Shoulder Impingement Syndrome

ObjectiveTo 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.DesignMulticentre, three group, randomised, double blind, sham controlled trial.SettingOrthopaedic departments at three public hospitals in Finland.Participants210 patients with symptoms consistent with shoulder impingement syndrome, enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015.InterventionsASD, diagnostic arthroscopy (placebo control), and exercise therapy.Main outcome measuresShoulder 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 clinically important difference was set at 15.ResultsIn the primary intention to treat analysis (ASD versus diagnostic arthroscopy), no clinically 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 clinically 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.ConclusionsIn this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months.Trial registrationClinicaltrials.gov NCT00428870.

Many treatments for shoulder impingement syndrome (SIS) are available in clinical practice; some of which have already been compared with other treatments by various investigators. However, a comprehensive treatment comparison is lacking. Several widely used electronic databases were searched for eligible studies. The outcome measurements were the pain score and the Constant-Murley score (CMS). Direct comparisons were performed using the conventional pair-wise meta-analysis method, while a network meta-analysis based on the Bayesian model was used to calculate the results of all potentially possible comparisons and rank probabilities. Included in the meta-analysis procedure were 33 randomized controlled trials involving 2300 patients. Good agreement was demonstrated between the results of the pair-wise meta-analyses and the network meta-analyses. Regarding nonoperative treatments, with respect to the pain score, combined treatments composed of exercise and other therapies tended to yield better effects than single-intervention therapies. Localized drug injections that were combined with exercise showed better treatment effects than any other treatments, whereas worse effects were observed when such injections were used alone. Regarding the CMS, most combined treatments based on exercise also demonstrated better effects than exercise alone. Regarding surgical treatments, according to the pain score and the CMS, arthroscopic subacromial decompression (ASD) together with treatments derived from it, such as ASD combined with radiofrequency and arthroscopic bursectomy, showed better effects than open subacromial decompression (OSD) and OSD combined with the injection of platelet-leukocyte gel. Exercise therapy also demonstrated good performance. Results for inconsistency, sensitivity analysis, and meta-regression all supported the robustness and reliability of these network meta-analyses. Exercise and other exercise-based therapies, such as kinesio taping, specific exercises, and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended. For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. Notwithstanding, the choice of surgery should be made cautiously because similar outcomes may also be achieved by the implementation of exercise therapy.

BackgroundClavicular hook plates are effective fixation devices for distal clavicle fractures and severe acromioclavicular joint dislocations. However, increasing number of studies has revealed that subacromial portion of the hook may induce acromial bony erosion, shoulder impingement, or even rotator cuff damage. By sonographic evaluation, we thus intended to determine whether the presence of hook plate may induce subacromial shoulder impingement and its relationship relative to surrounding subacromial structures.MethodsWe prospectively followed 40 patients with either distal clavicle fracture or acromioclavicular joint dislocation that had surgery using the Arbeitsgemeinschaft für Osteosynthesefragen (AO) clavicular hook plate. All patients were evaluated by monthly clinical and radiographic examinations. Static and dynamic musculoskeletal sonography examinations were performed at final follow-up before implant removal. Clinical results for pain, shoulder function, and range of motion were evaluated using Constant-Murley and Disability of Arm, Shoulder, and Hand (DASH) scores.ResultsClinically, 15 out of 40 patients (37.5%) presented with subacromial impingement syndrome and their functional scores were poorer than the non-impinged patients. Among them, six patients were noted to have rotator cuff lesion. Acromial erosion caused by hook pressure developed in 20 patients (50%).ConclusionsWe demonstrated by musculoskeletal sonography that clavicular hook plate caused subacromial shoulder impingement and rotator cuff lesion. The data also suggest an association between hardware-induced impingement and poorer functional scores. To our knowledge, the only solution is removal of the implant after bony consolidation/ligamentous healing has taken place. Thus, we advocate the removal of the implant as soon as bony union and/or ligamentous healing is achieved.

Background and purposeIn 2013, the first clinical practice guideline for subacromial pain syndrome (SAPS) was developed in the Netherlands to support healthcare professionals. SAPS refers to non-traumatic, non-rheumatologic shoulder complaints that are particularly painful during arm elevation. It includes conditions such as supraspinatus tendinosis, calcific tendinitis, and degenerative supraspinatus tears. Over 50,000 patients annually consult orthopedic surgeons for these issues. In response to new evidence and clinical needs, an updated guideline was developed. Part 1 addresses prevention, diagnosis, imaging, and non-surgical treatment. Using a multidisciplinary, evidence-based approach, the guideline aims to answer key clinical questions around SAPS.MethodsInitiated by the Dutch Orthopedic Society, the guideline committee identified knowledge gaps through group sessions. Each module was based on a PICO-formatted key question and reviewed by professionals from different fields. The AGREE and GRADE methods were applied to ensure a systematic evaluation of evidence, leading to conclusions and recommendations.Results(i) Inform patients about the potential positive effects of a healthy lifestyle and encourage gradual exercise within sport and work. (ii) Perform a cluster of physical diagnostic tests to diagnose SAPS. (iii) Perform ultrasonography in patients with clinical suspicion of (partial thickness) rupture of the supraspinatus tendon. Consider MRI if ultrasound is not available or inconclusive. (iv) Consider barbotage for symptomatic calcific tendinosis, preferably with corticosteroid injection in the bursa, if a previous corticosteroid injection was ineffective. (v) Consider a subacromial corticosteroid injection (with a local anesthetic) to enable exercise therapy in patients with severe complaints that impair their ability to participate in exercise therapy. (vi) Consider suprascapular nerve block for patients with therapy-resistant SAPS when other non-surgical treatment is ineffective.ConclusionThe updated guideline provides multidisciplinary recommendations for physical examination, imaging, and conservative management of SAPS.