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Elif Turgut, Irem Duzgun and Gul Baltaci

Although there are various definitions of subacromial impingement syndrome (SIS), it is widely accepted that SIS is a mechanical shoulder dysfunction which is related to mechanically stressed rotator cuff tendons and long head of biceps tendon at subacromial space. 1 Scapular position and

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Aydan Aytar, Gul Baltaci, Tim Uhl, Handan Tuzun, Pinar Oztop and Metin Karatas

Objective:

To determine the effects of scapular mobilization on function, pain, range of motion, and satisfaction in patients with subacromial impingement syndrome (SAIS).

Design:

Randomized, 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 randomized 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 Hand Questionnaire (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.

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Dong-Rour Lee and Laurentius Jongsoon Kim

Context:

Many studies have explored closed kinetic chain (CKC) shoulder exercises (SEs) with a sling because they are safer and more effective than open-chain exercises, especially in early stages of treatment. However, the application of CKC SE in youth baseball players has rarely been attempted, although teenage baseball players also experience shoulder pain.

Objective:

To investigate the effects of CKC SE on the peak torque of shoulder internal rotation (IR) and external rotation (ER) in youth baseball players.

Design:

Single-group pretest, posttest.

Setting:

Biomechanics laboratory.

Participants:

23 Little League Baseball players with subacromial impingement syndrome.

Interventions:

The CKC SE with a sling was CKC shoulder-flexion exercise, extension exercise, IR exercise, and ER exercise. This exercise regimen was conducted 2 or 3 times/wk for 8 wk.

Main Outcome Measures:

The peak torque of shoulder IR and ER was measured using an isokinetic dynamometer. Concentric shoulder rotation was performed, with 5 repetitions at an angular velocity of 60°/s and 15 at 180°/s.

Results:

The IR and ER peak torque significantly increased at each angular velocity after the exercise program. In particular, the increase in IR and ER peak torque values was statistically significant at an angular velocity of 180°/s.

Conclusions:

CKC SE was effective in increasing shoulder IR and ER strength, demonstrating its potential benefits in the prevention and treatment of shoulder injury. In addition, increased IR peak torque appears to improve throwing velocity in baseball players.

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Mark K. Timmons, Chuck A. Thigpen, Amee L. Seitz, Andrew R. Karduna, Brent L. Arnold and Lori A. Michener

Context:

The literature does not present a consistent pattern of altered scapular kinematics in patients with shoulder-impingement syndrome (SIS).

Objectives:

To perform meta-analyses of published comparative studies to determine the consistent differences in scapular kinematics between subjects with SIS and controls. In addition, the purpose was to analyze factors of the data-collection methods to explain the inconsistencies in reported kinematics. The results of this study will help guide future research and enable our understanding of the relationship between scapular kinematics and SIS.

Evidence Acquisition:

A search identified 65 studies; 9 papers met inclusion criteria. Sample sizes, means, and SDs of 5 scapular-kinematic variables were extracted or obtained from each paper’s lead author. Standard difference in the mean between SIS and controls was calculated. Moderator variables were plane of arm elevation, level of arm elevation (ARM) and population (POP).

Evidence Synthesis:

Overall, the SIS group had less scapular upward rotation (UR) and external rotation (ER) and greater clavicular elevation (ELE) and retraction (RET) but no differences in scapular posterior tilt (PT). In the frontal plane, SIS subjects showed greater PT and ER, and in the scapular plane, less UR and ER and greater ELE and RET. There was also greater ELE and RET in the sagittal plane. There was less UR at the low ARM and greater ELE and RET at the high ARM with SIS. Athletes and overhead workers showed less UR, while athletes showed greater PT and workers showed less PT and ER. The general population with SIS had greater ELE and RET only.

Conclusions:

Subjects with SIS demonstrated altered scapular kinematics, and these differences are influenced by the plane, ARM, and POP. Athletes and overhead workers have a different pattern of scapular kinematics than the general population. The scapular plane is most likely to demonstrate altered kinematics. These factors should be considered when designing futures studies to assess the impact of altered kinematics in patients with SIS.

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Fábio Carlos Lucas de Oliveira, Amanda L. Ager and Jean-Sébastien Roy

measured on ultrasonographic imaging in subacromial impingement syndrome . Knee Surg Sports Traumatol Arthrosc . 2015 ; 23 ( 2 ): 363 – 369 . PubMed ID: 23736252 doi: 10.1007/s00167-013-2542-8 23736252 14. Seitz AL , Michener LA . Ultrasonographic measures of subacromial space in patients with

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Stephen J. Thomas, Kathleen A. Swanik, Charles “Buz” Swanik, Kellie C. Huxel and John D. Kelly IV

Context:

Pathologies such as anterior instability and impingement are common in baseball and have been linked to decreases in internal rotation (IR) and concurrent increases in external rotation (ER). In addition, alterations to scapular position have been identified in this population, but the chronology of these adaptations is uncertain.

Objectives:

To determine whether there is a change in range of motion and scapular position after a single baseball season.

Design:

Prospective cohort.

Setting:

High school.

Participants:

19 high school baseball players (age 16.6 ± 0.8 y, mass 78.6 ± 12.0 kg, height 180.3 ± 6.2 cm).

Interventions:

Subjects were measured for all dependent variables at preseason and postseason.

Main Outcome Measures:

Participants were measured for glenohumeral (GH) IR and ER with the scapula stabilized. Total GH range of motion was calculated as the sum of IR and ER. Scapular upward rotation was measured at 0°, 60°, 90°, and 120° of GH abduction in the scapular plane, and scapular protraction, at 0°, hands on hips, and 90° of GH abduction.

Results:

Overall, the dominant arm had significantly less GH IR (11.4°, P = .005) and significantly more ER (4.7°, P = .001) than the nondominant arm. Total motion in the dominant arm was significantly less than in the nondominant arm (6.7°, P = .001). Scapular upward rotation in the dominant arm significantly increased at 0° (2.4°, P = .002) and significantly decreased at 90° (3.2°, P = .001) and 120° (3.2°, P < .001) of abduction from preseason to postseason. Scapular protraction in the nondominant arm significantly decreased at 45° (0.32 cm, P = .017) and 90° (0.33 cm, P = .006) from preseason to postseason.

Conclusion:

These data suggest that scapular adaptations may be acquired over a relatively short period (12 wk) in a competitive baseball season. Competitive high school baseball players also presented with significant GH motion differences between their dominant and nondominant arms. Total motion was also significantly less in the dominant arm than in the nondominant arm.

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Damla Karabay, Yusuf Emük and Derya Özer Kaya

Context: Selective strengthening of scapular stabilizers is one of the emphases of the recent literature. Closed kinetic chain (CKC) exercises are used extensively in shoulder rehabilitation. However, a limited number of studies have reported scapular muscle ratios during CKC exercises. Objectives: To determine the CKC exercises producing the optimal ratios of the scapular stabilizer muscles in healthy shoulders. Evidence Acquisition: A systematic search within PubMed, Embase, CINAHL Plus, and SPORTDiscus with Full Text and ULAKBIM National Medical Database was performed up to January 2018. Studies were selected according to the predetermined criteria. If the pooled mean ratios (upper trapezius [UT]/middle trapezius [MT], UT/lower trapezius [LT], and UT/serratus anterior [SA]), which were calculated from the percentage of maximum voluntary contractions of muscles, were <0.60, these exercises were considered as ideal for higher activation of the MT, LT, and SA than the UT. Evidence Synthesis: The search identified 1284 studies, and 29 observational studies were included for review. Seventy-nine CKC exercises were determined. Four exercises for the MT, 9 for the LT, and 59 for the SA were identified from the articles as being optimal exercises to activate the specified muscle more than the UT. Conclusions: This review identified optimal CKC exercises that provide good ratios between the MT, LT, and SA with the UT. Most exercises have optimal UT/SA ratios, but some exercises performed on unstable surfaces may lead to excessive activation of the UT relative to the SA. For the UT/MT, the isometric low row, inferior glide, and half supine pull-up with slings are the ideal exercises. Isometric one-hand knee push-up variations seem to be the best choice for the UT/LT. The results suggest that many CKC exercises may be utilized to enhance scapular muscle balance when rehabilitating shoulder pathology.

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Alya H. Bdaiwi, Tanya Anne Mackenzie, Lee Herrington, Ian Horlsey and Ann Cools

Context:

Compromise to the acromiohumeral distance (AHD) has been reported in subjects with subacromial impingement syndrome when compared with healthy subjects. In clinical practice, patients are taped with the intention of altering scapular position and influencing the AHD. However, research to determine the effects of taping on AHD is exiguous.

Objectives:

To evaluate the effect of ridged taping techniques to increase posterior scapular tilt and upward scapular rotation on the AHD.

Design:

1-group pretest/posttest repeated-measures design.

Setting:

Human performance laboratory.

Participants:

20 asymptomatic participants (10 male and 10 female) age 27 y (SD 8.0 y).

Intervention:

Ridged tapping of the scapula into posterior tilt and upward scapular rotation.

Main Outcome Measure:

Ultrasound measurement of the AHD.

Results:

AHD increased significantly after rigid tape application to the scapula (P < .003) in healthy shoulders in 60° of passive arm abduction.

Conclusion:

Taping techniques applied to the scapula had an immediate effect of increasing the AHD in healthy shoulders in 60° of passive arm abduction. Results suggest that taping for increasing posterior scapular tilt and increasing scapular upward rotation can influence the AHD and is a useful adjunct to rehabilitation in patients with subacromial impingement syndrome.

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Lucas Ettinger, Jason Weiss, Matthew Shapiro and Andrew Karduna

In this study, we aimed to determine if electromyography (EMG) normalization to maximal voluntary isometric contractions (MVIC) was influenced by subacromial pain in patients with subacromial impingement syndrome. Patients performed MVICs in unique testing positions for each shoulder muscle tested before and after subacromial injection of local anesthetic. In addition to collection of MVIC data, EMG data during an arm elevation task were recorded before and after injection. From a visual analog pain scale, patients had a 64% decrease in pain following the injection. Significant increases in MVICs were noted in 4 of the 7 shoulder muscles tested: anterior, middle and posterior deltoid, and lower trapezius. No significant differences were noticed for the upper trapezius, latissimus dorsi, or serratus anterior. MVIC condition (pre and post injection) had a significant influence on EMG normalization for the anterior deltoid and lower trapezius muscle. Results indicate that subacromial pain can influence shoulder muscle activity, especially for the deltoid muscles and lower trapezius. In addition, normalization to MVIC in the presence of pain can have unpredictable results. Caution should be taken when normalizing EMG data to MVIC in the presence of pain.

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Aimee L. Thornton, Cailee W. McCarty and Mollie-Jean Burgess

Clinical Scenario:

Shoulder pain is a common musculoskeletal condition that affects up to 25% of the general population. Shoulder pain can be caused by any number of underlying conditions including subacromial impingement syndrome, rotator-cuff tendinitis, and biceps tendinitis. Regardless of the specific pathology, pain is generally the number 1 symptom associated with shoulder injuries and can severely affect daily activities and quality of life of patients with these conditions. Two of the primary goals in the treatment of these conditions are reducing pain and increasing shoulder range of motion (ROM).3 Conservative treatment has traditionally included a therapeutic exercise program targeted at increasing ROM, strengthening the muscles around the joint, proprioceptive training, or some combination of those activities. In addition, these exercise programs have been supplemented with other interventions including nonsteroidal anti-inflammatory drugs, corticosteroid injections, manual therapy, activity modification, and a wide array of therapeutic modalities (eg, cryotherapy, EMS, ultrasound). Recently, low-level laser therapy (LLLT) has been used as an additional modality in the conservative management of patients with shoulder pain. However, the true effectiveness of LLLT in decreasing pain and increasing function in patients with shoulder pain is unclear.

Focused Clinical Question:

Is low-level laser therapy combined with an exercise program more effective than an exercise program alone in the treatment of adults with shoulder pain?