieved through decompression of the rotator cuff tendon passage . The primary objective of this superiority trial is to compare the efficacy of ASD versus diagnostic arthroscopy ( DA ) in patients with shoulder impingement syndrome ( SIS ) , where DA differs only by the lack of subacromial decompression . A third group of supervised progressive exercise therapy ( ET ) will allow for pragmatic assessment of the relative benefits of surgical versus non-operative treatment strategies . Methods and Analysis Finnish Subacromial Impingement Arthroscopy Controlled Trial is an ongoing multicentre , three-group r and omised controlled study . We performed two-fold concealed allocation , first by r and omising patients to surgical ( ASD or DA ) or conservative ( ET ) treatment in 2:1 ratio and then those allocated to surgery further to ASD or DA in 1:1 ratio . Our two primary outcomes are pain at rest and at arm activity , assessed using visual analogue scale ( VAS ) . We will quantify the treatment effect as the difference between the groups in the change in the VAS scales with the associated 95 % CI at 24 months . Our secondary outcomes are functional assessment ( Constant score and Simple shoulder test ) , quality of life ( 15D and SF-36 ) , patient satisfaction , proportions of responders and non-responders , reoperations/treatment conversions , all at 2 years post-r and omisation , as well as adverse effects and complications .  We recruited a total of 210 patients from three tertiary referral centres . We will conduct the primary analysis on the intention-to-treat basis . Ethics and Dissemination The study was approved by the Institutional Review Board of the Pirkanmaa Hospital District and duly registered at Clinical Trials.gov . The findings of this study will be disseminated widely through peer- review ed publications and conference presentations . Trial registration number NCT00428870 ; Pre- results Background Shoulder pain is a very common presentation in primary care . Evidence of benefit for subacromial corticosteroid injection is inconclusive and confined largely to studies with short follow-up . We plan a large , definitive , primary -care-based trial to determine efficacy and safety in patients with rotator cuff tendinopathy , and conducted a pilot trial to explore feasibility . Methods Six general practitioners ( GPs ) from Oxfordshire , UK underwent up date training in assessing painful shoulders and injecting the subacromial space . Each then recruited patients aged 35 to 74 years from primary care complaining of shoulder pain lasting no more than 6 months . Eligible participants were r and omized to receive either methylprednisolone acetate 40 mg with lidocaine 1 % ( total volume 1 ml ) , or lidocaine 1 % alone ( total volume 1 ml ) , injected into the subacromial space . The participants were blinded to treatment allocation . Feasibility outcomes were rates of recruitment , withdrawal , adherence to the protocol , completeness of follow-up , and success of patient masking . Clinical outcomes were the Oxford Shoulder Score ( OSS ) at baseline and at 4 and 12 weeks , and responses to three satisfaction questions at 2 , 4 and 12 weeks . Outcome data were collected by postal question naires . Results A total of 40 participants were r and omized ( 80 % of the target 50 participants ) over 26 weeks giving an overall recruitment rate  of 1.5 participants per week . Rates of follow-up were maintained to a high level for the full 12 weeks . Four participants requested a ‘ rescue ’ corticosteroid injection but no patients withdrew . The trial GPs gave high scores for their confidence that the patient had remained blinded to treatment allocation during the procedure . The OSS at 4 and 12 weeks and the responses to the satisfaction questions are reported . Conclusions It is feasible to recruit participants with shoulder pain in the primary care setting for a blinded , r and omized trial of corticosteroid injection . Online r and omization of participants from the practice is also feasible , and postal question naires provide an effective means of gathering outcome data in this area of study . The lessons learned from this pilot will usefully inform the design of a large , definitive efficacy trial in primary care . Trial registration Current Clinical Trials IS RCT Objective To compare the effectiveness of radial extracorporeal shockwave treatment with that of supervised exercises in patients with shoulder pain . Design Single blind r and omised study . Setting Outpatient clinic of physical medicine and rehabilitation department in Oslo , Norway . Participants 104 patients with subacromial shoulder pain lasting at least three months . Interventions Radial extracorporeal shockwave treatment : one session weekly for four to six weeks . Supervised exercises : two 45 minute sessions weekly for up to 12 weeks . Primary outcome measure Shoulder pain and disability index . Results A treatment effect in favour of supervised exercises at 6 , 12 , and 18 weeks was found . The adjusted treatment effect was −8.4 ( 95 % confidence interval −16.5 to −0.6 ) points . A significantly higher proportion of patients in the group treated with supervised exercises improved — odds ratio 3.2 ( 1.3 to 7.8 ) . More patients in the shockwave treatment group had additional treatment between 12 and 18 weeks — odds ratio 5.5 ( 1.3 to 26.4 ) . Conclusion Supervised exercises were more effective  than radial extracorporeal shockwave treatment for short term improvement in patients with subacromial shoulder pain . Trial registration Clinical trials NCT00653081 Objective To compare the effectiveness of subacromial corticosteroid injection combined with timely exercise and manual therapy ( injection plus exercise ) or exercise and manual therapy alone ( exercise only ) in patients with subacromial impingement syndrome . Design Pragmatic r and omised clinical trial . Setting Primary care based musculoskeletal service . Patients Adults aged 40 or over with subacromial impingement syndrome with moderate or severe shoulder pain . Interventions Injection plus exercise or exercise only . Main outcome measures Primary outcome was the difference in improvement in the total shoulder pain and disability index at 12 weeks . Results 232 participants were r and omised ( 115 to injection plus exercise , 117 to exercise only ) . The mean age was 56 ( range 40 - 78 ) , 127 were women , and all had had a median of 16 weeks of shoulder pain ( interquartile range 12 - 28 ) . At week 12 there was no significant difference between the groups in change in total pain and disability index ( mean difference between change in groups 3.26 ( 95 % confidence interval −0.81 to 7.34 ) , P=0.116 ) . Improvement was significantly greater in the injection plus exercise group at week 1 ( 6.56 , 4.30 to 8.82 ) and week 6 ( 7.37 , 4.34 to 10.39 ) for the total pain and disability index ( P<0.001 ) , with no differences at week 24 ( −2.26 , −6.77 to 2.25 , P=0.324 ) . Conclusions In the treatment of patients with subacromial impingement syndrome , injection plus exercise and exercise only are similarly effective at 12 weeks . Trial registration IS RCT 25817033 ; EudraCT No 2005 - 003628 - 20 Background Arthroscopic subacromial decompression ( ASAD ) is a commonly performed surgical intervention for shoulder pain . The rationale is that removal of a bony acromial spur relieves symptoms by decompressing rotator cuff tendons passing through the subacromial space . However , the efficacy of this procedure is uncertain . The objective of this trial was to compare the efficacy and cost-effectiveness of ASAD in patients with subacromial pain using appropriate control groups , including placebo intervention . Methods / Design The trial is a three-group , parallel design , pragmatic , r and omised controlled study . The intervention content for each group ( ASAD , active monitoring with specialist re assessment ( AMSR ) and investigational shoulder arthroscopy only ( AO ) ) enables assessment of ( 1 ) the efficacy of the surgery against no surgery ; ( 2 ) the need for a specific component of the surgery — namely , removal of the bony spur ; and ( 3 ) quantification of the placebo effect . Concealed allocation was performed using a 1:1:1 r and omisation ratio and using age , sex , baseline Oxford Shoulder Score ( OSS ) and centre as minimisation criteria . The primary outcome measure is the OSS at 6 months post r and omisation .  A total of 300 patients recruited over 24 months from a minimum of 14 UK shoulder units over 24 months were required to detect a difference of 4.5 points on the OSS ( st and ard deviation , 9 ) with 90 % power and to allow for 15 % loss to follow-up . Secondary outcomes include cost-effectiveness , pain , complications and patient satisfaction . A substantial qualitative research component is included . The primary analysis will be conducted on the modified intention-to-treat analysis . Sensitivity analysis will be used to assess the robustness of the results with regard to the underlying assumptions about missing data using multiple imputation . Discussion This trial uses an innovative design to account for the known placebo effects of surgery , but it also will delineate the mechanism for any benefit from surgery . The investigational AO group is considered a placebo intervention ( not sham surgery ) , as it includes all components of subacromial decompression except the critical surgical element . Some discussion is also dedicated to the challenges of conducting placebo surgery trials . Trial registration sUK Clinical Research Network UKCRN12104 . Registered 22 May 2012.International St and ard R and omised Controlled Trial IS RCT N33864128 . Registered 22 June 2012 . Clinical Trials.gov NCT01623011 . Registered 15 June 2012 PURPOSE The purpose of our study was to compare the effectiveness of subacromial bupivacaine infusion and a transdermal fentanyl patch in the treatment of postoperative pain after arthroscopic shoulder surgery . METHODS Sixty patients with rotator cuff disease scheduled for elective arthroscopic shoulder surgery were enrolled in the study . For the treatment of postoperative pain , 30 patients constituted group F and received a 12.0-μg/h fentanyl patch for 72 hours and saline solution infusion in a subacromial manner at the rate of 4 mL/h . The remaining 30 patients constituted group B and received a placebo patch and an infusion of 2.5-mg/mL bupivacaine in a subacromial manner for 72 hours . The primary outcome measure was the postoperative numerical rating scale pain score . The consumption of opioids , ibuprofen , and acetaminophen was also recorded . The Constant scores and general recovery were followed up until the 90th postoperative day . RESULTS There was no statistically significant difference in the numerical rating scale scores ( P = .60 ) between the groups . No differences in the use of rescue analgesic were observed except that the patients receiving bupivacaine used more ibuprofen ( median , 1,200 mg v 600 mg ) during the day of surgery ( P = .042 ) . No difference was found in general recovery between the groups . CONCLUSIONS A fentanyl patch delivering 12-μg/h fentanyl offers an easy and safe treatment option as a part of multimodal analgesia with few adverse effects in the treatment of postoperative pain in a carefully selected patient group after arthroscopic shoulder surgery . LEVEL OF EVIDENCE Level I , r and omized controlled trial Objective The aim of this study was to compare the accuracy of blind vs. ultrasonography-guided corticosteroid injections in subacromial impingement syndrome and determine the correlation between accuracy of the injection location and clinical outcome . Design Forty-six patients with subacromial impingement syndrome were r and omized for ultrasonography-guided ( group 1 , n = 23 ) and blind corticosteroid injections ( group 2 , n = 23 ) . Magnetic resonance imaging analysis  was performed immediately after the injection . Changes in shoulder range of motion , pain , and shoulder function were recorded . All patients were assessed before the injection and 6 wks after the injection . Results Accurate injections were performed in 15 ( 65 % ) group 1 patients and in 16 ( 70 % ) group 2 patients . There was no statistically significant difference in the injection location accuracy between the two groups ( P > 0.05 ) . At the end of the sixth week , regardless of whether the injected mixture was found in the subacromial region or not , all of the patients showed improvements in all of the parameters evaluated ( P < 0.05 ) . Conclusions Blind injections performed in the subacromial region by experienced individuals were reliably accurate and could therefore be given in daily routines . Corticosteroid injections in the subacromial region were very effective in improving the pain and functional status of patients with subacromial impingement syndrome during the short-term follow-up Subacromial impingement syndrome ( SAIS ) is a major contributing factor of shoulder pain ; and treatment approaches ( Kinesio ® taping [ KT ] , Exercise [ EX ] , manual therapy [ MT ] , and high-intensity laser therapy [ HILT ] ) have been developed to treat the pain . The key objective of this study was to compare the effects of KT , MT , and HILT on the pain , the range of motion ( ROM ) , and the functioning in patients with SAIS . Seventy patients with SAIS were r and omly divided into four groups based on the treatment(s ) each group received [ EX ( n = 15 ) , KT + EX ( n = 20 ) , MT + KT + EX ( n = 16 ) , and MT + KT + HILT + EX ( n = 19 ) ] . All the patients were assessed before and at the end of the treatment ( 15th day ) . The main outcome assessment s included the evaluation of severity of pain by visual analogue scale ( VAS ) and shoulder flexion , abduction , and external rotation ROM measurements by a universal goniometry . Shoulder pain and disability index ( SPADI ) was used to measure pain and disability associated with shoulder pathology . Statistically significant differences were found in the treatment results of all parameters in MT + KT + EX and HILT + MT + KT + EX groups ( p < 0.05 ) . When the means of ROM and SPADI results of three groups were compared , statistically significant differences were found between all the groups ( p < 0.05 ) . These differences were significant especially between the groups MT + KT + EX and KT + EX ( p < 0.05 ) and HILT + MT + KT + EX and KT + EX ( p < 0.05 ) . HILT and MT were found to be more effective in minimizing pain and disability and increasing ROM in patients with SAIS . Further studies with follow-up periods are required to determine the advantages of these treatments conclusively Objective : To evaluate the impact on recovery , of single subacromial injection of methylprednisolone in patients with persistent , post-traumatic impingement of the shoulder . Design : R and omised , controlled study . Setting : Large accident and emergency department in Leicester , UK . Participants : 98 patients with persistent , post-traumatic impingement of the shoulder . Intervention : Single subacromial injection of methylprednisolone with bupivicaine ( group S , n=54 ) or bupivicaine only ( group C , n=44 ) . Main outcome measures : Pain using a 10 cm visual analogue scale ( VAS ) and active shoulder abduction . Results : Comparison of pain scores by the 10 cm VAS between group and group C showed no statistical difference at 3 , 6 , or 12 weeks . Mean patient pain scores at 12 weeks were 1.38 in both groups ( p=0.99 ) . There were 16 patients in group S ( mean age 52 years ) with a 10 cm VAS greater than 1 ( 95 % CI CI 0.17 to 0.43 ) , compared with 13 patients ( mean age 57 years ) in group C ( 95 % CI 0.17 to 0.45 ) . Comparison of active shoulder abduction between group S and group C showed no statistical difference at 3 , 6 , or 12 weeks . Mean active abduction at 12 weeks was 168.9 ° in group S and 170.3 ° in group C ( p=0.8 ) . There were 10 patients in group S ( mean age 60.5 ) with active abduction less than 170 at 12 weeks ( 95 % CI 0.09 to 0.31 ) , compared with five patients ( mean age 62 years ) in group C ( 95 % CI 0.04 to 0.24 ) . Conclusions : Single subacromial injection of methylprednisolone has no beneficial impact on reducing the pain , or the duration of immobility in patients with persistent post-traumatic impingement of the Background The physiotherapy dynamic humeral centring ( DHC ) aims to prevent subacromial impingement of rotator cuff tendons during elevation of the arm . The objective of the study was to determine whether DHC acts via an effect on subacromial impingement mechanism by assessing its effect on painful elevation of the arm in subacromial impingement syndrome . Methods This is a secondary analysis of results of a r and omised controlled trial of the effectiveness of DHC .  Sixty-nine patients with subacromial impingement syndrome were prospect ively included . Patients and the assessor were blinded to the study hypothesis and treatment , respectively . Patients underwent DHC or non-specific mobilisation as a control for 6 weeks in 15 supervised individual outpatient sessions with home exercises . Outcomes were pain-free range of motion and presence of painful arc of the shoulder , both in active flexion and abduction of the arm at 3 months . Results At 3 months , pain-free range of motion , both flexion and abduction , was greater in the DHC group than in the mobilisation group . The number of patients with painful arc during flexion was decreased in the DHC group . Conclusions DHC improves painful active elevation of the arm . We suggest that DHC may act via a specific effect on subacromial impingement mechanism OBJECTIVE To determine whether subacromial injection with high-dose corticosteroid in patients with periarticular shoulder disorders is better than low-dose corticosteroid or placebo in improving pain , function , and active range of motion ( AROM ) . DESIGN Multicenter , r and omized , triple-blind , placebo-controlled trial . SETTING Primary ( n=2 ) and university-affiliated ( n=1 ) tertiary-care hospitals . PARTICIPANTS Volunteers ( N=79 ) with periarticular shoulder disorders with at least 1 month 's duration of pain . INTERVENTION Participants were r and omly assigned to receive ultrasound-guided subacromial injection with triamcinolone acetonide , 40 or 20 mg , or placebo . After a single injection , participants were followed up for 8 weeks . MAIN OUTCOME MEASURES Visual analog scale ( VAS ) of average shoulder pain level during the past 1 week , Shoulder Disability Question naire ( SDQ ) , and angles of shoulder AROM ( including flexion , abduction , external rotation , internal rotation ) pre- and posttreatment at weeks 2 , 4 , and 8 . RESULTS There were no significant differences among the 3 groups ( triamcinolone acetonide , 40 mg , group 1 , n=27 ; triamcinolone acetonide , 20 mg , group 2 , n=25 ; placebo , group 3 , n=27 ) in terms of demographic and clinical characteristics at baseline . ( 1 ) Within-group comparison : VAS score , SDQ score , and AROM for groups 1 and 2 significantly improved at weeks 2 , 4 , and 8 ( P<.0167 ) . However , there was no difference in VAS score , SDQ score , and AROM scores for group 3 . ( 2 ) Between-group comparison : significant differences in VAS score , SDQ score , and abduction , external rotation , and internal rotation of AROM were shown between groups 1 and 2 and group 3 at weeks 2 , 4 , and 8 ( P<.05 ) . CONCLUSIONS This was the first study to assess the efficacy of corticosteroid according to 2 different doses , which are the most widely used in subacromial injection for participants with periarticular shoulder disorders . This study showed no significant differences between the high- ( triamcinolone acetonide , 40 mg ) and low-dose ( 20 mg ) corticosteroid groups , indicating preferred use of a low dose at the initial stage Background Shoulder problems are a common complaint of the musculoskeletal system . Physical therapists treat these patients with different modalities such as exercise , massage , and shoulder taping . Although different techniques have been described , the effectiveness of taping has not yet been established . The aim of this study is to assess the effectiveness and cost-effectiveness of usual physical therapy care in combination with a particular tape technique for subacromial impingement syndrome of the shoulder compared to usual physical therapy care without this tape technique in a primary healthcare setting . Methods and design An economic evaluation alongside a r and omized controlled trial will be conducted . A sample of 140 patients between 18 and 65 years of age with a diagnosis of subacromial impingement syndrome ( SAIS ) as assessed by physical therapists will be recruited . Eligible patients will be r and omized to either the intervention group ( usual care in combination with the particular tape technique ) or the control group ( usual care without this tape technique ) . In both groups , usual care will consist of individualized physical therapy care . The primary outcomes will be shoulder-specific function ( the Simple Shoulder Test ) and pain severity ( 11-point numerical rating scale ) . The economic evaluation will be performed using a societal perspective . All relevant costs will be registered using cost diaries . Utilities ( Quality Adjusted Life Years ) will be measured using the EuroQol . The data will be collected at baseline , and 4 , 12 , and 26 weeks follow-up . Discussion This pragmatic study will provide information about the effectiveness and cost-effectiveness of taping in patients presenting with clinical signs of SAIS.Trial registration Trial registration number : HYPOTHESIS Needle lavage is frequently performed before consideration of surgical removal in shoulders with calcific tendinitis because this may avoid surgery . However , its role in nonoperative treatment has not been fully investigated in terms of clinical and radiographic response . We hypothesized that needle decompression and subacromial steroid injection would show good clinical results in chronic calcific tendinitis patients . MATERIAL S AND METHODS Thirty-five shoulders in 30 consecutive patients with painful calcific tendinitis were treated by ultrasound-guided needle decompression and subacromial corticosteroid injection . Patients were prospect ively evaluated using American Shoulder and Elbow Surgeons ( ASES ) and Constant scores at 1 , 3 , and 6 months after the intervention . Size and morphology of the calcific deposits were compared with those in baseline radiographs at each visit . RESULTS At 6 months after the index procedure , 25 shoulders ( 71.4 % ) showed ASES and Constant score improvements from 48.0 and 53.7 to 84.6 and 87.9 , respectively ( P < .01 ) . Ten shoulders ( 28.6 % ) showed no symptom relief at the last follow-up . In shoulders with pain improvement , the mean size of calcific deposits reduced from 13.6 to 5.6 mm ( P < .01 ) , and in shoulders with no pain improvement or that underwent operation , mean size was 13.1 mm at initial visits and 12.7 mm at final visits ( P = .75 ) . DISCUSSION Shoulders showing little evidence of deposit size reduction at 6 months after needle decompression are less likely to achieve symptomatic improvement and may be considered as c and i date s for surgical removal . CONCLUSION Needle decompression with subacromial steroid injection is effective in 71.4 % of calcific tendinitis within 6 months . The size of calcific deposits in patients that achieved symptom relief was reduced HYPOTHESIS We prospect ively studied patients with impingement syndrome to look at outcomes of nonoperative treatment on a temporal basis . MATERIAL S AND METHODS Temporal outcomes of 100 consecutive patients treated for impingement syndrome were prospect ively evaluated . All patients began a st and ardized , nonoperative treatment protocol consisting of a subacromial steroid injection , followed by physical therapy . RESULTS Data were available on 94 patients at the final two-year follow-up assessment . Overall , 74 of 94 patients did not require surgery . In that group , the average American Shoulder and Elbow Surgeons ( ASES ) outcome score increased from 56 to 95 , with an average decrease in the pain score from 4.8 to 0.6 . Improvement was demonstrated in patient shoulder outcome scores ( ASES score ) and visual analog pain scores between treatment initiation and the one-year follow-up assessment ( p < .0001 ) ; no improvement was identified past one year . Of the non-surgical patients , 22 continued to have some shoulder pain . CONCLUSION Of patients with impingement syndrome treated nonoperatively , 79 % did not require surgery after two-year follow-up . Predictors of patients going on to surgical intervention included the total number of subacromial steroid/lidocaine injections and patient response to the initial subacromial injection . Of the patients not undergoing surgery , 30 % continued to have some shoulder pain . LEVEL OF EVIDENCE Level 1 ; Prospect i ve prognosis study , > 80 % follow-up QUESTION Are there different effects of home exercises and supervised exercises on pain and disability for people with subacromial impingement ? DESIGN R and omised trial with two treatment arms , concealed allocation , blinded assessment of some outcomes , and intention-to-treat analysis . PARTICIPANTS Forty-six patients with subacromial impingement were recruited from an interdisciplinary outpatient clinic of physical medicine and rehabilitation at a university hospital in Norway . INTERVENTION The home exercise group had one supervised exercise treatment followed by exercises at home for 6 weeks . The supervised exercise group had up to 10 supervised exercise treatments in addition to home exercises for 6 weeks . OUTCOME MEASURES The primary outcome was the Shoulder Pain and Disability Index ( SPADI ) . Secondary outcome variables were : average pain during the past week , the Fear Avoidance Beliefs Question naire , participant satisfaction with treatment , active range of motion , work status and clinical shoulder tests . Pain was assessed weekly and all outcomes were assessed at 6 weeks . Participants were free to seek ongoing treatment of their choice until 26 weeks , when the SPADI was assessed again . RESULTS While both groups improved considerably , the groups did not differ significantly on the SPADI after the intervention at 6 weeks ( 0 points , 95 % CI -14 to 14 ) or when followed up at 26 weeks ( -2 points , 95 % CI -21 to 17 ) . There were no between-group differences for pain at any time . The remaining outcomes also did not differ significantly , except for the clinical tests of shoulder impingement . In the supervised exercise group , 11 out of 23 participants had two or more positive tests , compared to 18 out of 21 in the home exercise group . CONCLUSION Supervision of more than the first session of a 6-week exercise regimen did not cause significant differences in pain and disability in people with subacromial impingement . TRIAL REGISTRATION NCT01257113 Corticosteroids are commonly used in the treatment of the impingement syndrome . Efficacy , as well as accurate placement , have been question ed . The purpose of this prospect i ve , r and omized study is to assess the accuracy of subacromial injections and to correlate accuracy with short term clinical outcome at 3 months . Sixty shoulders , which were diagnosed with impingement syndrome , were r and omized to receive a subacromial injection of corticosteroids , local anesthetic , and contrast dye from 1 of 3 locations : anterolateral , lateral , or posterior . Accuracy was confirmed by 3 radiographic views of the shoulder , while clinical ratings were assessed by the UCLA shoulder score and a 10-point visual pain analog scale during the initial , post-injection , and 3-month visits . The overall accuracy was 70 % , with no difference among the 3 portals . Accuracy was not related to body mass index . Furthermore , accurate injections did not significantly improve the UCLA score , pain scale , or patient satisfaction at 3 months . In contrast , accurate injections produced a positive Neer 's impingement test more often ( 35/39 vs 9/16 ; P = .009 ) . Overall , there was an improvement in the UCLA score ( 26.2 - 32.2 ; P < .001 ) and a decrease in the pain scale ( 7.2 - 3.43 ; P < .001 ) at 3-month follow-up . In conclusion , the accuracy of injection was 70 % . Clinical improvement did not correlate with accuracy ; however , accuracy did reliably produce a positive impingement test . This multimodal treatment plan did produce significant improvement in shoulder function and pain level in the short term Objective To evaluate if a specific exercise strategy , targeting the rotator cuff and scapula stabilisers , improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome , thereby decreasing the need for arthroscopic subacromial decompression . Design R and omised , participant and single assessor blinded , controlled study . Setting Department of orthopaedics in a Swedish university hospital . Participants 102 patients with long st and ing ( over six months ) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed , recruited through orthopaedic specialists . Interventions The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation . The control exercise programme consisted of unspecific movement exercises for the neck and shoulder . Patients in both groups received five to six individual guided treatment sessions during 12 weeks . In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks . Main outcome measures The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain . Secondary outcomes were patients ’ global impression of change because of treatment and decision regarding surgery . Results Most ( 97 , 95 % ) participants completed the 12 week study . There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group ( 24 points ( 95 % confidence interval 19 to 28.0 ) v 9 points ( 5 to 13 ) ; mean difference between group : 15 points ( 8.5 to 20.6 ) ) . Significantly more patients in the specific exercise group reported successful outcome ( defined as large improvement or recovered ) in the patients ’ global assessment of change because of treatment : 69 % ( 35/51 ) v 24 % ( 11/46 ) ; odds ratio 7.6 , 3.1 to 18.9 ; P<0.001 . A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery : 20 % ( 10/51 ) v 63 % ( 29/46 ) ; odds ratio 7.7 , 3.1 to 19.4 ; P<0.001 ) . Conclusion A specific exercise strategy , focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers , is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome . By extension , this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study . Trial registration Clinical trials This prospect i ve , r and omized trial was performed to compare the results of treating subacromial impingement syndrome of the shoulder by a guided self-training program with the treatment by conventional physiotherapy or a functional brace .  Sixty patients with the diagnosis of an outlet impingement syndrome of the shoulder ( Neer I and II ) were treated either by strengthening the depressors of the humeral head with a guided self-training program , by conventional physiotherapy , or by wearing a functional brace . The Constant-Murley score was assessed after 6 and 12 weeks . Shoulder pain was monitored with a visual analog scale . All three groups showed a significant improvement in shoulder function as well as a significant reduction in pain . There were no statistically significant differences among the groups . Guided self-training can lead to results similar to those of conventional physiotherapy . The comparable effect of the functional brace remains unclear and might be explained by an influence on proprioception Background Platelet-rich plasma ( PRP ) is an autologous platelet concentrate . It is prepared by separating the platelet fraction of whole blood from patients and mixing it with an agent to activate the platelets . In a clinical setting , PRP may be reapplied to the patient to improve and hasten the healing of tissue . The therapeutic effect is based on the presence of growth factors stored in the platelets . Current evidence in orthopedics shows that PRP applications can be used to accelerate bone and soft tissue regeneration following tendon injuries and arthroplasty . Outcomes include decreased inflammation , reduced blood loss and post-treatment pain relief . Recent shoulder research indicates there is poor vascularization present in the area around tendinopathies and this possibly prevents full healing capacity post surgery ( Am J Sports Med36(6):1171–1178 , 2008 ) . Although it is becoming popular in other areas of orthopedics there is little evidence regarding the use of PRP for shoulder pathologies . The application of PRP may help to revascularize the area and consequently promote tendon healing . Such evidence highlights an opportunity to explore the efficacy of PRP use during arthroscopic shoulder surgery for rotator cuff pathologies . Methods / Design PARot is a single center , blinded superiority-type r and omized controlled trial assessing the clinical outcomes of PRP applications in patients who undergo shoulder surgery for rotator cuff disease . Patients will be r and omized to one of the following treatment groups : arthroscopic subacromial decompression surgery or arthroscopic subacromial decompression surgery with application of PRP.The  study will run for 3 years and aims to r and omize 40 patients . Recruitment will be for 24 months with final follow-up at 1 year post surgery . The third year will also involve collation and analysis of the data . This study will be funded through the NIHR Biomedical Research Unit at the Oxford University Hospitals NHS Trust . Trial registration Current Controlled Trials : IS RCT Purpose Subacromial decompression is the st and ard surgical treatment of subacromial impingement syndrome . Unsatisfactory results have been reported for concomitant lesions as well as inadequate diagnosis . We sought to determine the predictive value of the preoperative examination for the results of arthroscopic subacromial decompression in impingement syndrome . Methods Forty-nine shoulder joints in 47 patients receiving arthroscopic subacromial decompression were prospect ively followed for a mean 3.7 ± 0.4 years . Prior to surgery , the impingement tests according to Neer , Hawkins – Kennedy ( in the neutral as well as abducted position ) , and the Jobe test ( empty can position ) were evaluated as well as the presence of a painful arc . The association between the presence of these sings , success of the operation , and improvement in Constant scores as well as WORC indices was analysed . Results Pre- to postoperative improvement in Constant scores as well as WORC indices was greater in case of a positive test result for every test studied . With the numbers available , significant greater improvements in Constant scores were observed only for patients with a positive Hawkins – Kennedy sign in the neutral position , Neer and Jobe tests , compared to patients with negative signs , respectively . No significant differences were observed for the improvement in WORC indices . Patients with at least four positive tests out of the five studied had greater improvement in Constant scores than patients with three or less positive test results . Five patients went on to receive subsequent shoulder surgery . There was no association between the necessity for revision surgery and the presence or absence of impingement signs . Conclusion The impingement tests according to Hawkins – Kennedy , Neer , and Jobe are valid predictors of outcome after subacromial decompression , as is the presence of multiple impingement tests . This study may aid in improving patient outcome and especially patient selection for subacromial decompression . Level of evidence Prognostic , Level OBJECTIVES To compare the effect of grade d physiotherapeutic training of the rotator cuff versus arthroscopic subacromial decompression in patients with subacromial impingement . METHODS R and omised controlled trial with 12 months ' follow up in a hospital setting . Ninety consecutive patients aged 18 to 55 years were enrolled . Symptom duration was between six months and three years . All fulfilled a set of diagnostic criteria for rotator cuff disease , including a positive impingement sign . Patients were r and omised either to arthroscopic subacromial decompression , or to physiotherapy with exercises aim ing at strengthening the stabilisers and decompressors of the shoulder . Outcome was shoulder function as measured by the Constant score and a pain and dysfunction score . " Intention to treat " analysis was used , with comparison of means and control of confounding variables by general equation estimation analysis . RESULTS Of 90 patients enrolled , 84 completed follow up ( 41 in the surgery group , 43 in the training group ) . The mean Constant score at baseline was 34.8 in the training group and 33.7 in the surgery group . After 12 months the mean scores improved to 57.0 and 52.7 , respectively , the difference being non-significant . No group differences in mean pain and dysfunction score improvement were found . CONCLUSIONS Surgical treatment of rotator cuff syndrome with subacromial impingement was not superior to physiotherapy with training . Further studies are needed to qualify treatment choice decisions , and it is recommended that sample s are stratified according to disability level STUDY DESIGN Case series . BACKGROUND Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome . This case series describes a st and ardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period . CASE DESCRIPTION Ten patients ( age range , 19 - 70 years ) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a st and ardized protocol for 10 visits over 6 to 8 weeks . The protocol included a 3-phase progressive strengthening program , manual stretching , thrust and nonthrust manipulation to the shoulder and spine , patient education , activity modification , and a daily home exercise program of stretching and strengthening . Patients completed a history and measures of impairments and functional disability at 2 , 4 , 6 , and 12 weeks . OUTCOMES Treatment success was defined as both a 50 % improvement on the Disabilities of the Arm , Shoulder , and H and ( DASH ) score and a global rating of change of at least " moderately better . " At 6 weeks , 6 of 10 patients had a successful ( mean + /- SD ) DASH outcome score ( initial , 33.9 + /- 16.2 ; 6 weeks , 8.1 + /- 9.2 ) . At 12 weeks , 8 of 10 patients had a successful DASH outcome score ( initial , 33.1 + /- 14 ; 12 weeks , 8.3 + /- 6.4 ) . As a group , the largest improvement was in the first 2 weeks . The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness ( 10 of 10 patients ) , limited shoulder internal rotation motion ( 8 of 10 patients ) , and reduced kyphosis of the midthoracic area ( 7 of 10 patients ) . DISCUSSION A program aim ed at strengthening rotator cuff and scapular muscles , with stretching and manual therapy aim ed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients . This case series describes a comprehensive impairment-based treatment which result ed in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks . LEVEL OF EVIDENCE Therapy , level 4 BACKGROUND Thoracic SMT can improve symptoms in patients with subacromial impingement syndrome . However , at this time the mechanisms of SMT are not well established . It is possible that changes in pain sensitivity may occur following SMT . OBJECTIVES To assess the immediate pain response in patients with shoulder pain following thoracic spinal manipulative therapy ( SMT )  using pressure pain threshold ( PPT ) , and to assess the relationship of change in pain sensitivity to patient-rated outcomes of pain and function following treatment . DESIGN R and omized Controlled Study . METHODS Subjects with unilateral subacromial impingement syndrome ( n = 45 ) were r and omly assigned to receive treatment with thoracic SMT or sham thoracic SMT . PPT was measured at the painful shoulder ( deltoid ) and unaffected regions ( contralateral deltoid and bilateral lower trapezius areas ) immediately pre- and post-treatment . Patient-rated outcomes were pain ( numeric pain rating scale - NPRS ) , function ( Pennsylvania Shoulder Score - Penn ) , and global rating of change ( GROC ) . RESULTS There were no significant differences between groups in pre-to post-treatment changes in PPT ( p ≥ 0.583 ) nor were there significant changes in PPT within either group ( p ≥ 0.372 ) following treatment . NPRS , Penn and GROC improved across both groups ( p < 0.001 ) , but there were no differences between the groups ( p ≥ 0.574 ) . CONCLUSION There were no differences in pressure pain sensitivity between participants receiving thoracic SMT versus sham thoracic SMT . Both groups had improved patient-rated pain and function within 24 - 48 h of treatment , but there was no difference in outcomes between the groups Abstract Objective To assess the efficacy of arthroscopic subacromial decompression ( ASD )  by comparing it with diagnostic arthroscopy , a placebo surgical intervention , and with a non-operative alternative , exercise therapy , in a more pragmatic setting . Design Multicentre , three group , r and omised , double blind , sham controlled trial . Setting Orthopaedic departments at three public hospitals in Finl and . Participants 210 patients with symptoms consistent with shoulder impingement syndrome , enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015 . Interventions ASD , diagnostic arthroscopy ( placebo control ) , and exercise therapy . Main outcome measures Shoulder pain at rest and on arm activity ( visual analogue scale ( VAS ) from 0 to 100 , with 0 denoting no pain ) , at 24 months . The threshold for minimal clinical ly important difference was set at 15 . Results In the primary intention to treat analysis ( ASD versus diagnostic arthroscopy ) , no clinical ly relevant between group differences were seen in the two primary outcomes at 24 months ( mean change for ASD 36.0 at rest and 55.4 on activity ; for diagnostic arthroscopy 31.4 at rest and 47.5 on activity ) . The observed mean difference between groups ( ASD minus diagnostic arthroscopy ) in pain VAS were −4.6 ( 95 % confidence interval −11.3 to 2.1 ) points ( P=0.18 ) at rest and −9.0 ( −18.1 to 0.2 ) points ( P=0.054 ) on arm activity . No between group differences were seen between the ASD and diagnostic arthroscopy groups in the secondary outcomes or adverse events . In the secondary comparison ( ASD versus exercise therapy ) , statistically significant differences were found in favour of ASD in the two primary outcomes at 24 months in both VAS at rest ( −7.5 , −14.0 to −1.0 , points ; P=0.023 ) and VAS on arm activity ( −12.0 , −20.9 to −3.2 , points ; P=0.008 ) , but the mean differences between groups did not exceed the pre-specified minimal clinical ly important difference . Of note , this ASD versus exercise therapy comparison is not only confounded by lack of blinding but also likely to be biased in favour of ASD owing to the selective removal of patients with likely poor outcome from the ASD group , without comparable exclusions from the exercise therapy group . Conclusions In this controlled trial involving patients with a shoulder impingement syndrome , arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months . Trial registration Clinical trials.gov NCT00428870 Shoulder impingement syndrome ( SIS ) is a complex , multi-factorial problem that is treated with a variety of different conservative options . One conservative option that has shown effectiveness is manual therapy to the thoracic spine . Another option , manual therapy to the cervical spine , has been studied only once with good results , evaluating short-term outcomes , in a small sample size . The purpose of this study was to investigate the benefit of neck manual therapy for patients with SIS . The study was a r and omised , single blinded , clinical trial where both groups received pragmatic , evidence -based treatment to the shoulder and one group received neck manual therapy .  Subjects with neck pain were excluded from the study .  Comparative pain , disability , rate of recovery and patient acceptable symptom state ( PASS ) measures were analyzed on the 68 subjects seen over an average of 56.1 days ( st and ard deviation (SD)=55.4 ) . Eighty-six percent of the sample reported an acceptable change on the PASS at discharge . There were no between-groups differences in those who did or did not receive neck manual therapy ; however , both groups demonstrated significant within-groups improvements . On average both groups improved 59.7 % ( SD=25.1 ) for pain and 53.5 % ( SD=40.2 ) for the Quick Disabilities of the Shoulder and H and Question naire ( QuickDASH ) from baseline . This study found no value when neck manual therapy was added to the treatment of SIS . Reasons may include the lack of therapeutic dosage provided for the manual therapy approach or the lack of benefit to treating the neck in subjects with SIS who do not have concomitant neck problems OBJECTIVES To help clinicians underst and the clinical relevance of subacromial bursa ( SAB ) thickness on ultrasound investigations in marathon swimmers . DESIGN A prospect i ve , observational cohort study . METHODS Twenty two open-water marathon swimmers entered in a 19.7 km open-water event received comprehensive , bilateral , shoulder ultrasounds on three occasions : 4 months prior to the race , 2 weeks prior to the race and within 1 week after the race . The SAB thickness was measured in the longitudinal plane of supraspinatus , with other abnormailities also recorded . The swimmers completed question naires detailing presence and severity of shoulder pain , volume of swimming completed that week and their breathing pattern . RESULTS SAB thickness increased with season progression : mean of 1.55 ( ± 0.68 ) 4 months prior to the race , 1.63 ( ± 0.68 ) 2 weeks prior to the race and 1.86 ( ± 0.69 ) 1 week after the race . SAB thickness is significantly ( p=0.05 ) correlated ( β=0.11 ) with kilometres swum in the pool in the preceding week . SAB thickness was not significantly correlated with pain when measured prior to the race . However , at 1 week post race , SAB thickness of shoulders with pain were significantly greater than those without pain , p-value=0.032 . CONCLUSIONS SAB thickness increases with increasing swimming training . Commonly , this increase is not correlated to pain , suggestive of a painless adaptive process . The significant correlation between pain and SAB thickness soon after an exacerbating event suggests that painful acute SAB thickening is a different entity to chronic , painless adaptive SAB thickening . These two entities can only be differentiated by clinical history and examination BACKGROUND The purpose of this study was to compare the effect of compressive cryotherapy ( CC ) vs. ice on postoperative pain in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression . A commercial device was used for postoperative CC . A st and ard ice wrap ( IW ) was used for postoperative cryotherapy alone . METHODS Patients scheduled for rotator cuff repair or subacromial decompression were consented and r and omized to 1 of 2 groups ; patients were r and omized to use either CC or a st and ard IW for the first postoperative week . All patients were asked to complete a " diary " each day , which included visual analog scale scores based on average daily pain and worst daily pain as well as total pain medication usage . Pain medications were then converted to a morphine equivalent dosage . RESULTS Forty-six patients completed the study and were available for analysis ; 25 patients were r and omized to CC and 21 patients were r and omized to st and ard IW . No significant differences were found in average pain , worst pain , or morphine equivalent dosage on any day . CONCLUSION There does not appear to be a significant benefit to use of CC over st and ard IW in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression . Further study is needed to determine if CC devices are a cost-effective option for postoperative pain management in this population of patients The purpose of the present study was to evaluate the effectiveness of a special sensorimotor exercise rehabilitation program on  shoulder function .  In a prospect i ve intervention study we evaluated 32 patients with subacromial pain syndrome , all of whom took part in a conservative rehabilitation program . No patient had surgery on the shoulder involved prior to the study . All patients performed a st and ardised sensorimotor training for the glenohumeral joint , which involved , in particular , the glenohumeral and scapulothoracal stabilisers . In this rehabilitation program special proprioceptive exercise tools ( body-blade , BOING ) were used as well as Tai Chi and aquatic gymnastics . The entire program lasted 4 weeks and was performed and supervised by the same physiotherapist . Prior to and after the program all patients underwent a st and ardised series of tests . These included the Constant- and the UCLA-Score tests and sensorimotor functions with an angle reproduction test , a threshold to motion test as well as isometric strength testing with a Cybex unit . Prior to the rehabilitation program all subjects showed decreased proprioceptive capabilities . This was particularly evident in the threshold to motion test . After 4 weeks of rehabilitation , significant increases in the Constant- and UCLA-Score tests were found . The sensorimotor test also showed an increased proprioceptive capability especially in the threshold to motion test . The angle reproduction test showed only moderate improvement , whereas the isokinetic strength test showed no improvement at all . The present study shows that patients with subacromial pathology suffer from a proprioceptive deficit which can be improved by a special rehabilitation program within only 4 weeks Subacromial impingement syndrome ( SIS ) is a frequent cause of shoulder pain . Our purpose in this double-blinded , r and omized , and controlled study was to demonstrate whether the pulsed electromagnetic field ( PEMF ) provides additional benefit when used with other conservative treatment modalities in acute phase rehabilitation program of SIS . Forty-six patients with unilateral shoulder pain who had been diagnosed as having SIS were included in this trial . The cases were r and omly separated into two groups . All cases received a treatment program for 3 weeks consisting of Codman ’s pendulum exercises and subsequent cold pack gel application on shoulders with pain 5 times a day , restriction of daily activities that require the h and s to be used over the head , and meloxicam tablet 15 mg daily . One group was given PEMF ; the other group was given sham PEMF daily , 25 min per session , 5 days per week for 3 weeks . Shoulder pain during rest and activity and which causes disturbance of sleep was evaluated using a visual analogue scale , and total Constant score investigated shoulder function . Daily living activities were evaluated by shoulder disability question naire . Results were assessed before and after treatment . When compared with the baseline values , significant improvements in all these variables were observed at the end of the treatment in both groups ( p < 0.05 ) . No significant difference between treatments was observed for any of these variables ( p > 0.05 ) . There is no convincing evidence that electromagnetic therapy is of additional benefit in acute phase rehabilitation program of SIS Summary Background Arthroscopic sub-acromial decompression ( decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically ) is a common surgery for subacromial shoulder pain , but its effectiveness is uncertain . We did a study to assess its effectiveness and to investigate the mechanism for surgical decompression . Methods We did a multicentre , r and omised , pragmatic , parallel group , placebo-controlled , three-group trial at 32 hospitals in the UK with 51 surgeons . Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons , were eligible for arthroscopic surgery , and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection . Exclusion criteria included a full-thickness torn rotator cuff . We r and omly assigned participants ( 1:1:1 ) to arthroscopic subacromial decompression , investigational arthroscopy only , or no treatment ( attendance of one re assessment appointment with a specialist shoulder clinician 3 months after study entry , but no intervention ) . Arthroscopy only was a placebo as the essential surgical element ( bone and soft tissue removal ) was omitted . We did the r and omisation with a computer-generated minimisation system . In the surgical intervention groups , patients were not told which type of surgery they were receiving ( to ensure masking ) . Patients were followed up at 6 months and 1 year after r and omisation ; surgeons coordinated their waiting lists to schedule surgeries as close as possible to r and omisation . The primary outcome was the Oxford Shoulder Score ( 0 [ worst ] to 48 [ best ] ) at 6 months , analysed by intention to treat . The sample size calculation was based upon a target difference of 4·5 points ( SD 9·0 ) . This trial has been registered at Clinical Trials.gov , number NCT01623011 . Findings Between Sept 14 , 2012 , and June 16 , 2015 , we r and omly assigned 313 patients to treatment groups ( 106 to decompression surgery , 103 to arthroscopy only , and 104 to no treatment ) . 24 [ 23 % ] , 43 [ 42 % ] , and 12 [ 12 % ] of the decompression , arthroscopy only , and no treatment groups , respectively , did not receive their assigned treatment by 6 months . At 6 months , data for the Oxford Shoulder Score were available for 90 patients assigned to decompression , 94 to arthroscopy , and 90 to no treatment . Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months ( decompression mean 32·7 points [ SD 11·6 ] vs arthroscopy mean 34·2 points [ 9·2 ] ; mean difference −1·3 points ( 95 % CI −3·9 to 1·3 , p=0·3141 ) . Both surgical groups showed a small benefit over no treatment ( mean 29·4 points [ SD 11·9 ] , mean difference vs decompression 2·8 points [ 95 % CI 0·5–5·2 ] , p=0·0186 ; mean difference vs arthroscopy 4·2 [ 1·8–6·6 ] , p=0·0014 ) but these differences were not clinical ly important . There were six study -related complications that were all frozen shoulders ( in two patients in each group ) . Interpretation Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinical ly important . Additionally , surgical decompression appeared to offer no extra benefit over arthroscopy only . The difference between the surgical groups and no treatment might be the result of , for instance , a placebo effect or postoperative physiotherapy . The findings question the value of this operation for these indications , and this should be communicated to patients during the shared treatment decision-making process . Funding Arthritis Research UK , the National Institute for Health Research Biomedical Research Centre , and the Royal College of Surgeons ( Engl and ) OBJECTIVE Shoulder tendinitis and subacromial bursitis are acute , painful inflammatory musculoskeletal conditions that may recur as a result of overuse . We investigated the efficacy of celecoxib in managing patients with acute shoulder tendinitis/bursitis . METHODS In this double blind , placebo controlled , parallel group study , patients with acute onset shoulder tendinitis and /or subacromial bursitis were r and omized to receive one of : celecoxib 400 mg followed by 200 mg bid , naproxen 500 mg bid , or placebo bid for 14 days . The primary measure of efficacy was the mean reduction in Maximum Pain Intensity at Rest , measured using a 100 mm visual analog scale , from baseline to Days 7 and 14 . RESULTS Of the 306 patients r and omized to treatment , 254 completed the study . On Day 7 , the mean reduction from baseline in Maximum Pain Intensity at Rest was significantly greater in the celecoxib group compared with the placebo group ( -27.7 + /- 2.75 mm vs -18.4 + /- 2.63 mm , respectively ; p < 0.05 ) . Similarly , on Day 14 , the mean reduction from baseline in Maximum Pain Intensity at Rest was greater in the celecoxib group compared with placebo ( -35.0 + /- 3.06 mm vs -25.0 + /- 3.05 mm ; p < 0.05 ) . The mean reduction from baseline in Maximum Pain Intensity at Rest was also greater in the naproxen group compared with the placebo group at Day 7 ( -26.4 + /- 2.70 mm vs -18.4 + /- 2.63 mm ; p < 0.05 ) , but not on Day 14 . Secondary measures of efficacy also showed treatment with celecoxib to be significantly better than placebo treatment and similar to treatment with naproxen . In addition , celecoxib was well tolerated in these patients . CONCLUSION Celecoxib showed comparable efficacy to naproxen in relieving the pain of patients with acute shoulder tendinitis and /or subacromial bursitis HYPOTHESIS The objective of this study was to compare the efficacy of subacromial injection of triamcinolone compared to injection of ketorolac in the treatment of external shoulder impingement syndrome . METHODS Thirty-two patients diagnosed with external shoulder impingement syndrome were included in this double-blinded r and omized controlled clinical trial . Each patient was r and omized into the steroid group or nonsteroidal anti-inflammatory drugs ( NSAID ) group . The steroid syringe contained 40 mg triamcinolone ; and the NSAID syringe contained 60 mg ketorolac . Each patient was evaluated in terms of arc of motion , visual analog scale ( VAS ) for evaluating pain , and the UCLA ( The University of California at Los Angeles ) shoulder rating scale . RESULTS At 1 month follow-up , both treatment arms result ed in increased range of motion and decreased pain . The steroid group decreased in active abduction while the NSAID group increased ( steroid : 134 ° , NSAID : 151 ° , P = .03 ) . The mean improvement in the UCLA shoulder rating scale at 4 weeks was 7.15 for the NSAID group and 2.13 for the steroid group ( P = .03 ) . Subgroup analysis of the UCLA scale demonstrated an increase in both forward flexion strength ( P = .04 ) and patient satisfaction ( P = .03 ) in the NSAID group . No significant difference could be seen in all other outcome measures . CONCLUSION In this study , an injection of ketorolac result ed in greater improvements in the UCLA shoulder rating scale than an injection of triamcinolone at 4 weeks follow-up . While both triamcinolone and ketorolac are effective in the treatment of isolated subacromial impingement , ketorolac appears to have equivalent if not superior efficacy ; all the while decreasing patient exposure to the potential side-effects of corticosteroids OBJECTIVE To determine the effects of scapular mobilization on function , pain , range of motion , and satisfaction in patients with subacromial impingement syndrome ( SAIS ) . DESIGN R and omized , double-blind , placebo-controlled clinical trial . SETTING University hospital clinics in Turkey . PARTICIPANTS 66 participants ( mean ± SD age 52.06 ± 3.71 y ) with SAIS . INTERVENTIONS Participants were r and omized into 3 groups : scapular mobilization , sham scapular mobilization , and supervised exercise . Before the interventions transcutaneous electrical stimulation and hot pack were applied to all groups . Total intervention duration for all groups was 3 wk with a total of 9 treatment sessions . MAIN OUTCOME MEASURES Shoulder function and pain intensity were primary outcome measures ; range of motion and participant satisfaction were secondary outcome measures . Shoulder function was assessed with the short form of the Disabilities of the Arm , Shoulder and H and Question naire ( DASH ) . A visual analog scale was used to evaluate pain severity . Active range of motion was measured with a universal goniometer . A 7-point Likert scale was used to evaluate satisfaction . Outcome measurements were performed at baseline , before visits 5 and 10 , 4 wk after visit 9 , and 8 wk after visit 9 . RESULTS There was no group difference for DASH score ( P = .75 ) , pain at rest ( P = .41 ) , pain with activity ( P = .45 ) , pain at night ( P = .74 ) , and shoulder flexion ( P = .65 ) , external rotation ( P = .63 ) , and internal rotation ( P = .19 ) . There was a significant increase in shoulder motion and function and a significant decrease in pain across time when all groups were combined ( P < .001 ) . The level of satisfaction was not significantly different for any of the questions about participant satisfaction between all groups ( P > .05 ) . CONCLUSION There was not a significant advantage of scapular mobilization for shoulder function , pain , range of motion , and satisfaction compared with sham or supervised-exercise groups in patients with SAIS ABSTRACT Objective : To verify effects of kinesio taping ( KT ) in shoulder subacromial impingement syndrome ( SIS ) when compared to sham taping applied in the same way with KT . Patients and Methods : Patients were r and omized as group 1 ( n = 21 ) KT group and group 2 ( n = 20 ) sham-taping group . Taping was applied every three days , three times during the study period . We assessed all the patients at baseline , at the end of the taping period ( 12th day ) , and at one-month post-intervention . We assessed pain on the 100 mm visual analog scale ( VAS ) . Shoulder range of motion ( ROM ) , Constant Scores , and Nottingham Health Profile ( NHP ) scores were evaluated . Results : Of the 41 participants , 13 were males ( 32 % ) and 28 were females ( 68 % ) . The mean age was 45 ± 15 years ( range 20–65 years ) . We documented a significant decrease in VAS for nocturnal pain , and Constant Score in both groups . The KT group showed additional significant change in NHP pain and physical activity scores .  Conclusion : KT and sham taping generated similar results regarding pain and Constant Scores OBJECTIVE To examine the influence of pain on activation in brief maximal and sustained submaximal isometric abduction in patients with rotator tendinosis of the shoulder . DESIGN R and omized , controlled experimental trial . PARTICIPANTS Ten patients with complaints of at least 3 months ' duration ( median range , 1 to 2 years ) and nine healthy controls . INTERVENTION Patients and controls were r and omized into subacromial local anesthetic injection on 2 different days . METHODS The uninvolved shoulder was tested first , elbow flexed 90 degrees , shoulder abducted 45 degrees . The protocol consisted of three brief maximal voluntary contractions ( MVCs ) , followed by a sustained submaximal contraction until exhaustion and three MVCs during a 20-minute recovery period . Electromyography ( EMG ) was obtained bilaterally from the supraspinatus , infraspinatus , upper trapezius , and middle deltoid muscles . Pain was scored on a visual analogue scale ( 0 to 100 ) . RESULTS Mean pain rating on MVC of the involved side of patients was reduced from 28 to 10 by subacromial injection . Mean MVC force improved from 163N to 184N ( 95 % confidence interval for the difference , 14 to 29N ) . The accompanying EMG amplitude during MVC increased significantly in three of the four muscles examined . Pain , force , and EMG of the uninvolved side and in controls were unaltered . Endurance time and EMG ( given as microV ) during the submaximal contraction were not influenced by pain . MVC did not fully recover during the postexhaustive period , while the corresponding EMG amplitudes were comparable to values in unfatigued muscle . CONCLUSION Pain reduced central motor drive during maximal efforts in the unfatigued state , but no additional reduction was seen after a sustained submaximal contraction Background Subacromial impingement syndrome ( SIS ) is the most frequently recorded shoulder disorder . When conservative treatment of SIS fails , a subacromial decompression is warranted . However , the best moment of referral for surgery is not well defined . Both early and late referrals have disadvantages – unnecessary operations and smaller improvements in shoulder function , respectively . This paper describes the design of a new interdisciplinary treatment strategy for SIS ( TRANSIT ) , which comprises rules to treat SIS in primary care and a well-defined moment of referral for surgery . Methods / Design The effectiveness of an arthroscopic subacromial decompression versus usual medical care will be evaluated in a r and omized controlled trial ( RCT ) . Patients are eligible for inclusion when experiencing a recurrence of SIS within one year after a first episode of SIS which was successfully treated with a subacromial corticosteroid injection . After inclusion they will receive injection treatment again by their general practitioner . When , after this treatment , there is a second recurrence within a year post-injection , the participants will be r and omized to either an arthroscopic subacromial decompression ( intervention group ) or continuation of usual medical care ( control group ) . The latter will be performed by a general practitioner according to the Dutch National Guidelines for Shoulder Problems . At inclusion , at r and omization and three , six and 12 months post-r and omization an outcome assessment will take place . The primary outcome measure is the patient-reported Shoulder Disability Question naire . The secondary outcome measures include both disease-specific and generic measures , and an economic evaluation . Treatment effects will be compared for all measurement points by using a GLM repeated measures analyses . Discussion The rationale and design of an RCT comparing arthroscopic subacromial decompression with usual medical care for subacromial impingement syndrome are presented . The results of this study will improve insight into the best moment of referral for surgery for SIS Shoulder-related dysfunction is the second most common musculoskeletal disorder and is an increasing burden on health-care systems . Commonly used clinical question naires suffer from subjectivity , pain dominance and a ceiling effect . Objective functional measurement has been identified as a relevant issue in clinical rehabilitation . Inertia based motion analysis ( IMA ) is a new generation of objective outcome assessment tool ; it can produce objective movement parameters while being fast , cheap and easy to operate . In this prospect i ve study , an inertial sensor comprising a three-dimensional accelerometer and gyroscope is attached at the humerus to measure shoulder movements during two motion tasks in patients with subacromial impingement syndrome at baseline and at five-year after treatment . One hundred healthy subjects served as healthy reference data base and 15 patients were measured pre- and post-treatment . IMA was better able to detect improvement in shoulder movements compared to the clinical question naires ( Disability of Arm , Shoulder and H and ( DASH ) and Simple Shoulder Test ( SST ) ; p < 0.05 ) and was hardly correlated with the clinical question naires ( Pearson R = 0.39 ) . It may therefore add an objective functional dimension to outcome assessment . The fast assessment ( t < 5 min ) of a simple motion test makes it suitable for routine clinical follow-up BACKGROUND A corticosteroid injection in the glenohumeral joint conducted blindly is technically dem and ing with a low rate of accuracy despite satisfactory clinical outcomes in the treatment for adhesive capsulitis . This study prospect ively compared the clinical outcomes of patients with idiopathic adhesive capsulitis treated by a single corticosteroid injection in different locations of the shoulder . MATERIAL S AND METHODS We r and omly assigned 191 patients with adhesive capsulitis to 1 of 4 groups based on corticosteroid injection location : group I , subacromial ; group II , intra-articular ; group III , intra-articular combined with subacromial space ; and group IV , medication .  Pain relief and patient satisfaction were assessed with a visual analog scale and functional outcomes were evaluated with the American Shoulder and Elbow Surgeons score up to 24 weeks after treatment . RESULTS Patients treated with corticosteroids achieved faster pain relief and had greater satisfaction levels than patients in group IV during the 16 weeks after treatment . However , no significant difference in pain scores was observed among the 4 groups at 24-week follow-up visits ( P = .670 ) . Shoulder motion and function improved in all groups at final follow-up . However , shoulder motion in the injection groups recovered faster than that in group IV . At 24 weeks after treatment , no significant differences in shoulder motion or functional outcomes were found among the 4 groups ( P = .117 ) . CONCLUSIONS The efficacy of a single corticosteroid injection was not found to be related to the site of injection . However , a single corticosteroid injection provided faster pain relief , a higher level of patient satisfaction , and an earlier improvement in shoulder motion and function than medication in patients with adhesive capsulitis Background : Rotator cuff tendinopathy ( RCT ) is a significant source of disability and loss of work .  Platelet-rich plasma ( PRP ) has been suggested to be beneficial in the treatment of RCT . Purpose : To investigate the effect of PRP injections on pain and shoulder functions in patients with chronic RCT . Study Design : R and omized controlled trial ; Level of evidence , 1 . Methods : A total of 40 patients , 18 to 70 years of age , with ( 1 ) a history of shoulder pain for > 3 months during overhead-throwing activities , ( 2 ) MRI findings of RCT or partial tendon ruptures , and ( 3 ) a minimum 50 % reduction in shoulder pain with subacromial injections of an anesthetic  were included in this placebo-controlled , double-blind r and omized clinical trial . Patients were r and omized into a PRP group ( n = 20 ) or placebo group ( n = 20 ) . Patients received an ultrasound-guided injection into the subacromial space that contained either 5 mL of PRP prepared from autologous venous blood or 5 mL of saline solution . All patients underwent a 6-week st and ard exercise program . Outcome measures ( Western Ontario Rotator Cuff Index [ WORC ] , Shoulder Pain and Disability Index [ SPADI ] , 100-mm visual analog scale [ VAS ] of shoulder pain with the Neer test , and shoulder range of motion ) were assessed at baseline and at 3 , 6 , 12 , and 24 weeks and 1 year after injection . Results : Comparison of the patients revealed no significant difference between the groups in WORC , SPADI , and VAS scores at 1-year follow-up ( P = .174 , P = .314 , and P = .904 , respectively ) . Similar results were found at other assessment points . Within each group , the WORC , SPADI , and VAS scores showed significant improvements compared with baseline at all time points ( P < .001 ) . In the range of motion measures , there were no significant group × time interactions . Conclusion : At 1-year follow-up , a PRP injection was found to be no more effective in improving quality of life , pain , disability , and shoulder range of motion than placebo in patients with chronic RCT who were treated with an exercise program OBJECTIVE The purpose of this study was to compare abnormalities detected on conventional shoulder radiography with improvement in pain and shoulder function after subacromial injections . SUBJECTS AND METHODS We conducted a prospect i ve outcomes study including 98 consecutive patients after fluoroscopy-guided subacromial injections who returned outcome question naires and who underwent routine shoulder radiography .  Numeric pain rating scale ( NRS ) data were collected before and , along with patient global impression of change ( PGIC ) data , at 1 week and 1 month after injection . Outcome differences were assessed using the Student t test and Mann-Whitney U test . Logistic regression analysis was done , including radiographic variables compared with the outcome improvement . The odds ratios with 95 % CIs were identified for the significant predictors . RESULTS A significant difference in overall improvement was found depending on the posterior acromial slope . Patients with a slope of more than 36 ° had significantly lower NRS and PGIC scores at 1 week and 1 month ( p < 0.025 ) compared with those with a slope of 36 ° or less , with 86.4 % of patients with a slope of more than 36 ° reporting significant improvement at 1 month . This was the only variable linked with improvement in the logistic regression analysis , with an odds ratio of 2.16 ( 95 % CI , 1.11 - 4.22 ) . Patients with calcific tendinitis had significantly lower NRS scores at both 1 week and 1 month ( p = 0.03 and 0.05 , respectively ) and PGIC scores at 1 week ( p = 0.05 ) . CONCLUSION A posterior acromial slope of more than 36 ° and the presence of calcific tendinitis on conventional shoulder radiography are associated with better outcomes . Patients with a slope of more than 36 ° showed the best improvement The goal of this study was to compare the  Oxford Shoulder Score ( OSS ) , the  Shoulder Pain and Disability Index ( SPADI ) , and the Short Form 36 ( SF-36 ) for their correlation , agreement , sensitivity to change , and test-retest reliability in patients with a clinical diagnosis of subacromial impingement . All patients attending a specialist subacromial impingement clinic over a 6-month period completed the OSS , SPADI , and SF-36 at each visit . A total of 323 sets of observations were recorded in 110 patients . The first 38 of these patients were also sent the question naires to complete before their visit . There was good correlation between the OSS and SPADI scores ( correlation coefficient = 0.85 ) and good agreement between the scores on each scale ( weighted kappa = 0.79 ) . The correlation with total SF-36 was poor ( 0.37 for OSS and 0.26 for SPADI ) . The OSS and SPADI showed good effect sizes compared with the total SF-36 score and good test-retest reliability . These data support the use of the OSS or SPADI in patients with subacromial impingement BACKGROUND AND PURPOSE Exercise therapy is a commonly used conservative therapy for long-term subacromial pain . However , there is no consensus regarding what type of exercises and dosage is most effective . The aim of this study was to compare the effect of two exercise programmes : 1 ) high-dosage ( HD ) medical exercise therapy versus 2 ) low-dosage ( LD ) exercise therapy programme for subjects with long-term subacromial pain . METHODS This study used a r and omized , controlled clinical trial with an intention-to-treat analysis . Sixty-one subjects were r and omly assigned by concealment either to an HD medical exercise therapy group ( n = 31 ) or to an LD exercise therapy group ( n = 30 ) . Pain ( visual analogue scale [ VAS ] ) and function ( Shoulder Rating Question naire [ SRQ ] ) were measured at inclusion , at end of treatment and at 6 and 12 months follow-up . RESULTS There were no differences between groups at inclusion ( baseline ) regarding any variables . During the three months treatment period , five subjects ( 8 % ) dropped out , and another seven ( 11 % ) dropped out at one-year follow-up . At the end of treatment , both pain and function had improved significantly in favour of the HD therapy , between-group differences in VAS were -2.7 ( -3.9 to 0.9 ) , and for activity limitations , the between-group differences in the SRQ increased by 24.5 points ( 14.5 - 35.7 ) . The differences between groups were both statistically and clinical ly significant at 6 and 12 months follow-up . CONCLUSION In subjects with long-term subacromial pain syndrome , HD medical exercise therapy is superior to a conventional LD exercise programme . For clinicians to obtain similar positive results with HD medical exercise therapy , factors such as good communication skills , constant close personal supervision during exercise treatment and having from three to five subjects in a group setting are important The histological changes found in the supraspinatus tendon have similarities with the findings in Achilles- , patellar- and extensor carpi radialis brevis (ECRB)-tendinopathy . In recent studies , we have found a vasculo-neural ingrowth in chronic painful Achilles and patellar tendinopathy , and demonstrated good short-term clinical effects with injections of the sclerosing substance polidocanol . In this collaborative two-centre pilot study , 15 patients ( 10 males and 5 females , mean age 46 years ) with a long duration of shoulder pain ( mean 28 months ) , and given the diagnosis chronic painful shoulder impingement syndrome , were included . They had tried rest , traditional rehabilitation exercises and multiple subacromial corticosteroid injections , without effect . We found vascularity ( neovessels ) in chronic painful , but not in pain-free , supraspinatus tendons , and prospect ively studied the clinical effects of ultrasound ( US ) and colour Doppler (CD)-guided injections of polidocanol , targeting the area with neovessels . The patients evaluated the amount of shoulder pain during horizontal shoulder activity on a visual analogue scale ( VAS ) , and satisfaction with treatment . Two ( median ) ( range 1–5 ) polidocanol treatments ( with 4–8 weeks in between ) were given . In four patients ( considered treatment failure ) , cortisone was injected into an inflamed subacromial bursa at one separate occasion weeks after the last polidocanol injection . At follow-up , 8 ( median ) ( range 4–17 ) months after the treatment , 14 patients were satisfied with the result . Using the visual analogue scale evaluation ( VAS ) , the pain dropped from 79 before treatment to 21 at follow-up ( P < 0.05 ) . In the short-term perspective , sclerosing polidocanol injections targeting the neovessels in the supraspinatus tendon and /or bursa wall seems to have a potential to reduce the pain during shoulder loading activity PURPOSE To assess the accuracy of shoulder infiltrations in the subacromial bursa ( SAB ) by a posterior or an anteromedial approach . Magnetic resonance imaging ( MRI ) and clinical outcome were used for evaluation . TYPE OF STUDY A prospect i ve r and omized study . METHODS Thirty-three patients ( 22 women , 11 men ; average age , 46 years ; range , 25 to 64 years ) with clinical signs of subacromial impingement were infiltrated with a mixture of bupivacaine , methylprednisolone , and gadolinium-DTPA directly followed by MRI to determine the actual site of injection . The SAB was r and omly infiltrated posteriorly ( n = 17 ) or anteromedially ( n = 16 ) . Injection confidence of the surgeon and body-mass index of the patient were recorded . Follow-up consisted of the Constant Score , Simple Shoulder Test , and visual analog scale score for pain taken within 24 hours and 6 weeks after infiltration . RESULTS Thirteen injections ( 76 % ) were in the SAB with a posterior approach and 10 ( 69 % ) with an anteromedial approach . Many surrounding structures were hit as well , especially the rotator cuff . A positive correlation between the injection confidence of the orthopaedic surgeon and the MRI was found in 66 % . Only injection of the SAB alone result ed in a significant decrease of the pain ( P = .004 ) and an increase in the functional scores . Injection in the bursa and rotator cuff muscle showed a significant increase in pain ( P = .032 ) but no change in clinical scores . The body mass index had no influence on the scores . CONCLUSIONS Injections in the SAB are inaccurate , despite the confident feeling of the clinician . The finding that many different structures can be infiltrated with 1 injection can create both false-positive and -negative results . LEVEL OF EVIDENCE Level II BACKGROUND Subacromial impingement syndrome ( SIS ) is the most common reason for shoulder pain .  Ultrasound and laser are the physical therapy modalities , in conservative treatment of SIS . AIM The aim of this study was to define and compare the efficacy of ultrasound , laser and exercise in the treatment of SIS . DESIGN This was a r and omized controlled trial with-pre and post-treatment evaluations SETTING Out- patients referred to physical medicine and rehabilitation unit . POPULATION This study was performed on 52 patients with SIS . The patients were r and omly allocated into three groups METHODS The patients were treated five days a week for three weeks with hotpack+ultrasound+exercise ( the first group ) ; hotpack+laser+exercise ( the second group ) , or hotpack+exercise ( the third group ) . The pre and post treatment ranges of motion were measured in the patients . The visual analogue scale ( VAS ) was used to evaluate the severity of pain . Constant scoring was used to evaluate the shoulder functions and the results were compared after the treatment . RESULTS When the post-treatment results of the groups were compared with the pretreatment results , there was a statistically significant improvement in each of the three groups , in the pain , the range of motion and the functional improvement at the shoulder ( P<0.05 ) . However , the inter-group comparison did not reveal any statistically significant difference in the parameters indicating improvement ( P>0.05 ) . CONCLUSION The results of this study demonstrated that ultrasound and laser treatments were not superior to each other in the treatment of SIS . CLINICAL REHABILITATION IMPACT . Exercise treatment forms the base for the conservative treatment Abstract Background : There are no studies on economic issues concerning rehabilitation exercises for shoulder pain . Objective : The aim of the study was to investigate sick leave and the associated costs after a medical exercise therapy programme in patients with longst and ing subacromial pain/impingement . Methods : A r and omised controlled trial in which 61 patients were r and omly assigned either to a high-dosage medical exercise therapy group ( HD )  ( n=31 ) or to a low dosage exercise therapy group ( LD )  ( n=30 ) . Both groups were given three treatments a week over 3 months . The differences between the groups were number of repetitions , number of sets and time performing global aerobic exercises . Results : The outcome for the HD group was significantly ( p<0.05 ) better compared to the LD group . The reduction in costs for sick leave for the HD group was 59.1 % , whereas for the LD group , the reduction was only 42.3 % , which is a significant difference . Conclusion : In patients with longst and ing subacromial pain , HD medical exercise therapy might be an efficient treatment approach Background The surgical repair of shoulder pathologies , including rotator cuff disease and acromio-clavicular joint arthritis , have undergone many technical advances . However the debilitating postoperative stiff shoulder remains a common and significant complication of these surgeries , occurring in 4.9 to 23.2 % of patients undergoing rotator cuff repairs . The pathology of the pathological postoperative stiff shoulder and its associated condition “ frozen shoulder ” are poorly understood and both lack formal objective clinical diagnostic criteria . Additionally , although factors associated with the development of idiopathic frozen shoulder have been well described , multiple studies looking at predictors of postoperative stiff shoulder have produced conflicting results . It has been hypothesised that increased pain in the postoperative period , and depression may be predictors of the development of postoperative stiff shoulder . Method A prospect i ve cohort study involving 132 consecutive participants . Preoperatively , participants undergoing arthroscopic subacromial decompression and /or excision of the distal clavicle and /or rotator cuff repair  will complete question naires about their levels of  shoulder pain using a numerical rating scale from 0 to 10 , and answer a Patient Health Question naire – 9 depression question naire . Postoperatively , the participants ’ pain levels will be self-assessed at two , five and seven days and weeks four , seven and ten . They will complete the depression question naire twice , at the time of their routine first and final postoperative appointments with the treating surgeon . At the final appointment , approximately three months postoperatively , the treating surgeon will clinical ly diagnose participants as having a postoperative stiff shoulder or not . Their shoulders ’ range of motion will be measured . The incidence of postoperative stiff shoulder will be determined , both pain and depression will be analysed as predictors for its development and incidences determined by different objective criteria will be compared . Discussion This trial will add to clinical underst and ing of the postoperative stiff shoulder by providing further insight into the incidence of this condition following shoulder surgery and assessing whether perioperative pain and depression can be used as clinical predictors of postoperative stiff shoulder or markers for possible early intervention . This study will also allow the comparison of incidences determined by different objective criteria in the same cohort . Trial registration Australian New Zeal and Clinical Trials Registry (ANZCTR).ACTRN12613001271796.17 - 11 - 2013 Subacromial corticosteroid injection is one of the most frequently used management tools in subacromial impingement syndrome ( SIS ) despite controversial reports on the efficacy . Our purpose , in this single blinded , r and omised and controlled study was to clarify whether the corticosteroid injection provides additional benefit when used with other conservative treatment modalities in 48 patients with stage 2 SIS . The patients were r and omly divided into three groups according to the two therapeutic injections applied with a 10-day interval : group 1 : 10 cc of 1 % lignocaine + 40 mg of methylprednisolone for the first and second injections , group 2 : 10 cc of 1 % lignocaine + 40 mg of methylprednisolone for the first injection and only 10 cc of 1 % lignocaine for the second injection , group 3 : only 10 cc of 1 % lignocaine for the first and second injections . All the patients were prescribed 500 mg of naproxen sodium to use two times daily , instructed to rest and perform Codman ’s pendulum exercises during the first 15 days . Shoulder pain during rest , activity , and causing disturbance of sleep was evaluated using a visual analogue scale and shoulder function was investigated by total Constant score and its subsectional parameters which are pain , daily living activities , active range of motion and strength before the therapy and 1 and 3 months after the therapy onset . Significant improvements from the baseline values in all pain and function parameters were observed at the first and second evaluation in all groups . Group 1 patients had more favourably improved values in pain causing sleep disturbance and daily living activity parameters than group 2 and 3 patients only in the 1st month after therapy onset . We found that subacromial corticosteroid injections in the acute or subacute phase of SIS provided additional short-term benefit without any complication when used together with nonsteroidal anti-inflammatory drugs ( NSAIDs ) and exercise The aim of this clinical trial was to evaluate the effectiveness of therapeutic MD on pain , functional capacity , muscle strength , quality of life , and depression in patients with subacromial impingement syndrome ( SIS ) . A total of 40 inpatient subjects with definite SIS were included in this study . These patients were sequentially r and omized into 2 groups . Group 1 ( n = 20 ) received therapeutic MD . Group 2 ( n = 20 ) was served as control group and received sham MD . Superficial heat and exercise program were given to both groups . Both of the programs were performed 5 times weekly for 3 weeks . Patients were assessed before treatment ( BT ) , after treatment ( AT ) , and at a 1-month follow-up ( F ) . Outcome measures included visual analogue scale , goniometry , Shoulder Pain and Disability Index , Shoulder Disability Question naire , shoulder isokinetic muscle testing , h and grip strength , Short Form 36 , and Beck Depression Index . The patients with SIS in each group had significant improvements in pain , shoulder ROM , disability , shoulder muscles and grip strength , quality of life , and depression AT and F when compared with their initial status ( P < 0.05 ) . There was no statistically significant difference between the groups according to all the parameters regarding the change scores between AT – BT test and F – BT test ( P > 0.05 ) . A 2,450-MHz MD regimen showed no beneficial effects in patients with SIS , so the superficial heat and exercise program , as it is efficient , may be preferable for the treatment of SIS , alone OBJECTIVE The aim of this study was to determine the effectiveness of Kinesio taping ( KT ) application added to the exercise treatment of subacromial impingement syndrome ( SIS ) . METHODS Thirty-eight ( 25 female , 13 male ) patients with SIS were r and omly divided into therapeutic KT ( n=19 ) and sham KT ( n=19 ) groups . All patients received the same exercise therapy in addition to therapeutic or sham KT at 3-day intervals for 12 days . The groups were compared according to pain , range of motion ( ROM ) , muscle strength and DASH and Constant scores before treatment and at the 5th and 12th treatment days . RESULTS Within group comparisons showed significant improvements in both groups at the 5th and 12th day evaluations ( p<0.05 ) . In comparisons between the groups , pain with movement and DASH scores in the therapeutic group were significantly lower at the 5th day ( p<0.01 ) . There were significant improvements in night pain , pain with movement , DASH score , shoulder external rotation muscle strength , and pain free shoulder abduction ROM in the therapeutic group at the 12th day ( p<0.05 ) . Passive shoulder flexion ROM increased more in the sham group at the 12th day ( p<0.05 ) . CONCLUSION The addition of KT application to the exercise program appears to be more effective than the exercise program alone for the treatment of SIS BACKGROUND The treatment effect of acromioplasty for chronic subacromial pain syndrome ( SAPS ) on long-term shoulder function and rotator cuff deterioration has still to be determined . This study aim ed to determine the long-term clinical and radiologic treatment effect of arthroscopic acromioplasty in patients with chronic SAPS . METHODS In this double-blind , r and omized clinical trial , 56 patients with chronic SAPS ( median age , 47 years ; age range , 31 - 60 years ) were r and omly allocated to arthroscopic bursectomy alone or to bursectomy combined with acromioplasty and were followed up for a median of 12 years . The primary outcome was the Constant score . Secondary outcomes included the Simple Shoulder Test , visual analog scale ( VAS ) for pain , VAS for shoulder functionality , and rotator cuff integrity assessed with magnetic resonance imaging or ultrasound . RESULTS A total of 43 patients ( 77 % ) were examined at a median of 12 years ' follow-up . Intention-to-treat analysis at 12 years ' follow-up did not show a significant additional treatment effect of acromioplasty on bursectomy alone in improvement in Constant score ( 5 points ; 95 % confidence interval , -5.1 to 15.6 ) , Simple Shoulder Test score , VAS score for pain , or VAS score for shoulder function . The prevalence of rotator cuff tears was not significantly different between the bursectomy group ( 17 % ) and acromioplasty group ( 10 % ) . CONCLUSIONS There were no relevant additional effects of arthroscopic acromioplasty on bursectomy alone with respect to clinical outcomes and rotator cuff integrity at 12 years ' follow-up . These findings bring the effectiveness of acromioplasty into question and may support the idea of a more conservative approach in the initial treatment of SAPS OBJECTIVE Magnetic resonance imaging ( MRI ) showed that subacromial/subdeltoid bursitis is the most frequent shoulder lesion in polymyalgia rheumatica ( PMR ) . We evaluated whether shoulder ultrasonography ( US ) was as effective as MRI in the detection of this lesion and assessed the sensitivity and specificity of bilateral subacromial/subdeltoid bursitis in the diagnosis of PMR . METHODS A case-control study of 57 consecutive case patients with untreated PMR and 114 controls seen over a 6 month period in 3 secondary referral rheumatology centers . Control patients consisted of the next 2 consecutive patients with bilateral shoulder aching and stiffness observed after the case patient . In all case and control patients the glenohumeral joint space , bursae , and long head biceps tendon were assessed by bilateral shoulder US . The first 24 case patients were also examined by bilateral shoulder MRI . RESULTS US showed subacromial/subdeltoid bursitis in 55/57 ( 96 % ) patients with PMR and in 25/114 ( 22 % ) controls ( p < 0.001 ) . The lesion was bilateral in 53/55 ( 96 % ) case patients and in 1/25 ( 4 % ) controls ( p < 0.001 ) . The frequency of glenohumeral joint synovitis and biceps tenosynovitis did not differ significantly between case patients and controls . In 100 % of case patients MRI showed subacromial/subdeltoid bursitis confirming US findings . The sonographic evidence of bilateral bursitis had a sensitivity of 92.9 % , specificity of 99 . 1 % , and positive predictive value of 98 . 1 % for the diagnosis of PMR . CONCLUSION US and MRI were equally effective in confirming bilateral subacromial and subdeltoid bursitis in PMR . This finding , in view of its high sensitivity and specificity , could be used as a new diagnostic criterion for PMR Purpose . To investigate the effectiveness of low-level laser therapy ( LLLT ) in addition to exercise programme on shoulder function in subacromial impingement syndrome ( SAIS ) . Method . Sixty-seven patients with SAIS were r and omly assigned to either a group that received laser ( n = 34 ) or a group that received placebo Laser ( n = 26 ) . Pain , functional assessment , disability and muscle strength of shoulder were assessed before and after a 3-week rehabilitation programme . Besides Laser or placebo Laser , superficial cold and progressive exercise programme were administered to both groups , 5 days a week , for 3 weeks . A progressive exercise programme that was done daily twice under supervision in clinic and at home was given to the patients . Results . After the treatment , all outcome measurements had shown significant improvement except muscle strength in both the groups . When the parameters of the improvement were compared , there were no significant differences between the two groups after treatment . Conclusion . We concluded that there is no fundamental difference between LLLT and placebo LLLT when they are supplementing an exercise programme for rehabilitation of patients with shoulder impingement syndrome Objective The objective of this study was to evaluate the effectiveness of proprioceptive exercises on shoulder proprioception , range of motion , pain , muscle strength , and function in patients with subacromial impingement syndrome . Design Sixty-one patients with subacromial impingement syndrome participated in this prospect i ve , single-blind r and omized controlled trial . All patients were r and omly divided into two groups : control group ( conventional physiotherapy , n = 30 ) and intervention group ( proprioceptive exercise and conventional physiotherapy , n = 31 ) . The primary outcome measures were sense of kinesthesia and active and passive repositioning for proprioception at 0 degrees and 10 degrees external rotation at 12 wks . The secondary outcome measures were pain at rest , at night , and during activities of daily living with the visual analog scale ( 0–10 cm ) , the Western Ontario Rotator Cuff index , the American Shoulder and Elbow Surgeons index , range of motion , and isometric muscle strength at both 6 and 12 wks . Results After treatment , significant improvement was found in range of motion , pain , isometric muscle strength , kinesthesia at 0 degrees external rotation , and functional tests in both groups . The intervention group showed a significant improvement in kinesthesia at 10 degrees external rotation and active and passive repositioning at 10 degrees external rotation . When groups were compared , there were no statistically significant differences in any of the parameters at 12 wks . Conclusions Although proprioceptive exercises may provide better proprioceptive acuity , no additional positive effect on other clinical parameters was observed Objective To compare the effectiveness of ultrasound guided corticosteroid injection in the subacromial bursa with systemic corticosteroid injection in patients with rotator cuff disease . Design Double blind r and omised clinical trial . Setting Outpatient clinic of a physical medicine and rehabilitation department in Oslo , Norway . Patients 106 patients with rotator cuff disease lasting at least three months . Interventions Ultrasound guided corticosteroid and lidocaine injection in the subacromial bursa and lidocaine injection in the gluteal region ( local group ) ; corticosteroid and lidocaine injection in the gluteal region and ultrasound guided lidocaine injection in the subacromial bursa ( systemic group ) . Main outcome measures Difference in improvement in the overall shoulder pain and disability index score after six weeks . Results Six weeks after the intervention , the mean difference in improvement in overall shoulder pain and disability index score between the local group and the systemic group was −5.2 ( 95 % confidence interval −13.9 to 3.5 ) ; it was −4.1 ( −12.3 to 4.1 , P=0.32 ) after adjustment for baseline score . A small but statistically significant difference in improvement between groups occurred in favour of the local group for two secondary outcome measures : the Western Ontario rotator cuff index ( 8.1 , 0.7 to 15.6 ) and change in main complaint ( 2.0 , 0 to 4 ) . Conclusions No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease . Trial registration Clinical trials NCT00640575 BACKGROUND To determine whether radiofrequency based plasma microtenotomy has a positive effective in the treatment of shoulder impingement syndrome with cuff tendinosis . MATERIAL S AND METHODS Eighty patients with impingement syndrome and cuff tendinosis that were treated arthroscopically were enrolled in the study . The patients were r and omly assigned to receive either arthroscopic subacromial decompression ( ASD ) alone ( ASD group , n = 40 ) or arthroscopic subacromial decompression combined with radiofrequency ( RF ) based plasma microtenotomy ( RF group , n = 40 ) . Clinical outcome data including VAS pain score , shoulder range of motion ( ROM ) , ASES , UCLA , Constant-Murley , and SST score were recorded preoperatively and at 3 weeks , 6 weeks , 3 months , 6 months , and 1 year postoperatively . RESULTS Sixty-five out of eighty patients ( 81.3 % ) were available for the final follow-up at 1 year postoperation . There were 32 patients in the ASD group and 33 in the RF group . Both treatment groups showed significantly ( P = .031 in the ASD group vs P = .017 in the RF group ) reduced pain 3 weeks postoperatively . Both treatment groups showed significantly improved functional scores 3 months postoperatively . Both treatment groups showed significantly improved flexion elevation ( FE ) and external rotation ( ER ) 1 year postoperatively and internal rotation ( IR ) 6 months postoperatively . No significant difference between the 2 groups was found in any of the outcome measurements at any time point postoperatively . CONCLUSION Arthroscopic subacromial decompression is a reliable treatment for refractory impingement syndrome . The additional radiofrequency based plasma microtenotomy did not show any significant positive effects regarding pain relief , ROM , or functional recovery HYPOTHESIS Ultrasound (US)-guided needling with subacromial corticosteroid injection is more effective than extracorporeal shock wave therapy ( ESWT ) for function restoration and pain relief in patients with calcific tendinitis of the shoulder . METHODS Fifty-four patients diagnosed with unilateral painful calcific tendinitis were r and omly allocated to a US needling or ESWT group . The US needling group underwent US-guided needling and received a subacromial corticosteroid injection . The ESWT group received ESWT 3 times a week . All patients were prospect ively evaluated ; American Shoulder and Elbow Surgeons , Simple Shoulder Test , and visual analog scale for pain scores were recorded before the procedure and at 6 weeks , 12 weeks , 6 months , 12 months , and the last follow-up . The size and morphology of the deposits were evaluated by radiography . RESULTS The average follow-up period was 23.0 months . At last follow-up , the mean size of the deposits was significantly different between the 2 groups ( P = .001 ) ; it decreased to 0.5 mm from 14.8 mm in the US needling group and to 5.6 mm from 11.0 mm in the ESWT group . There were also significant improvements in clinical outcomes in both groups after treatment ( P < .05 ) . At 1-year follow-up , the US needling group had significantly better scores than the ESWT group with regard to the American Shoulder and Elbow Surgeons assessment ( 90.3 and 74.6 , respectively ; P = .001 ) , Simple Shoulder Test ( 83.3 and 70.8 , respectively ; P = .015 ) , and visual analog scale for pain ( 1.4 and 3.3 , respectively ; P = .003).The initial calcium deposit sizes and clinical outcomes were weakly correlated in both groups ( P > .05 ) . CONCLUSION Both treatment modalities for calcific tendinitis improved clinical outcomes and eliminated calcium deposits . US-guided needling treatment , however , was more effective in function restoration and pain relief in the short term We have carried out a prospect i ve double-blind r and omised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug , tenoxicam , with a single injection of methylprednisolone in patients with subacromial impingement . A total of 58 patients were r and omly allocated into two groups . Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine . The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm , Shoulder and H and ( DASH ) and the Oxford Shoulder Score ( OSS ) as secondary measures . Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group ( p = 0.003 ) than in the tenoxicam group . The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two ( p < 0.01 ) , four ( p < 0.01 ) and six weeks ( p < 0.020 ) after the injection . The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group . Although the difference was statistically significant at two ( p < 0.001 ) and four ( p = 0.003 ) weeks after the injection , it was not at six weeks ( p = 0.055 ) . Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks . Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks Arthroscopic subacromial decompression was performed on 114 patients with rotator cuff impingement who had not responded to nonoperative measures . None of the patients had a full-thickness cuff tear . Patients with associated instability , symptomatic acromioclavicular joint disease , or ruptures of the long head of biceps were not included . Results were determined by question ing patients about their satisfaction with the outcome of surgery and by functional assessment of the shoulder with the parameters of pain , ability to perform daily activities , and range of motion according to the Constant scoring system . When review ed at a mean interval of 19 months after surgery , 85 patients ( 75 % ) were satisfied with the outcome . Pain scores improved by an average of 8.6 points ; " activities of daily living " scores improved by an average of 5.8 points ; range-of-motion scores improved by an average of 3.6 points . The improvements in all 3 parameters scored were significant ( P < .05 ) . The following variables were statistically analyzed to assess their influence on final outcome : age , sex , occupation , duration of symptoms before surgery , dominance of the affected shoulder , outcome of the impingement test , state of the cuff , and experience of the surgeon performing the operation . The duration of symptoms before surgery was the most significant predictor of outcome . Symptoms of prolonged duration were associated with an unsatisfactory subjective results ( P < .01 ) and with smaller improvements in the parameters of the Constant score ( P < .001 ) . Recovery after arthroscopic subacromial decompression and eventual outcome were related to the extent of cuff damage . Patients with partial thickness tears or fraying of the cuff had a delayed return to work ( P < .001 ) and were found to have smaller increases in the pain and range-of-motion scores ( P < .05 ) . A satisfactory subjective result was most often associated with a positive impingement test ( P < .05 ) . Unsatisfactory outcomes were associated with a question able diagnosis and lack of clear evidence of impingement at arthroscopy , inadequate decompression of the subacromial space , or the presence of calcium deposits in the rotator cuff Chen MJL , Lew HL , Hsu TC , Tsai WC , Lin WC , Tang SFT , Lee YC , Hsu RCH , Chen CPC : Ultrasound-guided shoulder injections in the treatment of subacromial bursitis . Am J Phys Med Rehabil 2006;85:31–35 . Objective : To investigate the treatment effectiveness between ultrasound-guided and blind injection techniques in the treatment of subacromial bursitis . Design : A total of 40 patients with sonographic confirmation of subacromial bursitis were recruited into this study . These patients were divided into blind and ultrasound-guided injection groups . The shoulder abduction range of motion was compared before injections and 1 wk after the completion of injections in both groups . Results : The shoulder abduction range of motion before injection in the blind injection group was 71.03 ± 12.38 degrees and improved to 100 ± 18.18 degrees 1 wk after the injection treatments . However , the improvement did not reveal significant statistical differences ( P > 0.05 ) . The shoulder abduction range of motion before injection in the ultrasound-guided injection group was 69.05 ± 14.72 degrees and improved to 139.29 ± 20.14 degrees 1 wk after the injection treatments ( P < 0.05 ) . Conclusions : Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa . The ultrasound-guided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis OBJECTIVES To evaluate the short-term efficacy of muscle shortening manoeuvre ( MSM ) , by inducing an increase in strength of the shoulder muscles , for the treatment of shoulder impingement syndrome ( SIS ) . METHODS Sixty subjects ( mean age : 58.6 years ) with SIS were assigned to one of 3 different treatment interventions : 1 ) MSM : a series of fast accelerations in the upward direction was applied to the upper limb that was also su bmi tted to forces acting in the opposite direction ( added mass ) ; 2 ) traditional physiotherapeutic technique : scapulothoracic gliding ; 3 ) simple traction : the added mass was applied to the limb without the series of fast accelerations .  Pain intensity , Neer 's impingement sign , range of motion and muscle strength were assessed . Ultrasound ( US ) examination was performed before , immediately after and 30 days after each treatment to study the width of the subacromial-subdeltoid bursa , long biceps tendon sheath and acromioclavicular joint . Impingement was evaluated by dynamic examination . RESULTS After treatment with  MSM  , pain was significantly reduced ( p<0.001 ) , Neer 's impingement sign was negative , range of motion and muscle strength were increased . US examination showed that the widths of the subacromial-subdeltoid bursa ( p<0.001 ) , long biceps tendon sheath ( p<0.001 ) and acromioclavicular joint ( p<0.001 ) were significantly reduced ; impingement was no more detected . After 30 days , improvement in clinical and US findings was maintained . In the two control groups , no significant changes were observed after treatment . CONCLUSIONS Clinical and US findings demonstrate that MSM , by inducing an increase in muscle strength , is effective in the short-term treatment of SIS Objective : To evaluate the effect on pain intensity and function of an exercise concept focusing on specific eccentric strength training of the rotator cuff in patients with subacromial impingement syndrome . Design : Single-subject research design with baseline and treatment phases ( AB design ) . Setting : Home-based training programme supervised and supported by visits to physiotherapy clinic . Subjects : Ten patients , mean ( SD ) age 54 ( 8.6 ) years , symptom duration 12 ( 9.1 ) months . Intervention : Daily eccentric strengthening exercises of the rotator cuff during 12 weeks . Main measures : Primary outcome measures : Pain intensity , assessed with a visual analogue scale , and function , using the Patient-Specific Functional Scale . Secondary outcome measures : Shoulder function evaluated with the Constant score , and shoulder-related quality of life evaluated with the Western Ontario Rotator Cuff Index . Results : Pain intensity decreased significantly in eight of the ten subjects . Function improved significantly in all ten subjects . Constant score increased in nine subjects and Western Ontario Rotator Cuff Index increased in seven subjects . Mean Constant score for the whole group increased significantly from 44 to 69 points ( P = 0.008 ) . Mean Western Ontario Rotator Cuff Index increased from 51 to 71 % ( P = 0.021 ) . Conclusion : A 12-week eccentric strengthening programme targeting the rotator cuff and incorporating scapular control and correct movement pattern can be effective in decreasing pain and increasing function in patients with subacromial impingement syndrome . A r and omized controlled trial is necessary to provide stronger evidence of the method PURPOSE This study was conducted as a prospect i ve 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 h and s 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 OBJECTIVE To perform a cost-effectiveness analysis of subacromial corticosteroid injection combined with exercise compared with exercise alone in patients with moderate to severe shoulder pain from subacromial impingement syndrome . METHODS A within-trial cost-effectiveness analysis with 232 patients r and omized to physiotherapy-led injection combined with exercise ( n = 115 ) or exercise alone ( n = 117 ) . The analysis was from a health care perspective with 24-week follow-up . Re source use information was collected from all patients on interventions , medication , primary and secondary care contacts , private health care use and over-the-counter purchases . The measure of outcome was quality -adjusted life years ( QALYs ) , calculated from EQ-5D responses at baseline and three further time points . An incremental cost-effectiveness analysis was conducted . RESULTS Mean per patient NHS costs ( £ 255 vs £ 297 ) and overall health care costs ( £ 261 vs £ 318 ) were lower in the injection plus exercise arm , but this difference was not statistically significant . Total QALYs gained were very similar in the two trial arms ( 0.3514 vs 0.3494 QALYs ) , although slightly higher in the injection plus exercise arm , indicating that injection plus exercise may be the dominant treatment option . At a willingness to pay of £ 20,000 per additional QALY gained , there was a 61 % probability that injection plus exercise was the most cost-effective option . CONCLUSION Injection plus exercise delivered by therapists may be a cost-effective use of re sources compared with exercise alone and lead to lower health care costs and less time off work . TRIAL REGISTRATION International St and ard R and omised Controlled Trial Number Register , http://www.controlled-trials.com/is rct n/ , IS RCT 25817033 Study Design . A prospect i ve consecutive cohort study of patients with cervical spine pain and patients with lumbar spine pain referred to an academic medical center . Objectives . To investigate the presence of fear-avoidance beliefs in a sample of patients with cervical spine pain and to compare the association of pain intensity , disability , and fear-avoidance beliefs in patients with cervical spine pain with that in patients with lumbar spine pain . Summary of Background Data . Fear-avoidance beliefs are a specific psychosocial variable involved in the development of disability from low back pain . Psychosocial variables are believed to play a role in cervical disability , but specific variables have not been investigated . Methods . Consecutive patients referred to a multidisciplinary center completed self-reports of  disability , pain intensity , and fear-avoidance beliefs during an initial evaluation session . Gender , type of symptom onset , acuity , and payer source were also recorded . Associations between disability , pain intensity , and fear-avoidance beliefs were investigated in patients with cervical spine pain and patients with lumbar spine pain . Results . In all , 163 patients completed the self-reports and were included in this study . Weaker relations between fear-avoidance beliefs and disability were found in patients with cervical pain than in those with lumbar pain . Significant differences in fear-avoidance beliefs were found for gender , type of symptom onset , and payer source ( workers ’ compensation , auto insurance , and traditional insurance ) . Conclusion . The associations among fear-avoidance beliefs , pain intensity , and disability differed between patients with cervical spine pain and patients with lumbar spine pain .  Fear-avoidance beliefs were significantly different in subgroups of patients In a prospect i ve study , 87 consecutive patients with 88 chronic , full-thickness tears of the rotator cuff were r and omly assigned to either open surgical tendon repair and anterior acromioplasty ( 50 shoulders ) or arthroscopic debridement and subacromial decompression ( 38 shoulders ) . All patients were reexamined 2 to 5 years after the operation with the University of California at Los Angeles 35-Point Scale for Pain and Function of the Shoulder . The average ratings were 30.5 ( rotator cuff repair ) and 25.1 ( arthoscopic debridement/decompression ) for each group . The open surgical repair group faired significantly better than the arthroscopic debridement group ( p = .0028 ) . Thirteen required subsequent procedures , four with tendon repair and nine with decompression . Five in the decompression group experienced cuff tear arthropathy . Surgical repair of full-thickness rotator cuff tears provided results superior to those of arthroscopic debridement and subacromial decompression Objectives : The primary aim of this study was to investigate the effect of medical exercise therapy in shoulder impingement patients , along with possible correlations between impairment variables . Study Design : A prospect i ve unblended r and omized clinical trial . Methods : Over four months , 61 participants were r and omly assigned into a high- grade d exercise therapy group ( HD ) ( n=31 ) and into a low- grade d exercise therapy group ( LD ) ( n=30 ) . Prognostic variables were similar between the groups at baseline . Five ( 8 % ) patients dropped out during the treatment period , and another four ( 6 % ) dropped out before followup . Pain was a composite score of a visual analogue scale ( VAS ) . Isometric strength was measured during four resisted break tests on the shoulder . Function was measured by means of a functional assessment question naire ( Shoulder Rating Question naire , SRQ ) . Both groups trained three times per week for twelve weeks , with tests pre- and posttraining and six months follow-up . Results : The HD group achieved significantly ( p < 0.05 ) better outcome effects than the LD group for pain , range of motion , isometric functional strength and function , but both groups increased function from pretest to posttest . Conclusions : In patients with uncomplicated subacromial pain syndrome , medical exercise therapy is an efficient treatment alternative , where high- grade doses should be emphasized . A major limitation is that the measurements were not undertaken by another person than the treating physiotherapists BACKGROUND Local analgesic injections are commonly used for pain relief after shoulder surgery . The aim of this study was to compare the efficacy of local injections administered in the glenohumeral joint , the subacromial space , or both locations after arthroscopic rotator cuff repair . METHODS Between March 2011 and December 2011 , 121 consecutive patients who had undergone arthroscopic rotator cuff repair surgery were enrolled in the study and all patients were r and omly allocated to 3 groups . In group 1 , 40 patients received a postoperative glenohumeral injection of bupivacaine ( 20 mL ) and lidocaine ( 10 mL ) . In group 2 , 42 patients received the same postoperative injection , but it was administered in the subacromial space . In group 3 , 39 patients received the same amount of local anesthesia but with half injected in the glenohumeral joint and half in the subacromial space . The visual analog scale was used to assess pain intensity before surgery and at postoperative hours 1 , 2 , 6 , 12 , and 24 .  Demerol  was used as a postinjection rescue analgesic , and the total number of administrations was recorded at each time point . RESULTS There were no significant differences between groups in patient age , sex , or rotator cuff tear size ( P > .05 ) . The visual analog scale scores for pain between each group were not significantly different at any time point , including before surgery ( P > .05 ) . In addition , the amount of supplementary analgesic administered was not significantly different between the groups ( P > .05 ) . CONCLUSION Injection of local analgesics after arthroscopic rotator cuff repair relieves postoperative pain regardless of the injection location In a r and omized prospect i ve study , we selected 15 patients for arthroscopic subacromial decompression ( ASD ) and 19 patients for open subacromial decompression ( OSD ) . All had impingement syndrome ( Neer grade II ) , and had been unsuccessfully treated without surgery for more than 6 months . The UCLA Shoulder Rating Scale , Visual Analogue Scales for pain and satisfaction , isokinetic dynamometer recordings and physical testing were assessed preoperatively and at 1 ( except isokinetic testing ) , 3 , 6 , and 12 months , and , finally , 8 years after surgery . We found essentially no differences in the clinical tests between the groups during this period . The use of ASD or OSD seems to be a matter of cosmesis and personal preference In a prospect i ve r and omised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty . A total of 57 patients with a mean age of 47 years ( 31 to 60 ) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial . The type of acromion was classified according to Bigliani . Patients were assessed at follow-up using the Constant score , the simple shoulder test and visual analogue scores for pain and functional impairment . One patient was lost to follow-up . At a mean follow-up of 2.5 years ( 1 to 5 ) both bursectomy and acromioplasty gave good clinical results . No statistically significant differences were found between the two treatments . The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment . As a result , we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder A prospect i ve , r and omized , controlled , double-blind clinical study was performed to determine the short-term efficacy of subacromial injection of corticosteroids for the treatment of subacromial impingement syndrome . Forty patients were r and omized to receive either six milliliters of 1 per cent lidocaine without epinephrine ( the control group ) or two milliliters containing forty milligrams of triamcinolone acetonide per milliliter with four milliliters of 1 per cent lidocaine without epinephrine ( the corticosteroid group ) . The patients were re-examined serially until completion of the study . Nineteen patients , whose mean age was fifty-six years ( range , thirty-two to eighty years ) , were r and omized to the corticosteroid group , and twenty-one patients , whose mean age was fifty-seven years ( range , thirty-two to eighty-one years ) , were r and omized to the control group . The mean duration of symptoms before the injection was eight months for both groups . Eighteen patients in the corticosteroid group and nineteen patients in the control group had moderate or severe pain before the injection . At the most recent follow-up evaluation , at a mean of thirty-three weeks for the corticosteroid group and twenty-eight weeks for the control group , three patients in the corticosteroid group had moderate or severe pain , compared with fifteen patients in the control group . The mean active range of forward elevation and external rotation improved by 24 and 11 degrees , respectively , for the corticosteroid group and by 10 and 5 degrees , respectively , for the control group . We concluded that subacromial injection of corticosteroids is an effective short-term therapy for the treatment of symptomatic subacromial impingement syndrome . The use of such injections can substantially decrease pain and increase the range of motion of the shoulder OBJECTIVE To investigate symptoms and functional impairment in women with secondary lymphoedema of the breast following surgical treatment and to assess the therapeutic benefit of treatment with low-intensity and extremely low-frequency electrostatic fields ( Deep Oscillation ) , supplementing manual lymphatic drainage . METHODS Twenty-one patients were r and omized either to the treatment group ( n=11 ) : 12 sessions of manual lymphatic drainage supplemented by Deep Oscillation , or to the control group ( n=10 ) : manual lymphatic drainage alone . Assessment included subjective pain and swelling evaluation , range of motion of the shoulder and the cervical spine , and analysis of breast volume using a 3D measuring system . RESULTS Patients had high  pain and swelling scores at baseline . Shoulder mobility was impaired in all patients ; restriction of cervical spine mobility was common at baseline and declined further in the control group . Deep Oscillation result ed in significant pain reduction in the treatment group . The subjective reported reduction of swelling in both groups was confirmed objective ly by 3D measurement only in the treatment group . CONCLUSION Additional Deep Oscillation supplementary to manual lymphatic drainage can significantly enhance pain alleviation and swelling reduction in patients with secondary breast lymphoedema compared with manual lymphatic drainage alone Background Subacromial pain syndrome ( SPS ) involving rotator cuff tendinopathy is a common cause of shoulder pain and disability . Evidence suggests that structured physiotherapy may be as effective as surgery in this condition with significant improvements demonstrated in trials involving scapular retraining , rotator cuff strengthening and flexibility exercises . Most published programs typically utilise isotonic concentric and /or eccentric strengthening modes . Recently , immediate analgesic effects and muscle strength gains following heavy-load isometric exercises in lower limb tendinopathy conditions have been observed . It is pertinent to ascertain whether such outcomes can be replicated in SPS/rotator cuff tendinopathy . The primary aim of this study is to establish the feasibility of undertaking a full-scale r and omised controlled trial ( RCT ) that compares the effects of isometric , isotonic concentric and isotonic eccentric rotator cuff contractions when used as part of a semi-st and ardised exercise-based physiotherapy program in patients diagnosed with SPS . The secondary aim is to explore potential trends or treatment effects of the exercise intervention . Methods Thirty-six participants diagnosed with SPS will be r and omised to one of three intervention groups and undergo a one-on-one exercise-based physiotherapy intervention , involving scapular and rotator cuff muscle retraining and strengthening . Each group will utilise a different mode of rotator cuff strengthening — isometric , isotonic concentric or isotonic eccentric . Rotator cuff tendon responses to isometric loading are not yet established in the literature ; hence , individualised , progressive loading will be used in this pilot study in accordance with symptoms . The intervention will involve two phases : during Phase 1 ( weeks 1–6 ) participants undertake the active group-specific physiotherapy treatment ; in Phase 2 ( weeks 6–12 ) , they undertake a progressive , but no longer group-specific exercise program . To determine feasibility , an evaluation of key study parameters including ( a ) ease of recruitment ( rate and number as well as suitability of the assessment algorithm ) , ( b ) adherence to all phases of the exercise intervention including home program compliance and logbook completion , ( c ) participant non-completion ( drop out number and rate ) and ( d ) adverse events ( nature and number ) will be undertaken . Secondary outcomes will measure immediate effects : ( i ) within-treatment changes in pain perception ( verbal rating scale ( VRS ) and shoulder muscle strength ( h and -held dynamometer ) as well as longer-term changes : ( ii ) shoulder-related symptoms and disability ( Western Ontario Rotator Cuff Index ( WORC ) and Shoulder Pain and Disability Index ( SPADI ) ) , ( iii ) perception of pain ( 11-point numerical rating scale ( NRS ) , ( iv ) shoulder muscle strength ( h and -held dynamometer ) and ( v ) perceived global rating of change score . The immediate within-treatment assessment of pain and muscle strength will be undertaken in treatments 2 and 3 , and the longer term measures will be collected at the primary ( conclusion of Phase 1 at 6 weeks ) and secondary ( conclusion of Phase 2 at 12 weeks ) end-points of the study . Discussion The findings of this pilot study will permit evaluation of this study design for a full-scale RCT .Trial registration Australian New Zeal and Clinical Trials Registry , BACKGROUND This study assessed the hypothesis that injection of high-molecular weight hyaluronate in the treatment of subacromial impingement syndrome is effective and safe , compared with corticosteroid injection in the shoulder joint . METHODS One hundred five patients were allocated r and omly into 2 groups : 1 group was injected once a week for 3 weeks with hyaluronate and the other group was injected once with corticosteroid . All injections were guided to the subacromial space by an ultrasonogram . Eighty patients were followed up for 12 weeks after the injection : 38 patients in the hyaluronate group and 42 patients in the corticosteroid group . The functional outcome was measured using the American Shoulder and Elbow Surgeons st and ardized shoulder assessment form ( ASES ) . RESULTS The Visual Analogue Scale ( VAS ) score at 12 weeks was decreased significantly from 58.6 ± 19.3 to 24.6 ± 23.1 in the hyaluronate group ( P < .0001 ) and from 57.2 ± 19.9 to 36.9 ± 26.5 ( P < .0001 ) in the corticosteroid group . There was a significant difference in the VAS score between the hyaluronic acid group and corticoid group ( P = .0180 ) at 12 weeks . The functional ASES scores in the hyaluronate and corticosteroid groups were increased from 17.6 ± 4.8 to 22.4 ± 6.5 and from 17.3 ± 4.9 to 21.7 ± 5.8 , respectively , at 12 weeks ( P = .4825 ) . There was no difference in the number of patients requiring rescue medication between the hyaluronate group and corticosteroid group at 12 weeks ( P = .9254 ) . CONCLUSION A subacromial hyaluronate injection to treat impingement syndrome produces similar pain and functional improvement to corticosteroid at a short-term follow-up OBJECTIVE To compare the effectiveness of exercise therapy aim ed at restoring neuromuscular control mechanisms at the shoulder with other conservative interventions for the treatment of chronic shoulder pain with and without accompanying stiffness . DESIGN R and omized control trial . PATIENTS A total of 138 volunteers with unilateral shoulder pain of local mechanical origin . METHODS Subjects were r and omly allocated to receive exercise therapy aim ed at restoring dynamic stabilizing mechanisms and muscle co-ordination at the shoulder ; or subacromial corticosteroid injection ; or a combination of physical modalities and range of motion exercises . Outcome measurements of pain intensity , functional impairment , active range of motion , isometric muscle force and self-assessed improvement were taken at baseline and after 5 weeks of treatment . RESULTS The mean/median changes in all outcome measurements at 5 weeks indicated that subjects in each treatment group , improved significantly with no difference between the treatment groups . Comparison with an earlier no-treatment trial would suggest that this improvement is greater than that which could be expected by natural recovery . CONCLUSION Exercise therapy aim ed at restoring neuromuscular control , corticosteroid injection and multiple physical modalities and range of motion exercises are equally effective in the short-term treatment of shoulder pain , with exercise therapy and corticosteroid injection being less costly to administer The aim of the study was to compare the efficacy of kinesiological taping and subacromial injection therapy in patients with subacromial impingement syndrome ( SIS ) . Seventy patients diagnosed with SIS were r and omly assigned to group 1 ( n = 35 , injection group ) or group 2 ( n = 35 , kinesiological taping group ) . Betamethasone plus prilocaine was injected to subacromial space in the patients in group 1 . In group 2 , tape was applied three times for a period of five consecutive days with a 2-day recovery interval . A 3-month exercise program was prescribed for both groups including stretching and strengthening exercises . All patients were assessed at baseline and at 1 and 3 months post-intervention . Assessment s were made by visual analog scale ( VAS ) for pain , range of motion ( ROM ) measurements , specific tests , and Shoulder Pain and Disability Index ( SPADI ) . Significant differences were detected in VAS and SPADI scores as well as ROM measurements in both groups when compared to baseline ( p > 0.05 ) . No significant differences were detected between the groups except for active flexion degree in favor of group 1 ( p = 0.004 ) . Both kinesiological taping and steroid injection in conjunction with an exercise program were found to be effective in the treatment of SIS . Kinesio taping may be an alternative treatment option in the rehabilitation of SIS especially when a non-invasive technique is needed OBJECTIVES We studied the value of ultrasound ( US ) to define shoulder pathology and guide local steroid injection in comparison with a st and ard injection in the management of the acute painful shoulder . METHODS Seventy consecutive patients with acute shoulder pain were assessed clinical ly and by US . Patients were r and omized to receive either a st and ard subacromial infiltration of 7 mg of betamethasone or a US-guided injection according to the US diagnosis . Follow-up evaluations were performed by an independent assessor who was blinded to the results of the initial US and clinical assessment s. RESULTS Sixty-seven patients completed the study . Both groups showed a significant reduction in both daytime and night pain compared to baseline . The US injection group had significantly less pain at rest at 2 and 6 weeks ( NRS : 1.6 vs 3.3 , P<0.005 ; 3 vs 4.2 , P<0.04 ) . The percentage of good responders was significantly higher in US group at 2 weeks , ( 81 % vs 54 % , P<0.005 ) and 6 weeks ( 64 % vs 38 % , P<0.05 ) . At 2 and 6 weeks , responder rate and activity pain scores as well as Constant score were in favour of US , though did not reach statistical significance . CONCLUSION Local steroid injection for shoulder pain leads to significant improvements in pain and function for up to 12 weeks . An US examination to define the origin of shoulder pain as well as to guide injection provides significant additional benefits for up to 6 weeks . We recommend routine US examination as part of the management of acute shoulder pain STUDY DESIGN R and omized controlled trial with immediate follow-up . OBJECTIVES To evaluate the immediate effects of a low-amplitude , high-velocity thrust thoracic spine manipulation ( TSM ) on pain and scapular kinematics during elevation and lowering of the arm in individuals with shoulder impingement syndrome ( SIS ) . The secondary objective was to evaluate the immediate effects of TSM on scapular kinematics during elevation and lowering of the arm in individuals without symptoms . BACKGROUND Considering the regional interdependence among the shoulder and the thoracic and cervical spines , TSM may improve pain and function in individuals with SIS . Comparing individuals with SIS to those without shoulder pathology may provide information on the effects of TSM specifically in those with SIS . METHODS Fifty subjects ( mean ± SD age , 31.8 ± 10.9 years ) with SIS and 47 subjects ( age , 25.8 ± 5.0 years ) asymptomatic for shoulder dysfunction were r and omly assigned to 1 of 2 interventions : TSM or a sham intervention . Scapular kinematics were analyzed during elevation and lowering of the arm in the sagittal plane , and a numeric pain rating scale was used to assess shoulder pain during arm movement at preintervention and postintervention . RESULTS For those in the SIS group , shoulder pain was reduced immediately after TSM and the sham intervention ( mean ± SD preintervention , 2.9 ± 2.5 ; postintervention , 2.3 ± 2.5 ; P<.01 ; moderate effect size [ Cohen d = 0.2 ] ) . Scapular internal rotation increased 0.5 ° ± 0.02 ° ( P = .04 ; small effect size [ Cohen d<0.1 ] ) during elevation of the arm after TSM and sham intervention in the SIS group only . Subjects with and without SIS who received TSM and asymptomatic subjects who received the sham intervention had a significant increase ( 1.6 ° ± 2.7 ° ) in scapular upward rotation postintervention ( P<.05 ; small effect size [ Cohen d<0.2 ] ) , which was not considered clinical ly significant . Scapular anterior tilt increased 1.0 ° ± 4.8 ° during elevation and lowering of the arm postmanipulation ( P<.05 ; small effect size [ Cohen d<0.2 ] ) in the asymptomatic subjects who received TSM . CONCLUSION Shoulder pain in individuals with SIS immediately decreased after a TSM . The observed changes in scapular kinematics following TSM were not considered clinical ly important . LEVEL OF EVIDENCE Therapy , level 4 . J Orthop Sports Phys Ther 2014;44(7):475 - 487 . Epub 22 May 2014 . doi:10.2519/jospt.2014.4760 BACKGROUND Multiple factors have been associated with the presence of a subacromial pain syndrome ( SPS ) , including deficits in performance of scapular and glenohumeral muscles . Such deficits can lead to inadequate kinematics and decreased acromiohumeral distance ( AHD ) . Exercises that aim at correcting these deficits , such as movement training , were suggested to improve symptoms and functional limitations . To date , few studies have assessed outcomes following an intervention focused on movement training . OBJECTIVES Evaluate the effects of a rehabilitation program based on movement training on symptoms , functional limitations and AHD in individuals with SPS . DESIGN Prospect i ve single group pre-post design . METHODS Twenty-five participants with SPS ( SPS group ) participated in a 6-week program .  Twenty asymptomatic volunteers were recruited for normative AHD values ( control group ) . Outcomes of both groups were evaluated at baseline and 6 weeks , i.e. immediately following intervention for the SPS group . Changes in symptoms and functional limitations for SPS group were assessed using the Western Ontario Rotator Cuff ( WORC ) index and Disability of the Arm Shoulder and H and ( DASH ) question naire . Changes in AHD for both groups were assessed using ultrasonographic measures . RESULTS Following the rehabilitation program , the scores on WORC and DASH were significantly improved ( p < 0.001 ) . AHD increased significantly in the SPS group ( p = 0.019 ) , especially in a subgroup with initial deficits ( p < 0.001 ) . CONCLUSION The rehabilitation program yielded improvements in symptoms and functional limitations in participants with SPS . Moreover , it led to an increase of the AHD -- thus potentially decreasing subacromial compression , particularly in participants with an initially smaller AHD . The trial was registered at Clinical Trials.gov : identifier -- NCT02395770 Forty-eight patients with frozen shoulder for less than six months were assigned at r and om to receive three shoulder injections into the subacromial bursa or glenohumeral joint at weekly intervals . The treatment groups were ( 1 ) intra-articular methylprednisolone and lidocaine , ( 2 ) intrabursal methylprednisolone and lidocaine , ( 3 ) intra-articular lidocaine , ( 4 ) intrabursal lidocaine . The same physical therapy program was carried out for all patients . Assessment s of pain and range of motion were performed by a physical therapist who was uninformed about the nature of the injection therapy . There was no significant difference in outcome between intrabursal injection and intra-articular injection . Injection of steroid with lidocaine had no advantage over lidocaine alone in restoring shoulder motion , but partial , transient pain relief occurred in two thirds of the steroid-treated patients OBJECTIVE Calcific tendonitis of rotator cuff is observed on plain radiographs in 10 % of adults , but remains asymptomatic in half these cases . We looked for differences on ultrasound ( US ) and power Doppler findings between symptomatic and asymptomatic cases of shoulder calcific tendonitis . METHODS US was performed in 62 patients ( 81 shoulders ) with symptomatic ( n=57 ) or asymptomatic ( n=24 ) calcific tendonitis . Calcific plaque morphology , power Doppler signaling , and widening of the subacromial-subdeltoid bursa ( SSB ) were recorded . US-guided steroid injection into the SSB ( n=21 ) or needle puncture of calcific deposits ( n=29 ) was performed at the end of US evaluation in 50 of the 57 patients , and a question naire was sent to each patient after 11+/-6 months . RESULTS Larger ( p=0.0015 ) and fragmented ( p=0.01 ) calcifications were associated with pain . A power Doppler signal and a widening of the SSB was identified in 21 and 17 of the 57 symptomatic calcification respectively , but in none of the cases of asymptomatic calcification ( p<0,005 ) . At least one of these signs was present in 31 of the 57 ( 54 % ) symptomatic shoulders ( p<0.001 ) . Long-term outcome was favourable for 60 % of our patients after steroid injection . The presence of a SSB widening before bursal steroid injection was associated with an improvement of the symptoms ( p=0.06 ) . CONCLUSION Positive power Doppler signal within the calcific deposit and SSB widening are US features strongly associated with pain . Moreover , larger calcifications are also more symptomatic . According to these results , US can help physicians to confirm that calcification is responsible for shoulder pain A total of 159 patients ( 84 women and 75 men , mean age of 53 ( 20 to 87 ) ) with subacromial impingement were r and omised to treatment with subacromial injections using lidocaine with one of hyaluronic acid ( 51 patients ) , corticosteroid ( 53 patients ) or placebo ( 55 patients ) . Patients were followed up for 26 weeks . The primary outcome was pain on a visual analogue score ( VAS ) , and secondary outcomes included the Constant Murley score , shoulder pain score , functional mobility score , shoulder disability question naire and pain-specific disability score . The different outcome measures showed similar results . After three , six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections . The mean short-term reduction in pain on the VAS score at 12 weeks was 7 % ( SD 2.7 ; 97.5 % confidence interval ( CI ) 0.207 to 1.55 ; p = 0.084 ) in the hyaluronic acid group , 28 % ( SD 2.8 ; 97.5 % CI 1.86 to 3.65 ; p < 0.001 ) in the corticosteroid group and 23 % ( SD 3.23 ; 97.5 % CI 1.25 to 3.26 ; p < 0.001 ) in the placebo group . At 26 weeks there was a reduction in pain in 63 % ( 32 of 51 ) of patients in the hyaluronic acid group , 72 % ( 38 of 53 ) of those in the corticosteroid group and 69 % ( 38 of 55 ) of those in the placebo group . We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections . Corticosteroid injections produced a significant reduction in pain in the short term ( three to 12 weeks ) , but in the long term the placebo injection produced the best results The effect of triamcinolone subacromial bursa injection versus naproxen therapy was compared in a r and omized , double-blind , placebo-controlled  study of 100 patients who had painful shoulders . Outcome was compared using degree of active abduction , pain , limitation of function , and a clinical index that combined equally weighted measures of all of these . In a time-adjusted analysis , triamcinolone was superior to placebo in all clinical variables . Naproxen was superior to placebo in all variables except pain .  Triamcinolone was superior to naproxen in the relief of pain ( P = 0.04 ) and the clinical index ( P = 0.04 ) . Multiple linear regression analysis showed that naproxen and triamcinolone treatment accounted for only 16 % of the variation in outcome , compared with 44 % accounted for by the clinical index prior to treatment . Thus , patients with a poor pretreatment clinical index ( those with the most room for improvement ) were least likely to improve . We conclude that both triamcinolone ( P = 0.00005 ) and naproxen ( P = 0.02 ) are superior to placebo in the treatment of the painful shoulder There is a lack of evidence about the efficacy of routinely used interventions in shoulder pain , such as corticosteroid injection and physiotherapy . This pilot study was set up to assess the feasibility of a larger , r and omized controlled trial . Patients with the clinical presentation of a painful arc of less than 6 months ' duration were recruited through their general practitioners . A total of 112 patients were r and omized to 4 groups :  control , physiotherapy , a course of subacromial steroid injections , or both physiotherapy and steroid injections . The primary outcome measure was the Oxford Shoulder Score ( OSS ) . Follow-up was 18 weeks and by postal question naire at 1 year . No significant differences were found within groups between the OSS scores or the Physical Health total of the Medical Outcomes Study Short Form 36 ( SF-36 ) Health Survey at the beginning and end of the trial or at 1 year . By analysis of covariance , no significant differences were found between treatment groups . Larger studies are needed . A power calculation from our data suggests recruitment of more than 800 patients would be required to achieve a 90 % chance of a clinical ly significant difference being detected between these groups Fifty-five patients with shoulder pain due to rotator cuff tendinitis of less than 12 weeks ' duration were r and omized to receive either 40 mg methylprednisolone and lignocaine or lignocaine alone . No statistically significant difference could be discerned between the two groups during 12 weeks of follow-up OBJECTIVE The aim of this study was to assess the immediate and short-term effects of upper thoracic spine manipulation on pain intensity and myoelectric activity of the sternocleidomastoid muscles in young women with chronic neck pain . METHODS A r and omized clinical trial was carried out involving 32 women with chronic neck pain ( mean age , 24.8 ± 5.4 years ) allocated to an experimental group and a placebo group . Three evaluations were carried out : baseline , immediate postintervention , and short-term postintervention ( 48 - 72 hours after intervention ) . Myoelectric activity of the right and left sternocleidomastoid muscles was assessed at rest and during isometric contractions for cervical flexion and elevation of the shoulder girdle . Neck pain intensity was assessed at rest using a visual analog scale . Comparisons of the data were performed using 2-way repeated- measures analysis of variance with the Bonferroni correction . The level of significance was set at P < .05 . RESULTS A moderate treatment effect on myoelectric activity of the right and left sternocleidomastoid muscles during isometric elevation of the shoulder girdle was found in the experimental group only on the short-term postintervention evaluation ( d > 0.40 ) . No statistically significant differences were found for any of the variables analyzed in the intergroup comparisons at the different evaluation times ( P > .05 ) . CONCLUSION No statistically significant differences were found in the intragroup or intergroup analyses of the experimental and placebo groups regarding myoelectric activity of the cervical muscles or the intensity of neck pain at rest in the immediate or short-term postintervention evaluations A r and omized controlled trial of manipulation of the cervial spine was carried out on 52 patients in general practice , and the results were assessed symptomatically and goniometrically for three weeks . Manipulation produced a significant immediate improvement in symptoms in those with pain or stiffness in the neck , and pain/paraesthesia in the shoulder , and a nearly significant improvement in those with pain/paraesthesia in the arm/h and . Manipulation also produced a significant increase in measured rotation that was maintained for three weeks and an immediate improvement in lateral flexion that was not maintained . This is to our knowledge the first published formal trial of such manipulation and should increase interest in this form of treatment by the medical profession Background and Objectives . Peripherally administered opioids , e.g. , intra‐articular morphine , exert their analgesic action on local opioid receptors . The present study investigated the safety and efficacy of intrabursal oxycodone and bupivacaine in comparison with bupivacaine infiltration and interscalene brachial plexus block in conjunction with shoulder surgery . Methods . A prospect i ve , r and omized study was conducted in 45 patients ( 15 per group ) undergoing elective shoulder surgery during general anesthesia . At the end of the surgery , patients received either 10 mL 0.5 % bupivacaine ( group B ) or 5 mg oxycodone and 10 mL 0.5 % bupivacaine ( group OB ) in the subacromial bursa ; interscalene plexus blocks were performed preoperative ( group IPB ) . Postoperative analgesia was provided by patient‐controlled analgesia , and the amount of intravenous fentanyl used during the total perioperative period was recorded . Postoperative pain was assessed by a visual analog scale . Results . The total fentanyl consumption was lower in groups OB and IPB than in group B , and the difference reached statistical significance for both groups ( P = .045 and P = .006 , respectively ) . However , the groups OB and IPB did not differ in respect to their fentanyl requirements ( P = 1.000 ) . Visual analog scores for pain were lowest in group IBP during the first 6 postoperative hours . The incidence of adverse effects was similar in all groups ; serious adverse effects did not occur . Conclusions . According to the present study , intrabursal oxycodone and bupivacaine offer an acceptable and efficient method for postoperative analgesia after shoulder surgery STUDY OBJECTIVES To compare the peripheral analgesic effect of oxycodone , an opioid agonist , to the effect of bupivacaine infiltration and parenteral oxycodone administration in conjunction with shoulder surgery . DESIGN Prospect i ve , r and omized , double-blind study . SETTING University teaching hospital . PATIENTS 42 ASA physical status I and II patients scheduled for shoulder surgery with general anesthesia . INTERVENTIONS Patients were r and omized to three study groups : at the end of the surgery patients received either 10 ml of 0.5 % bupivacaine ( group BIB ) or 5 mg of oxycodone in 10 ml of saline ( group OIB ) in the subacromial bursa ; or 5 mg of oxycodone intramuscularly ( group OIM ) . Postoperative analgesia was provided by patient-controlled analgesia ( PCA ) . MEASUREMENTS AND MAIN RESULTS The fentanyl requirements were recorded for the 24-hour postoperative period and the total perioperative period . Postoperative pain was assessed by visual analog scale for pain ( VASP ) . Plasma oxycodone concentrations were measured in groups OIB and OIM . The total perioperative fentanyl consumption was significantly lower in groups BIB ( 0.97 + /- 0.09 mg ) and OIB ( 1.23 + /- 0.12 mg ) than in group OIM ( 1.61 + /- 0.12 mg ) ( p = 0.01 and 0.048 , respectively ) . Groups BIB and OIB were similar ( p = 0.34 ) . The absorption of oxycodone was significantly lower after subacromial than after intramuscular administration . CONCLUSION Intrabursal oxycodone and intrabursal bupivacaine reduced perioperative analgesic requirements similarly . Intrabursal oxycodone may offer an effective , simple , and safe method for postoperative analgesia after shoulder surgery [ Purpose ] A prospect i ve , r and omized , single-blind study was performed in order to compare the efficacy of ultrasound treatments of various duration s for patients with subacromial impingement syndrome . [ Subjects and Methods ] One hundred patients who had been diagnosed with subacromial impingement syndrome by clinical examination and magnetic resonance imaging were included in this study . Patients were r and omly divided into two groups of fifty patients per group . The first group received 15 sessions of therapeutic ultrasound ( 4 minutes ) , superficial heat and transcutaneous electrical stimulation therapy combined with exercise . The second group received the same treatment except that each of the 15 ultrasound sessions were eight minutes in length . The patients were evaluated before and after the treatment . A visual analog scale ( VAS ) was used to assess pain , the University of California at Los Angeles ( UCLA ) and Constant Scale were used to assess shoulder function and the Beck Depression Inventory ( BDI ) was used to quantify depressive symptoms . [ Results ] There were no statistically significant differences between the groups in age , time since the onset of pain , sex , education and depression levels prior to the treatment . The post-treatment evaluation of patients VAS , UCLA , Constant , and BDI scores showed statistically significant within group improvements . When the two groups were compared , we found no statistically significant differences in the Constant activities of daily living , Constant external rotation , Constant force and BDI scores . However , the second group scored better than the first group in all the remaining parameters . [ Conclusion ] Ultrasound therapy was found to have beneficial effects on pain and functional status in the treatment of subacromial impingement syndrome . Eight minutes of ultrasound treatment was shown to be more effective than 4 minutes of ultrasound treatment Background : Subacromial impingement syndrome ( SAIS ) is a painful condition result ing from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus . Objective : The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy ( HILT ) versus ultrasound ( US ) therapy in the treatment of SAIS . Design : The study was design ed as a r and omized clinical trial . Setting : The study was conducted in a university hospital . Patients : Seventy patients with SAIS were r and omly assigned to a HILT group or a US therapy group . Intervention : Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks . Measurements : Outcome measures were the Constant-Murley Scale ( CMS ) , a visual analog scale ( VAS ) , and the Simple Shoulder Test ( SST ) . Results : For the 70 study participants ( 42 women and 28 men ; mean [ SD ] age=54.1 years [ 9.0 ] ; mean [ SD ] VAS score at baseline=6.4 [ 1.7 ] ) , there were no between-group differences at baseline in VAS , CMS , and SST scores . At the end of the 2-week intervention , participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group . Statistically significant differences in change in pain , articular movement , functionality , and muscle strength ( force-generating capacity ) ( VAS , CMS , and SST scores ) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group . In particular , only the difference in change of VAS score between groups ( 1.65 points ) surpassed the accepted minimal clinical ly important difference for this tool . Limitations : This study was limited by sample size , lack of a control or placebo group , and follow-up period . Conclusions : Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks OBJECTIVES This study aims to assess and compare the efficacy of subacromial tenoxicam and steroid injections in treating patients with shoulder impingement syndrome . PATIENTS AND METHODS Forty patients having shoulder impingement syndrome with findings of rotator cuff tendinitis or subacromial bursitis on magnetic resonance imaging were included in the study . Patients were r and omized into two subacromial injection groups : patients in the first group ( 10 males , 10 females ; mean age 45.3 years ; range 32 to 67 years ) were administered 20 mg tenoxicam three times by weekly intervals , and patients in the second group ( 8 males , 12 females ; mean age 46.5 years ; range 29 to 73 years ) were administered 40 mg methylprednisolone acetate just for once . Visual analog scale ( VAS ) , active range of motion ( ROM ) of the shoulder joint , and Disabilities of Arm , Shoulder and H and ( DASH ) question naire scores were evaluated at baseline , six weeks after treatment , and first year . RESULTS Visual analog scale , DASH , and active ROM scores in both groups were statistically significantly improved . No statistically significant difference was detected between subacromial tenoxicam and steroid injections in terms of post-treatment VAS , DASH , and active ROM scores . Mean pre- and post-treatment VAS scores in tenoxicam group were 7.8 ( range , 3 - 9 ) and 2.6 ( range , 2 - 4 ) , respectively . Mean pre- and post-treatment VAS scores in steroid group were 6.2 ( range , 3 - 10 ) and 3.6 ( range , 0 - 7 ) , respectively . Mean pre- and post-treatment DASH scores in tenoxicam group were 59.4 ( range , 45 - 80 ) and 14.7 ( range , 8.3 - 25.8 ) , respectively . Mean pre- and post-treatment DASH scores in steroid group were 56.7 ( range , 33.3 - 85.8 ) and 18.1 ( range , 0 - 69.2 ) , respectively . Although the improvement in active ROM was higher in the steroid group , difference between two groups was not statistically significant . CONCLUSION Both subacromial tenoxicam and steroid injections may be successfully used in the treatment of patients with impingement syndrome .  Subacromial tenoxicam injection may be preferred as a first-line intervention in these patients thanks to its safe profile Background Psychologic factors are associated with pain and disability in patients with chronic shoulder pain . Recent research regarding the association of affective psychologic factors ( emotions ) with patients ’ pain and disability outcome after surgery disagrees ; and the relationship between cognitive psychologic factors ( thoughts and beliefs ) and outcome after surgery is unknown . Questions / purpose s ( 1 ) Are there identifiable clusters ( based on psychologic functioning measures ) in patients undergoing shoulder surgery  ? ( 2 ) Is poorer psychologic functioning associated with worse outcome ( American Shoulder and Elbow Surgeons [ ASES ] score ) after shoulder surgery ? Methods This prospect i ve cohort study investigated patients undergoing shoulder surgery for rotator cuff-related shoulder pain or rotator cuff tear by one of six surgeons between January 2014 and July 2015 . Inclusion criteria were patients undergoing surgery for rotator cuff repair with or without subacromial decompression and arthroscopic subacromial decompression only . Of 153 patients who were recruited and consented to participate in the study , 16 withdrew before data collection , leaving 137 who underwent surgery and were included in analyses . Of these , 124 ( 46 of 124 [ 37 % ] female ; median age , 54 years [ range , 21 - 79 years ] ) had a complete set of four psychologic measures before surgery  : Depression , Anxiety and Stress Scale ; Pain Catastrophizing Scale ; Pain Self-Efficacy Question naire ; and Tampa Scale for Kinesiophobia . The existence of clusters of people with different profiles of affective and cognitive factors was investigated using latent class analysis , which grouped people according to their pattern of scores on the four psychologic measures . Result ant clusters were profiled on potential confounding variables . The ASES score was measured before surgery and 3 and 12 months after surgery . Linear mixed models assessed the association between psychologic cluster membership before surgery and trajectories of ASES score over time adjusting for potential confounding variables . Results Two clusters were identified : one cluster ( 84 of 124 [ 68 % ] ) had lower scores indicating better psychologic functioning and a second cluster ( 40 of 124 [ 32 % ] ) had higher scores indicating poorer psychologic functioning . Accounting for all variables , the cluster with poorer psychologic functioning was found to be independently associated with worse ASES score at all time points ( regression coefficient for ASES : before surgery -9 [ 95 % confidence interval { CI } , -16 to -2 ] , p = 0.011 ) ; 3 months after surgery -15 [ 95 % CI , -23 to -8 ] , p < 0.001 ) ; and 12 months after surgery -9 [ 95 % CI , -17 to -1 ] , p = 0.023 ) . However , both clusters showed improvement in ASES score from before to 12 months after surgery , and there was no difference in the amount of improvement between clusters ( regression coefficient for ASES : cluster with poorer psychologic function 31 [ 95 % CI , 26 - 36 ] , p < 0.001 ) ; cluster with better psychologic function 31 [ 95 % CI , 23 - 39 ] , p < 0.001 ) . Conclusions Patients who scored poorly on a range of psychologic measures before shoulder surgery displayed worse ASES scores at 3 and 12 months after surgery . Screening of psychologic factors before surgery is recommended to identify patients with poor psychologic function . Such patients may warrant additional behavioral or psychologic management before proceeding to surgery . However , further research is needed to determine the optimal management for patients with poorer psychologic function to improve pain and disability levels before and after surgery . Level of Evidence Level II , therapeutic study OBJECTIVE The aim of this study was to compare the effectiveness of low-level laser therapy and ultrasound therapy in the treatment of subacromial impingement syndrome . MATERIAL S AND METHODS Thirty one patients with subacromial impingement syndrome were r and omly assigned to low-level laser therapy group ( n=16 ) and ultrasound therapy group ( n=15 ) . Study participants received 10 treatment sessions of low-level laser therapy or ultrasound therapy over a period of two-consecutive weeks ( five days per week ) . Outcome measures ( visual analogue pain scale , Shoulder Pain and Disability Index -SPADI- , patient 's satisfactory level and sleep interference score ) were assessed before treatment and at the 1st and 3rd months after treatment . All patients were analyzed by the intent-to-treat principle . RESULTS Mean reduction in VAS pain , SPADI disability and sleep interference scores from baseline to after 1 month , and 3 months of treatment was statistically significant in both groups ( P < 0.05 ) . However , there was no significant difference in the mean change in VAS pain , SPADI disability and sleep interference scores between the two groups ( P > 0.05 ) . The mean level of patient satisfaction in group 1 at the first and third months after treatment was 72.45 ± 23.45 mm and 71.50 ± 16.54 mm , respectively . The mean level of patient satisfaction in group 2 at the first and third months after treatment was 70.38 ± 21.52 mm and 72.09 ± 13.42 mm , respectively . There was no significant difference in the mean level of patient satisfaction between the two groups ( p > 0.05 ) . CONCLUSIONS The results suggest that efficacy of both treatments were comparable to each other in regarding reducing pain severity and functional disability in patients with subacromial impingement syndrome . Based on our findings , we conclude that low-level laser therapy may be considered as an effective alternative to ultrasound based therapy in patients with subacromial impingement syndrome especially ultrasound based therapy is contraindicated OBJECTIVE The study investigated the effectiveness of stretching , strengthening exercises , and the scapular stabilization exercises on the pain , shoulder range of motion ( ROM ) , muscle strength , joint position sense ( JPS ) , scapular dyskinesis and quality of life ( OL ) in the patients with subacromial impingement syndrome ( SIS ) . METHODS 27 women and 13 men , mean age 51 ( 24 - 71 ) years old , were included in this study . All the patients were separated into 2 groups according to simple r and om table . Stretching and strengthening exercises were given to the group I ( n=20 ) and scapular stabilization exercises were added to the group II ( n=20 ) . The pain severity , shoulder ROM , muscle strength , JPS , lateral scapular slide test ( LSST ) , Western Ontario Rotator Cuff ( WORC ) Index were evaluated before and after treatment . Patients completed a 6-week rehabilitation program , three times a week . RESULTS The results showed that all measurements improved statistically in both groups after treatment ( p < 0.05 ) . And the improvements in the muscle strength , JPS and scapular dyskinesia were significantly different in group II ( p < 0.05 ) . CONCLUSION It is suggested that in the treatment of SIS ; scapular stabilization exercises , given with stretching and strengthening exercises , can be more effective in increasing the muscle strength , developing the JPS and decreasing the scapular dyskinesis Background Role substitution is a strategy employed to assist health services manage the growing dem and for musculoskeletal care . Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic st and ards . This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinical ly and cost effective as that from an orthopaedic surgeon . Methods A double blind non-inferiority r and omized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service , from January 2013 to June 2014 . Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon . The main outcome measure was total Shoulder Pain and Disability Index ( SPADI ) score at baseline , six and 12 weeks , applying a non-inferiority margin of 15 points . Secondary outcomes tested for superiority included pain , shoulder movement , perceived improvement , adverse events , satisfaction , quality of life and costs . Results 278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon , with 64 r and omised ( physiotherapist 33 , orthopaedic surgeon 31 ) . There were no significant differences in baseline characteristics between groups . Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks ( upper limit of the 95 % one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks , respectively ) . There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks . From the perspective of the health funder , the physiotherapist was less expensive . Conclusions Corticosteroid injection for shoulder pain , provided by a suitably qualified physiotherapist is at least as clinical ly effective , and less expensive , compared with similar care delivered by an orthopaedic surgeon . Policy makers and service providers should consider implementing this model of care . Trial Registration Australia and New Zeal and Clinical Trials Registry Purpose To evaluate the relationship of a large acromion index and calcifying tendinitis of the supraspinatus tendon at the shoulder . Material s and methods Between 2002 and 2008 , 109 consecutive patients with isolated calcifying tendinitis of the supraspinatus tendon were prospect ively analysed by clinical investigation and st and ardized radiographs . Deposit size and appearance were measured and classified according to Bosworth and Gartner . The acromion index ( AI ) was calculated based on measurements on true anteroposterior radiographs . Pain record on VAS scale , active and passive range of motion and the constant score ( CS ) were recorded . Results The mean age of the patients was 48.2 ± 8.0 ( n = 46 male 48.6 ± 7.3 ; n = 63 female 47.9 ± 8.6 ; P > 0.05 ) . Pain and function were not significantly correlated with deposit size or classification . The acromion index ( mean 0.64 ± 0.08 ) was not significantly correlated with the affected or dominant side , gender , deposit size or classification or any functional parameter like pain and the CS or its subgroups . Conclusion The theoretical concept of a high acromion index result ing in an increased result ing upward force against the subacromial space , which influences pain and function in calcifying tendinitis of the shoulder , was not supported . Level of evidence Diagnostic clinical study , Level II In a controlled clinical prospect i ve study , 43 consecutive patients ( 43 shoulders ) with subacromial impingement resistant to conservative therapy and without full-thickness rotator cuff tears underwent arthroscopic subacromial decompression .  The patients were r and omized to either self-training or physiotherapist-guided rehabilitation for immediate postoperative rehabilitation . Postoperative follow-up was performed by an independent observer after 3 , 6 , and 12 months . With the use of the Constant score for evaluation of functional outcome , patients training themselves improved from a mean 53 points ( range 26 to 81 points ) to a mean 79 points ( range 45 to 100 ) points after 12 months . Physiotherapist-supervised patients improved from a mean 54 points ( range 20 to 90 points ) to a mean 80 points ( range 40 to 100 points ) . The self-training patients returned to work after a mean 8.5 weeks ( range 1 to 14 weeks ) , whereas the physiotherapist-supervised patients returned to work after a mean 8 weeks ( range 3 to 13 weeks ) . No statistical difference was found between the 2 rehabilitation methods . This study was unable to show any beneficial effect of physiotherapist-supervised rehabilitation after arthroscopic subacromial decompression of the shoulder Background Although arthroscopic subacromial decompression ( ASD ) is a common procedure for treatment of shoulder impingement , few long term results have been published . In this prospect i ve study , we determined whether the high degree of patient satisfaction at 6 months postoperatively reported by us earlier remained at the 6-year follow-up . Patients and methods We originally reported high patient satisfaction 6 months after  ASD for shoulder impingement in 50 prospect ively studied patients using the Disability of the Arm Shoulder and H and question naire ( DASH ) and the  Visual Analog Scale ( VAS ) .  Patients with associated shoulder disorders were excluded . The surgeons were experienced shoulder arthroscopists . 6 years after surgery , the  DASH question naire and the  VAS  were sent to these 50 patients . 2 patients had other medical problems of the upper extremity that affected the DASH and VAS scores , 1 patient was lost to follow-up , and another refused to participate . Thus , 46 patients with a mean age of 55 ( 33–78 ) years were included in this 6-year evaluation . Results The considerable improvement in both the DASH score and the VAS that was observed 6 months after surgery persisted or had even improved 6 years after surgery . Interpretation Properly selected patients with shoulder impingement treated with ASD remain satisfied 6 years after surgery DESIGN R and omized clinical trial . OBJECTIVES To determine the short-term effects of Kinesio Taping , applied to the cervical spine , on neck pain and cervical range of motion in individuals with acute whiplash-associated disorders ( WADs ) . BACKGROUND Research ers have begun to investigate the effects of Kinesio Taping on different musculoskeletal conditions ( eg , shoulder and trunk pain ) . Considering the demonstrated short-term effectiveness of Kinesio Tape for the management of shoulder pain , it is suggested that Kinesio Tape may also be beneficial in reducing pain associated with WAD . METHODS AND MEASURES Forty-one patients ( 21 females ) were r and omly assigned to 1 of 2 groups : the experimental group received Kinesio Taping to the cervical spine ( applied with tension ) and the placebo group received a sham Kinesio Taping application ( applied without tension ) . Both neck pain ( 11-point numerical pain rating scale ) and cervical range-of-motion data were collected at baseline , immediately after the Kinesio Tape application , and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients . Mixed-model analyses of variance ( ANOVAs ) were used to examine the effects of the treatment on each outcome variable , with group as the between-subjects variable and time as the within-subjects variable . The primary analysis was the group-by-time interaction . RESULTS The group-by-time interaction for the 2-by-3 mixed-model ANOVA was statistically significant for pain as the dependent variable ( F = 64.8 ; P<.001 ) , indicating that patients receiving Kinesio Taping experienced a greater decrease in pain immediately postapplication and at the 24-hour follow-up ( both , P<.001 ) . The group-by-time interaction was also significant for all directions of cervical range of motion : flexion ( F = 50.8 ; P<.001 ) , extension ( F = 50.7 ; P<.001 ) , right ( F = 39.5 ; P<.001 ) and left ( F = 3.8 , P<.05 ) lateral flexion , and right ( F = 33.9 , P<.001 ) and left ( F = 39.5 , P<.001 ) rotation . Patients in the experimental group obtained a greater improvement in range of motion than thosein the control group ( all , P<.001 ) . CONCLUSIONS Patients with acute WAD receiving an application of Kinesio Taping , applied with proper tension , exhibited statistically significant improvements immediately following application of the Kinesio Tape and at a 24-hour follow-up . However , the improvements in pain and cervical range of motion were small and may not be clinical ly meaningful . Future studies should investigate if Kinesio Taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period . LEVEL OF EVIDENCE Therapy , level 1b . J Orthop Sports Phys Ther 2009;39(7):515 - 521 , Epub 24 February 2009 . doi:10.2519/jospt.2009.3072 Subacromial impingement syndrome ( SAIS ) , which is associated with pain and a loss of function , has a high occurrence in the physically active population . Not all patients respond positively to treatment . Classifying patients can improve decision-making . The scapular kinematic and clinical impairments can aid in classifying the patients who are more likely to respond to physical therapy treatment . Thirty-three subjects ( males , 20 - 33 years ) presenting SAIS were studied to determine altered scapular kinematics and clinical impairments . Three measurements were collected : ( 1 ) three-dimensional scapular kinematics during performing functional tasks ; ( 2 ) impairment outcomes of range of motion and muscle force ; and ( 3 ) self-reported measurements of pain , satisfaction , and function . All patients received 6-week ( 2 times per week ) physical therapy treatment . Improvement with treatment was determined using the Global Rating of Change Scale . Scapular kinematics and clinical impairments were first identified by t-test in predicting improvement and then combined into a multivariate prediction method . A prediction method with three variables ( Flexilevel Scale of Shoulder Function score < 41 , muscle power of serratus anterior < 27.4 % body weight , degree of scapular internal rotation at 30 ° shoulder elevation during descending arm phase in unloaded condition<0.7 ° ) were identified . It appears that scapular kinematics and impairment features can be used to classify subjects with SAIS in addition to self-report . Prospect i ve validation of the proposed prediction method requires further investigation Purpose To investigate superior value of adding heavy load eccentric training to conservative treatment in patients with subacromial impingement . Methods Sixty-one patients with subacromial impingement were included and r and omly allocated to the traditional rotator cuff training ( TT ) group ( n = 30 , mean age = 39.4 ± 13.1 years ) or traditional rotator training combined with heavy load eccentric training ( TT + ET ) group ( n = 31 , mean age = 40.2 ± 12.9 years ) . Isometric strength was measured to abduction at 0 ° , 45 ° and 90 ° of scapular abduction and to internal and external rotation . The SPADI question naire was used to measure shoulder pain and function . Patients rated subjective perception of improvement . Outcome was assessed at baseline , at 6 and 12 weeks after start of the intervention . Both groups received 9 physiotherapy treatments over 12 weeks . At home , the TT group performed traditional rotator cuff strengthening exercises 1x/day . The TT + ET group performed the same exercises 1x/day and a heavy load eccentric exercise 2x/day . Results After treatment , isometric strength had significantly increased in all directions , and SPADI score had significantly decreased . The TT + ET group showed a 15 % higher gain in abduction strength at 90 ° of scapular abduction . Chi-square tests showed patients ’ self-rated perception of improvement was similar in both groups . Conclusion Adding heavy load eccentric training result ed in a higher gain in isometric strength at 90 ° of scapular abduction , but was not superior for decreasing pain and improving shoulder function . This study showed that the combination of a limited amount of physiotherapy sessions combined with a daily home exercise programme is highly effective in patients with impingement . Level of evidence II BACKGROUND Research ers have demonstrated moderate evidence for the use of exercise in the treatment of subacromial impingement syndrome ( SAIS ) . Recent evidence also supports eccentric exercise for patients with lower extremity and wrist tendinopathies . However , only a few investigators have examined the effects of eccentric exercise on patients with rotator cuff tendinopathy . PURPOSE To compare the effectiveness of an eccentric progressive resistance exercise ( PRE ) intervention to a concentric PRE intervention in adults with SAIS . STUDY DESIGN R and omized Clinical Trial . METHODS Thirty-four participants with SAIS were r and omized into concentric ( n = 16 , mean age : 48.6 ± 14.6 years ) and eccentric ( n = 18 , mean age : 50.1 ± 16.9 years ) exercise groups . Supervised rotator cuff and scapular PRE 's were performed twice a week for eight weeks . A daily home program of shoulder stretching and active range of motion ( AROM ) exercises was performed by both groups . The outcome measures of the Disabilities of the Arm , Shoulder , and H and ( DASH ) score , pain-free arm scapular plane elevation AROM , pain-free shoulder abduction and external rotation ( ER ) strength were assessed at baseline , week five , and week eight of the study . RESULTS Four separate 2x3 ANOVAs with repeated measures showed no significant difference in any outcome measure between the two groups over time . However , all participants made significant improvements in all outcome measures from baseline to week five ( p < 0.0125 ) . Significant improvements also were found from week five to week eight ( p < 0.0125 ) for all outcome measures except scapular plane elevation AROM . CONCLUSION Both eccentric and concentric PRE programs result ed in improved function , AROM , and strength in patients with SAIS . However , no difference was found between the two exercise modes , suggesting that therapists may use exercises that utilize either exercise mode in their treatment of SAIS . LEVEL OF EVIDENCE Therapy , level 1b Objective : To compare the short-term effectiveness of precut kinesiology tape ( PCT ) to a nonsteroidal anti-inflammatory drug ( NSAID ) as adjuvant treatment to exercise physiotherapy in improving pain and function in patients with shoulder impingement . Design : R and omized , controlled assessor-blind parallel- design trial with 3 groups . Setting : Academic-community hospital . Patients : One hundred patients ( mean age : 48 ± 12.3 , 61 men , 39 women ) with a diagnosis of subacromial impingement ( SAI ) syndrome were r and omized to a treatment group from October 2009 to June 2012 . Eighty-one patients completed the study . Interventions : Patients were r and omized to one of the 3 treatment groups : PCT and Exercise ( n = 33 ) , NSAID and Exercise ( n = 29 ) , or Exercise only ( n = 38 ) for a 4 session 2-week intervention with a registered physiotherapist . Main Outcome Measures : Numeric pain rating scales for pain at rest and pain with arm elevation , the Simple Shoulder Test ( SST ) , and the Constant Score were assessed pretreatment and post-treatment . Results : A statistically significant reduction in pain at rest and pain with arm elevation , as well as improvement in SST and Constant Score were observed in all 3 treatment groups , with minimal clinical ly important differences shown on pain with elevation and SST scores . Between-group differences on all outcome measures were not statistically significant or clinical ly meaningful . Conclusions : The improvements in pain and function observed with an NSAID or PCT as adjuvant treatments were no greater than with rehabilitation exercise alone . If adjuvant treatment is desired , PCT seems to be better tolerated than an NSAID , although the difference did not reach significance . Clinical Relevance : The routine addition of adjuvant treatment is not supported by the results of this study . As adjuvant therapy , PCT seems to be better tolerated  than an NSAID . If desired , clinicians may consider incorporating PCT along with an exercise component in the conservative treatment of SAI syndrome STUDY DESIGN R and omized controlled trial . OBJECTIVE To evaluate the effects of an exercise protocol , with and without manual therapy , on scapular kinematics , function , pain , and mechanical sensitivity in individuals with shoulder impingement syndrome . BACKGROUND Stretching and strengthening exercises have been shown to effectively decrease pain and disability in individuals with shoulder impingement syndrome . There is still conflicting evidence regarding the efficacy of adding manual therapy to an exercise therapy regimen . METHODS Forty-six patients were assigned to 1 of 2 groups , one of which received a 4-week intervention of stretching and strengthening exercises ( exercise alone ) and the other the same intervention , supplemented by manual therapy targeting the shoulder and cervical spine ( exercise plus manual therapy ) . All outcomes were measured preintervention and postintervention at 4 weeks . Outcome measures were scapular kinematics in the scapular and sagittal planes during arm elevation , function as determined through the Disabilities of the Arm , Shoulder and H and ( DASH ) question naire , pain as assessed with a visual analog scale , and mechanical sensitivity as assessed with pressure pain threshold . RESULTS Independent of the intervention group , small , clinical ly irrelevant changes in scapular kinematics were observed postintervention . A significant group-by-time interaction effect ( P = .001 ) was found for scapular anterior tilt during elevation in the sagittal plane , with a 3.0 ° increase ( 95 % confidence interval [ CI ] : -1.5 ° , 7.5 ° ) relative to baseline in the exercise-plus-manual therapy group compared to a decrease of 0.3 ° ( 95 % CI : -4.2 ° , 4.8 ° ) in the exercise-alone group . Pain , mechanical sensitivity , and the DASH score improved similarly for both groups by the end of the intervention period . CONCLUSION Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics , function , and pain in individuals with shoulder impingement syndrome . The noted improvements in pain and function are not likely explained by changes in scapular kinematics BACKGROUND DATA AND OBJECTIVE Although previous studies have evaluated the effect of different kinds of physical therapy in subacromial impingement syndrome ( SIS ) , there have been few investigations assessing the effectiveness of low-level laser therapy ( LLLT ) in shoulder disorders . The goal of this prospect i ve r and omized study was to assess whether gallium-arsenide ( Ga-As ) laser therapy improves the outcome of a comprehensive home exercise program in patients with SIS . MATERIAL S AND METHODS Forty-four newly-diagnosed SIS patients were enrolled in this study . Group 1 patients ( n = 22 ) received Ga-As laser therapy combined with a 12-wk comprehensive home exercise program , and group 2 patients ( n = 22 ) received the same 12-wk comprehensive home exercise program alone .  Night pain , shoulder pain and disability index ( SPADI ) , and University of California-Los Angeles end- result ( UCLA ) scores were used as outcome measures . RESULTS Both groups showed a significant reduction in night pain and SPADI scores at the second and 12th weeks with respect to baseline values , with the exception of the SPADI total score at the second week in group 1 . UCLA results improved significantly in both groups at the 12th in comparison to the second week . There were no significant differences between groups in mean actual changes in night pain and SPADI scores at the second week from baseline . When values at the 12th week were compared to baseline , mean actual changes in night pain differed significantly between the groups , with a larger change in group 1 , but there was no difference between groups in mean actual change in SPADI scores . Second- and 12th-week UCLA scores did not differ between the two groups . CONCLUSION Our study was unable to demonstrate any distinct advantage of low-level laser therapy over exercise alone . Comprehensive home exercise programs should be the primary therapeutic option in the rehabilitation process in SIS Thirty-one female Sprague-Dawley rats were used to determine the effects of subacromial corticosteroid injections on the rotator cuff . The injection technique was tested in 6 animals , which were excluded from the study . The remaining 25 rats were r and omly divided into three groups of 8 animals each ; a single rat received no injections . Every other week for 8 weeks , one shoulder in each rat was injected with methylprednisolone , betamethasone , or saline in a dosage equivalent to that used in humans . The supraspinatus and infraspinatus tendons were removed 10 days after the last injection and evaluated . There were no pathologic changes in the tendons injected with saline . In 43 % of the methylprednisolone-treated rats and 29 % of the betamethasone-treated rats , the tendons were abnormally soft and light-colored . In 43 % of the methylprednisolone group and 71 % of the betamethasone group , fragmentation of collagen bundles and inflammatory cell infiltration were evident . Subacromial injections of methylprednisolone or betamethasone repeated frequently can cause deleterious changes in the normal structure of the rat rotator cuff . In light of these findings , therapy for subacromial impingement syndrome of the shoulder with frequent , repeated steroid injections is potentially harmful The evidence to guide use of spinal manipulative therapy ( SMT ) for patients with shoulder pain is limited . A vali date d sham comparator is needed to ascertain the unique effects of SMT . We investigated the plausibility of a thoracic sham-SMT comparator for SMT in patients with shoulder pain . Participants ( n = 56 ) with subacromial impingement syndrome were r and omized to thoracic SMT or a sham-SMT .  An examiner blinded to group assignment took measures pre- and post-treatment of shoulder active range of motion ( AROM ) and perceived effects of the assigned intervention . Treatment consisted of six upper , middle and lower thoracic SMT or sham-SMT . The sham-SMT was identical to the SMT , except no thrust was applied . Believability as an active treatment was measured post-treatment . Believability as an active treatment was not different between groups ( χ(2 ) = 2.19 ; p = 0.15 ) . Perceptions of effects were not different between groups at pre-treatment ( t = 0.12 ; p = 0.90 ) or post-treatment ( t = 0.40 ; p = 0.69 ) , and demonstrated equivalency with 95 % confidence between groups at pre- and post-treatment . There was no significant change in shoulder flexion in either group over time , or in the sham-SMT for internal rotation ( p > 0.05 ) . The SMT group had an increase of 6.49 ° in internal rotation over time ( p = 0.04 ) . The thoracic sham-SMT of this study is a plausible comparator for SMT in patients with shoulder pain . The sham-SMT was believable as an active treatment , perceived as having equal beneficial effects both when verbally described and after familiarization with the treatment , and has an inert effect on shoulder AROM . This comparator can be considered for used in clinical trials investigating thoracic SMT . IRB number : HM 13182 OBJECTIVES : Conflicting results were reported about the effectiveness of Low level laser therapy on musculoskeletal disorders . The aim of this study was to investigate the effectiveness of 850‐nm gallium arsenide aluminum ( Ga‐As‐Al ) laser therapy on pain , range of motion and disability in subacromial impingement syndrome . METHODS : A total of 52 patients ( 33 females and 19 males with a mean age of 53.59±11.34 years ) with subacromial impingement syndrome were included . The patients were r and omly assigned into two groups . Group I ( n = 30 , laser group ) received laser therapy ( 5 joule/cm2 at each point over maximum 5‐6 painful points for 1 minute ) . Group II ( n = 22 , placebo laser group ) received placebo laser therapy . Initially cold pack ( 10 minutes ) was applied to all of the patients . Also patients were given an exercise program including range of motion , stretching and progressive resistive exercises . The therapy program was applied 5 times a week for 14 sessions . Pain severity was assessed by using visual analogue scale . Range of motion was measured by goniometer . Disability was evaluated by using Shoulder Pain and Disability Index . RESULTS : In group I , statistically significant improvements in pain severity , range of motion except internal and external rotation and SPADI scores were observed compared to baseline scores after the therapy ( p<0.05 ) . In Group II , all parameters except range of motion of external rotation were improved ( p<0.05 ) . However , no significant differences were recorded between the groups ( p>0.05 ) . CONCLUSIONS : The Low level laser therapy seems to have no superiority over placebo laser therapy in reducing pain severity , range of motion and functional disability
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 .