Aims

Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space.

Aims. The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy. Methods. Participants were recruited from two community musculoskeletal treatment centres in the UK. Patients were eligible if aged 18 years or older, and had a clinical diagnosis of subacromial impingement syndrome which the treating clinician thought was suitable for treatment with a subacromial injection. Consenting patients were randomly allocated 1:1 to a patient-blinded subacromial injection of CSI (standard care) or APS. The primary outcome measures of this study relate to rates of recruitment, retention, and compliance with intervention and follow-up to determine feasibility. Secondary outcome measures relate to the safety and efficacy of the interventions. Results. A total of 53 patients were deemed eligible, and 50 patients (94%) recruited between April 2022 and October 2022. Overall, 49 patients (98%) complied with treatment. Outcome data were collected in 100% of participants at three months and 94% at six months. There were no significant adverse events. Both groups demonstrated improvement in patient-reported outcome measures over the six-month period. Conclusion. Our study shows that it is feasible to recruit to a patient-blinded randomized controlled trial comparing APS and CSI for subacromial pain in terms of clinical outcomes and health-resource use in the UK. Safety and efficacy data are presented. Cite this article: Bone Jt Open 2024;5(7):534–542

Aims

The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery.

Aims

Rotator cuff tendinopathy has a multifactorial origin. Rejecting the mechanistic theory has also led to abandoning operative treatment at initial presentation in the first line. Physiotherapy exercise programmes are the accepted first line treatment. The aim of this study was to assess the long-term additional benefits of subacromial decompression in the treatment of rotator cuff tendinopathy.

Background. Shoulder impingement syndrome (SIS) is a common debilitating condition, treated across multiple health disciplines including Orthopaedics, Physiotherapy, and Rheumatology. There is little consistency in diagnostic criteria with ‘Shoulder impingement syndrome’ being used for a broad spectrum of complex pathologies. We assessed patterns in diagnostic procedures for SIS across multiple disciplines. Methods. This is a systematic review of electronic databases MEDLINE, PubMed, The Cochrane Library, Embase, Scopus and CINAHL five years of publications, January 2009 - January 2014. Search terms for SIS included subacromial impingement syndrome, subacromial bursitis. Searches were delimited to articles written in English. The PRISMA guidelines were followed. Two reviewers independently screened all articles, data was then extracted by one reviewer and twenty percent of the extraction was independently assessed by the co-reviewer. Studies included were intervention studies examining individuals diagnosed with SIS and we were interested in the process and method used for the diagnosis. Results. The search strategy yielded 3339 articles of which 1931 were duplicates. A further 1260 were excluded based on relevance obtained from title/abstract. A total of 148 articles were identified investigating SIS across thirty different journals internationally. Fourteen different health disciplines have investigated twenty-five different surgical and conservative treatments. Studies document their diagnostic approach, reporting on duration of symptoms, medical history, physical examination tests and radiological investigations. Duration of symptoms for inclusion ranged from a minimum of 2 weeks to 18 months where the median duration of symptoms is 3 months observed in 46 percent of the studies. Commonly used physical tests were Neer's test, Hawkins-Kennedy test, Jobe and Yocum, and a further eight tests identified. Neer's test or Hawkins-Kennedy tests were individually used in 72 percent of studies. Thirty of the studies used more than one and up to six physical tests per study to determine the presence of impingement. Radiological investigations were reported in twenty-eight studies, sixteen of these required more than one radiological investigation to confirm the diagnosis of SIS. Comparisons between disciplines identify important differences in diagnostic criteria used by different health professionals. Conclusions. This study highlights the variety of diagnostic methods which are currently used between health disciplines and will be a useful comparative tool for clinicians. Diagnostic transparency is pertinent for shoulder impingement syndrome to ensure all disciplines are treating the same pathology and importantly to contribute to our understanding of the common pathology

The December 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: cuff tears and plexus injury;

corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?

The October 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: PRP is not effective in tennis elbow; eccentric physiotherapy effective in subacromial pain; dexamethasone in shoulder surgery; arthroscopic remplissage for engaging Hill-Sach’s lesions; a consistent approach to subacromial impingement; delay in fixation of proximal humeral fractures detrimental to outcomes.

Introduction

The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically.

Introduction. There are over 110 special tests described in the literature for clinical examination of the shoulder, but there is no general consensus as to which of these are the most appropriate to use. Individual opinion appears to dictate clinical practice. Rationalising which tests and clinical signs are the most useful would not only be helpful for trainees, but would also improve day to day practice and promote better communication and understanding between clinicians. Methodology. We sent a questionnaire survey to all shoulder surgeons in the UK (BESS members), asking which clinical tests each surgeon found most helpful in diagnosing specific shoulder pathologies; namely sub-acromial impingement, biceps tendonitis, rotator cuff tears and instability; both anterior and posterior. Results. For impingement; Hawkins-Kennedy and Neer's tests were used by the majority of respondents, with 50% also routinely performing Neer's injection test. For frozen shoulder; the shoulder quadrant test was the commonest used, followed by loss of passive range of motion and loss of external rotation. For biceps tendonitis; Speed's and Yergason's tests were by far the commonest used. For rotator cuff tears the commonest signs were; the Napoleon belly press, Hornblower's sign, Gerber's sign, Jobe's sign and Codman's drop arm sign. For instability; the apprehension test, the Gerber-Ganz drawer test, load and shift test and Jobe's relocation test were the commonest used, with the jerk test also popular for posterior instability. We are also currently assessing how individuals actually perform these tests, and whether they are as the original authors described them. Conclusion. Our results demonstrated some variation in which tests were being used, but with an increased preference for certain tests. Interestingly a large number of respondents commented that the history was of paramount importance and that clinical signs should only substantiate the clinician's diagnosis

Intra-articular shoulder pathology has been recognised in more detail following widespread use of shoulder arthroscopy. The purpose of this epidemiological study is to present the incidence and exact type of SLAP lesions in our operated population and to correlate them with the presence of other shoulder lesions. Between 2004 and 2010 425 patients underwent shoulder arthroscopy in our department (311 for rotator cuff tears or subacromial impingement, 102 for shoulder instability, 12 for SLAP lesions). Eighty-two SLAP lesions (19.2% overall) were recognized during these procedures. In 44 cases the lesion was SLAP type I (53.6%), in 10 type II (12.2%), in 1 type III (1.2%), in 1 type IV (1.2%), in 24 type V (29.26%) and finally in 2 type VI (2.43%). In more detail SLAP I lesions were associated in 8 patients with subacromial impingement syndrome, in 33 with RC tear and in 3 patients with anterior instability. Type II, III and IV were preoperatively diagnosed, while type V and VI lesions were found in patients with chronic anterior shoulder instability. SLAP lesions are diagnosed more accurately during shoulder arthroscopy rather than with plain shoulder MRI scan. In our study population only 12 cases were accurately diagnosed with a pre-operative MRI scan, while the remaining 70 cases were missed. Additionally, there was significant correlation between rotator cuff problems and SLAP I lesions, while chronic shoulder instability was associated with SLAP V and VI (25.4% of patients with instability). Shoulder arthroscopy not only has changed SLAP lesion diagnosis and treatment but also reveals the correlation of various SLAP lesion types with specific shoulder pathologies

The June 2012 Shoulder & Elbow Roundup³⁶⁰ looks at: reverse shoulder replacement; torn rotator cuffs and platelet-rich fibrin; rotator cuff repair; frozen shoulder; whether an arthroscopic rotator cuff repair actually heals; the torn rotator cuff’s effect on activities of daily living; subacromial impingement; how to improve the reliability of the Constant-Murley score; and failure of the Neer modification of an open Bankart procedure.

The effect of timing of a manipulation under anaesthetic (MUA) and injection of corticosteroid and local anaesthetic for the treatment of frozen shoulder has attracted little attention to date. All studies describe a period of conservative treatment before proceeding to an MUA. Delay has been associated with a poorer outcome.

We present a retrospective review of a prospectively collected, single-surgeon, consecutive series of 246 patients with a primary frozen shoulder treated by MUA within four weeks of presentation. The mean duration of presenting symptoms was 28 weeks (6 to 156), and time to initial post-operative assessment was 26 days (5 to 126). The Oxford shoulder score (OSS) improved by a mean of 16 points (Wilcoxon signed-ranks test, p < 0.001) with a mean OSS at this time of 43 (7 to 48). Linear regression analysis showed no correlation between the duration of presenting symptoms and OSS at initial follow-up (R2 < 0.001) or peri-operative change in OSS (R2 < 0.001) or OSS at long-term follow-up (R2 < 0.03). Further analysis at a mean of 42 months (8 to 127) revealed a sustained improvement with a mean OSS of 44 (16 to 48).

A good outcome follows an MUA and injection of corticosteroid and local anaesthetic in patients with primary frozen shoulder, independent of the duration of the presenting symptoms, and this improvement is maintained in the long term.

Purpose: Subacromial impingement syndrome is a painful condition which occurs during overhead activities as the rotator cuff is compressed between the greater tuberosity and the acromion. Unrecognized secondary causes of impingement syndrome may lead to treatment failure. Posterior capsular tightness, believed to alter shoulder joint kinematics, is often cited as a secondary cause but scientific evidence is lacking. The objective of this study was to evaluate the effect of posterior capsular tightness on pressure in the subacromial space. Method: Ten fresh-frozen cadaver shoulder specimens were mounted on a custom testing apparatus. With the scapula fixed, the deltoid and cuff muscles were loaded statically with a constant ratio to elevate the humerus in the scapular plane under physiologic loading conditions. For each treatment (intact capsule, 1cm and 2cm plication), pressure in the subacromial space and glenohumeral kinematics were recorded during elevation. The treatment order was randomly assigned to each specimen. Peak pressure and translation of the humeral head center were compared using a repeated measures ANOVA. Results: Peak subacromial pressures (mean±sd) were similar between treatment groups: 345±152 kPa, 410±213 kPa and 330±164 kPa for the intact, 1cm and 2cm plication respectively (p> 0.05). No significant differences were found for superior or antero-posterior translations of the humeral head at the peak pressure position (p> 0.05). Conclusion: Posterior capsular tightness, as a sole variable, did not contribute significantly to increased pressure in the subacromial space or to increased anterior or superior humeral head translation during abduction. Clinically, posterior capsular tightness may occur in association with impingement syndrome but may not play a significant role in causation

There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful and debilitating condition. We conducted a review of the evidence of the effectiveness of interventions used to manage primary frozen shoulder using the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Physiotherapy Evidence Database, MEDLINE and EMBASE without language or date restrictions up to April 2009. Two authors independently applied selection criteria and assessed the quality of systematic reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Data were synthesised narratively, with emphasis placed on assessing the quality of evidence.

In total, 758 titles and abstracts were identified and screened, which resulted in the inclusion of 11 systematic reviews. Although these met most of the AMSTAR quality criteria, there was insufficient evidence to draw firm conclusions about the effectiveness of treatments commonly used to manage a frozen shoulder. This was mostly due to poor methodological quality and small sample size in primary studies included in the reviews. We found no reviews evaluating surgical interventions.

More rigorous randomised trials are needed to evaluate the treatments used for frozen shoulder.

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.

In a prospective randomised 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

Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good. The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome. The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded. Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient. 58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003). In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection

Background: The aim of this study is to evaluate the efficacy of extracorpereal shock wave therapy (ESWT) in some of most frequent muscularskeletal pathologies. Material and methods: From July to October 2004 310 patients were treated with ESWT, suffering from the following pathologies: 96 symptomatic calcific tendonitis of the shoulder, 53 symptomatic sub-acromial impingement, 48 humeral epichondylitis, 52 plantar fasciitis, 24 pertrochanteric bursitis, 15 Achilleous tendinopathy and 22 patellar tendinopathy. Patients were evaluated clinically and instrumentally before the first application and at one and three months of follow-up. Three disability scales we utilized (NRS, Mcgill Pain Questionnaire e Chronic Pain Grade Questionnaire). Results: We observed a reduction of the pain and an increase of the articular functionality in 83% of calcific tendonitis of the shoulder, in 55% of sub-acromial impingement, in 76% of epichondylitis, in 74% of palantar fasciitis, in 90% of pertrochanteric bursitis, in 82% of Achilleous tendinopathy and in 86% of patellar tendinopaty. Discussion: The data confirm the therapy with ESWT is efficient in some of most frequent musculoskeletal pathologies, with variable outcome in the various pathologies under investigation

Purpose: Appropriate treatment of full-thickness tears of the rotator cuff with subacromial impingement remains a subject of debate. Considering that in most patients, spontaneous tears of the long biceps tendon reduces the pain and that subacromial osteoarthritis is well tolerated by many patients, we proposed arthroscopic tenotomy of the long biceps in this indication with the aim of relieving pain. We report here the long-term outcome. Material and methods: Between 1988 and 1999, 307 arthroscopic tenotomies of the long biceps tendon were performed in patients with unrepairable tears of the rotator cuff tendons (massive full thickness tears, old patients, non-motivated patients). The procedure was isolated in 64% and associated with acromioplasty in 36%. All patients were given prior medical treatment. Mean age at surgery was 64.3 years. The preoperative subacromial height was 6.6 mm. The tendon lesion was an isolated tear of the supraspinatus in 31%, tears of two tendons in 44.6% and tears of three tendons in 21.8%, and isolated tears of the subscapularis in 2.6%. Mean follow-up was 57 months (24–168). Results: The Constant score improved from 48.4 to 67.6 points (p< 0.001). Glenohumeral osteoarthritis (Samilson) increased from 38% to 67% of the shoulders postoperatively. Association with acromioplasty improved the objective and subjective result solely in the group of isolated tears of the supraspinatus. The size of the tear and the degree of fatty degeneration of the rotator cuff muscles had a statistically significant influence on functional and radiographic outcome (p< 0.001) while time since surgery had no effect on radiographic outcome (p< 0.001). Discussion: This simple easy-to-perform procedure yielded pain relief at rest and also nighttime pain. It can be recommended for massive rotator cuff tears with sub-acromial impingement in elderly or poorly-motivated patients whose pain fails to respond to medical treatment. This procedure does not allow recovery of shoulder motion or force