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Introduction: Alterations of scapular kinematics are generically reported as scapular dyskinesis (SD), and are a nonspecific response to various shoulder pathologies. The most widely used classification is Kibler's (K), which is, however, characterized by poor sensitivity. To overcome this limit, using a 3D motion analysis system, we identified a specific pattern for each type of SD according to Kibler., Materials and Methods: We analyzed 34 patients with a total of 68 shoulders who came to our observation for shoulder pain. All patients underwent clinical examination, video-recording and motion analysis with SHoW Motion 3D kinematic tracking system (SM). Three independent observers classified SD into K types I, II and III. Only patients with concordant classification among the 3 operators were studied to identify a characteristic graphic pattern by type of SD., Results: Typical patterns emerged from the examination with SM. K. type 1 consists of decreased or reversed posterior tilt and increased protraction in flexion-extension (FE) in early degrees of motion. K. type 2 consists of increased protraction and marked reversal of lateral rotation in abduction-adduction (Ab-Ad) in early degrees of movement. K. type 3 has been subdivided into two subgroups: K. type 3-A, composed of patients with massive rotator cuff lesions, shows an increase in all scapular movements in both FE and Ab-Ad. K. type 3-B, composed of patients with scapular stiffness and/or impingement, presents a slight increase in posterior tilt and lateral rotation in the final grades of FE and Ab-Ad., Conclusions: The SM system allows reproducible dynamic analyses with low intra- and intra- operator variability. In our study, we demonstrated its applicability in the classification of SD. It also provides an objective and quantitative assessment of motor pattern alteration that is essential in the follow-up of patients to evaluate the effectiveness of rehabilitation and/or surgical treatment. LEVEL OF EVIDENCE 3: According to "The Oxford 2011 Levels of Evidence"., (© 2024. The Author(s).)

Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Neuromuscular fatigue induces superior migration of the humeral head in individuals with subacromial pain. This has been attributed to weakness of rotator cuff muscles and overactive deltoid muscles. Investigation of common inputs to motoneuron pools of the rotator cuff and deltoid muscles offers valuable insight into the underlying mechanisms of neuromuscular control deficits associated with subacromial pain. This study aims to investigate intermuscular coherence across the rotator cuff and deltoid muscles during a sustained submaximal isometric fatiguing contraction in individuals with and without subacromial pain. Twenty symptomatic and 18 asymptomatic young adults participated in this study. Surface electromyogram (EMG) was recorded from the middle deltoid (MD) and infraspinatus (IS). Intramuscular EMG was recorded with fine-wire electrodes in the supraspinatus (SS). Participants performed an isometric fatiguing contraction of 30° scaption at 25% maximum voluntary contraction (MVC) until endurance limit. Pooled coherence of muscle pairs (SS-IS, SS-MD, IS-MD) in the 2-5 Hz (delta), 5-15 Hz (alpha), and 15-35 Hz (beta) frequency bands during the initial and final 30 s of the fatigue task were compared. SS-IS and SS-MD delta-band coherence increased with fatigue in the asymptomatic group but not the symptomatic group. In the alpha and beta bands, SS-IS and SS-MD coherence increased with fatigue in both groups. IS-MD beta-band coherence was greater in the symptomatic than the asymptomatic group. Individuals with subacromial pain failed to increase common drive across rotator cuff and deltoid muscles and have altered control strategies during neuromuscular fatigue. This may contribute to glenohumeral joint instability and subacromial pain experienced by these individuals. NEW & NOTEWORTHY Through the computation of shared neural drive across glenohumeral muscles, this study reveals that individuals with subacromial pain were unable to increase shared neural drive within the rotator cuff and across the supraspinatus and deltoid muscles during neuromuscular fatigue induced by sustained isometric contraction. These deficits in common drive across the shoulder muscles likely contribute to the joint instability and pain experienced by these individuals.

OBJECTIVE: To explore modifiable psychosocial factors, sleep-related variables, indices of central pain processing and patients' characteristics as potential prognostic factors for pain, shoulder function, and quality of life (QoL) 1 year after rotator cuff repair. DESIGN: This observational longitudinal study included 142 patients who were undergoing rotator cuff repair. All measures took place pre-rotator cuff repair (T0), and 12 weeks (T1) and 12 months (T2) after rotator cuff repair. METHODS: Mixed-effects linear regression modeled relationships between the Western Ontario Rotator Cuff Index (WORC, model A), the Subjective Shoulder Value (SSV, model B), and EuroQol's EQ-5D-5L for QoL (model C), and potential prognostic factors over time. Factors included psychosocial variables, sleep-related indices, and proxies of central pain processing. Patients' age, sex, and body mass index complemented the analyses. RESULTS: At follow-up (T2), data from 124 participants were available for analysis. Five prognostic factors were identified for the 1-year outcome. Better expectations for symptom reduction ( P <.0001, -1.4 mm) and an increase in Douleur Neuropathique 4 score ( P = .0481, -0.9 mm) affected the evolution of WORC over time (model A). An increase in injury perception subscale consequence ( P = .0035, 0.04%) influenced the SSV trajectory (model B). In addition, when sleep quality ( P = .0011, -0.13%) and sleep efficiency ( P = .0002, 0.005%) improved, the EQ-5D-5L slope was affected (model C). CONCLUSION: Addressing cognitions, pain mechanisms and sleep behavior prior to rotator cuff repair can identify people who are at risk of a poor outcome after surgery. J Orthop Sports Phys Ther 2024;54(8):530-540. Epub 4 July 2024. doi:10.2519/jospt.2024.12398 .

Purpose: To investigate pain hypervigilance in individuals suffering from chronic neck and shoulder pain (CNSP) and its underlying brain mechanism., Methods: The evaluation of pain vigilance was conducted through the utilization of pain vigilance and awareness questionnaires. Voxel-wise regional homogeneity (ReHo) from 60 CNSP patients and 60 healthy controls (HCs) using resting-state fMRI data. Voxel-wise two-sample T-test was conducted to reveal the ReHo variations between CNSP and HC. Correlation analyses were utilized to reveal the connection between brain abnormalities and medical measurements. Furthermore, a mediation analysis was conducted to elucidate the pathway-linking changes in brain function with medical measurements., Results: Our present study revealed three main findings. Firstly, patients with CSNP demonstrated a heightened vigilance of pain in comparison to healthy adults, a common occurrence among individuals with chronic pain conditions. Secondly, we observed brain abnormalities in various brain regions in CSNP patients, and these alterations were associated with the extent of pain vigilance. Lastly, the pain hypervigilance impact on the severity of pain was found to be controlled by regional neural activity in the anterior cingulate cortex (ACC) in subjects with CSNP., Conclusion: Our findings suggested that long-term repetitive nociceptive input caused by chronic pain further aggravates the pain intensity by impairing the vigilance-related pain processing within the anterior cingulate cortex in CNSP patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Irritability is a foundational clinical reasoning concept in rehabilitation to evaluate reactivity of the examination and treatment. While originally theorized to reflect tissue damage, a large body of evidence supports pain is a biopsychosocial experience impacted by pain sensitivity and psychological factors. Therefore, the purpose of this study was to examine biopsychosocial contributors to irritability., Methods: 40 patients with shoulder ( n  = 20) and low back ( n  = 20) pain underwent Quantitative Sensory Testing (QST) (Pressure Pain Threshold, Heat Pain Threshold, Conditioned Pain Modulation, Temporal Summation), completed pain-related psychological questionnaires, an Exercise-Induced Hypoalgesia protocol, and standardized irritability assessment based on Clinical Practice Guidelines. Participants were then categorized as irritable or not irritable based on Maitland's criteria and by irritability level based on Clinical Practice Guidelines. An independent samples t-test examined for differences in QST and psychological factors by irritability category. A MANOVA examined for differences in QST and psychological factors by irritability level (high, moderate, low)., Results: Significantly lower heat and pressure pain thresholds at multiple locations ( p  < 0.05), as well as less efficient conditioned pain modulation ( p  = 0.02), were demonstrated in individuals categorized as irritable. Heat and pressure pain thresholds were also significantly lower in patients with high irritability compared to other levels. Significantly higher depression and anger, as well as lower self-efficacy, were reported in individuals with an irritable presentation., Discussion/conclusion: Biopsychosocial factors, including widespread hyperalgesia and elevated psychological factors, may contribute to an irritable presentation.

Overhead sports overload the shoulder complex due to movement repetition and the great amount of force created during the athletic motion, which may cause adaptations in the shoulder and lead to shoulder pain. However, overhead movements include the kinetic chain, and alterations in some of the structures throughout the kinetic chain may increase stress on the shoulder complex and be associated with shoulder pain., Purpose: To compare kinetic chain components in overhead athletes with and without shoulder pain., Methods: Forty-one volleyball and handball athletes (21 with and 20 without shoulder pain) were included and assessed for hip internal (IR) and external rotation (ER) range of motion (ROM), hip and trunk isometric strength, trunk endurance and neuromuscular control of the lower and upper limbs (Y balance test)., Results: Athletes with shoulder pain showed smaller IR ROM in both hips, lower endurance time for trunk extensors and flexors, decreased reach distance in the anterior and posteromedial direction, as well as a smaller composite score in the Y balance test (p < 0.05)., Conclusion: Volleyball and handball athletes with shoulder pain showed changes in ROM throughout the kinetic chain in addition to lower core endurance, and decreased neuromuscular control of lower limbs., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Pain sensitivity is the main finding of central sensitization (CS) and can occur in patients with chronic shoulder pain. However, there is limited evidence concerning the distribution of pain sensitivity in shoulders, forearms, and legs in patients with CS associated with chronic shoulder pain. The present study aimed to determine the distribution of pain sensitivity in patients with CS associated with chronic subacromial pain syndrome (SPS)., Method: This cross-sectional study included 58 patients with chronic SPS and CS (patient group) and 58 healthy participants (control group). The presence of CS was determined using the Central Sensitization Inventory (CSI). To determine the distribution of pain sensitivity, pressure pain threshold (PPT) measurements were performed from the shoulders, forearms, and legs., Results: There was no significant difference between the two groups in terms of sociodemographic data (p > 0.05). The patient group had a significantly higher CSI score (p < 0.001) and lower PPTs in all regions (p < 0.05) than the control group. Unlike the control group, the patient group had lower PPTs on the affected side for the shoulder [mean difference (MD) 95% confidence interval (CI): 1.2 (-1.7 to -0.6)], forearm [MD 95% CI: 1.1 (-1.7 to -0.6)], and leg [MD 95% CI: 0.9 (-1.4 to -0.3)] compared with the contralateral side (p < 0.001)., Conclusion: Pain sensitivity is more pronounced in the affected shoulder and the forearm and leg located on this side than in those on the contralateral side in patients with CS associated with chronic SPS., Competing Interests: Declaration of Competing interest The authors have no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Hypothesis and Background: It is known that, though widely used, shoulder range of motion (ROM) measurements are not standardized and have a high rate of intra- and interobserver differences. Particularly, the inconsistency in quantitative and qualitative measurements and their relationship to patient-reported outcome measures (PROMs) make shoulder health difficult to determine., Methods: This was a prospective study of 147 patients who presented with a chief complaint of shoulder pain to the orthopedic sports medicine and shoulder clinic of a single fellowship-trained surgeon. Measured by 1 examiner, quantitative ROM measurements were taken with a goniometer and qualitative ROM measured by the anatomic level that the patient could reach. The following PROMs were used as well: American Shoulder and Elbow Surgeons shoulder score, Single Assessment Numeric Evaluation, Shoulder Pain and Disability Index, Oxford Shoulder Score, Disabilities of the Arm, Shoulder, and Hand questionnaire, 12-Item Short Form Health Survey, and Patient-Reported Outcomes Measurement Information System pain interference short form 6a (PROMIS 6a). Statistical analysis was performed with SPSS using the Pearson correlation and 2-sample t test. The Benjamini-Hochberg correction was used to determine the P value at which statistical significance was reached to correct for multiple comparisons., Results: Qualitative internal rotation (IR) (the hand behind back reach test) and qualitative forward flexion (FF) correlated with all goniometer angle measurements and PROMs (both shoulder and general health scores). These qualitative measures proved to be an appropriate proxy for IR and FF goniometer measurements. Qualitative external rotation (ER) was not a good substitute for quantitative ER measurement. Quantitative ER correlated with all PROMs. As ROM increased when measured by quantitative ER, qualitative IR, and qualitative FF, shoulder and general health PROMs incrementally increased as well., Discussion/conclusions: Qualitative IR measurement, the hand-behind-back reach test, is an adequate substitution for IR goniometer angle as well as a strong representation of global shoulder ROM, shoulder health, and general health while factoring in patient age. Qualitative FF measurement is also an appropriate proxy for quantitative FF and represents global shoulder and general health without factoring in age. Quantitative ER, via goniometer angle, is a better assessment of the shoulder than qualitative ER and is a representation of overall shoulder and general health. We recommend the use of quantitative ER, qualitative IR, and qualitative FF measurements to best understand a patient's overall shoulder health and its impact on their overall health., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Shoulder pain is the third most common musculoskeletal disorder yet diagnosis remains challenging. In some cases, shoulder symptoms can be partially attributed to a cervical origin., Objectives: To estimate the prevalence of cervical contribution in patients presenting with shoulder pain. To determine symptom reproduction and symptom modification (i.e., pain intensity and pain location) after cervical spine screening (CSS) and compare these changes between patients with and without cervical contribution., Design: Observational study., Method: Sixty patients were included. Cervical contribution was present if a ≥30.0% change in shoulder pain intensity on active movement was recorded after CSS. The CSS consisted of several tests and shoulder symptom modification or reproduction was noted. The presence of a centralization phenomenon was also noted and was considered to be present if the location of pain diminished from more distal areas after the CSS., Results: A 50.0% prevalence of cervical contribution (CI95% 37,35-62,65) was found. Cervical contribution was more likely in those that demonstrated centralization of their pain after the CSS (p = 0.002) and those that had a history of previous neck pain (p = 0.007). Symptom reproduction occurred for 23 out of the 60 participants (38.3%), being present in 18 of those with cervical contribution (60.0%). After the CSS, a statistically significant decrease of shoulder pain intensity was found for those classified as having cervical contribution (p < 0.001)., Conclusions: Cervical contribution is prevalent in 50% of patients presenting with shoulder pain; this was evidenced as shoulder symptom modification and, to a lesser extent, symptom reproduction following a CSS., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: The methods previously proposed in the literature to assess patients with rotator cuff related shoulder pain, based on special orthopedic tests to precisely identify the structure causing the shoulder symptoms have been recently challenged. This opens the possibility of a different way of physical examination., Objective: To analyze the differences in shoulder range of motion, strength and thoracic kyphosis between rotator cuff related shoulder pain patients and an asymptomatic group., Method: The protocol of the present research was registered in the International Prospective Register of Systematic Review (PROSPERO) (registration number CRD42021258924). Database search of observational studies was conducted in MEDLINE, EMBASE, WOS and CINHAL until July 2023, which assessed shoulder or neck neuro-musculoskeletal non-invasive physical examination compared to an asymptomatic group. Two investigators assessed eligibility and study quality. The Newcastle Ottawa Scale was used to evaluate the methodology quality., Results: Eight studies ( N  = 604) were selected for the quantitative analysis. Meta-analysis showed statistical differences with large effect for shoulder flexion (I2 = 91.7%, p  < 0.01, HG = -1.30), external rotation (I2 = 83.2%, p  < 0.01, HG = -1.16) and internal rotation range of motion (I2 = 0%, p  < 0.01, HG = -1.32). Regarding to shoulder strength; only internal rotation strength showed statistical differences with small effect (I2 = 42.8%, p  < 0.05, HG = -0.3)., Conclusions: There is moderate to strong evidence that patients with rotator cuff related shoulder pain present less shoulder flexion, internal and external rotation range of motion and less internal rotation strength than asymptomatic individuals., Competing Interests: Alfonso Gil-Martínez is an Academic Editor for PeerJ., (©2024 Manoso-Hernando et al.)

Background: Dysfunctional gliding of deep fascia and muscle layers forms the basis of myofascial pain and dysfunction, which can cause chronic shoulder pain. Ultrasound shear strain imaging may offer a non-invasive tool to quantitatively evaluate the extent of muscular dysfunctional gliding and its correlation with pain. This case study is the first to use ultrasound shear strain imaging to report the shear strain between the pectoralis major and minor muscles in shoulders with and without chronic pain., Case Presentation: The shear strain between the pectoralis major and minor muscles during shoulder rotation in a volunteer with chronic shoulder pain was measured with ultrasound shear strain imaging. The results show that the mean ± standard deviation shear strain was 0.40 ± 0.09 on the affected side, compared to 1.09 ± 0.18 on the unaffected side (p<0.05). The results suggest that myofascial dysfunction may cause the muscles to adhere together thereby reducing shear strain on the affected side., Conclusion: Our findings elucidate a potential pathophysiology of myofascial dysfunction in chronic shoulder pain and reveal the potential utility of ultrasound imaging to provide a useful biomarker for shear strain evaluation between the pectoralis major and minor muscles., (© 2024. The Author(s).)

Background: Low back pain can affect musculoskeletal problems of the upper limb in adolescent overhead athletes. However, few epidemiological studies have examined this causal relationship. This prospective cohort study aimed to investigate the relationship between baseline low back pain experience and the occurrence of future shoulder and elbow pain among high school baseball players., Methods: Participants comprised 383 high school baseball players from 43 high school baseball teams who had undergone baseline medical evaluations (a self-completed questionnaire and physical examination). The occurrence of shoulder and elbow pain during a 1-year follow-up and associations with baseline low back pain (positive subjective symptom during the last year at baseline) adjusted for flexibility of the scapulo-thoracic region, shoulder, and lower extremities, such as straight-leg raise angle (hamstring tightness), Thomas test (iliopsoas tightness), heel-buttock-distance (quadriceps tightness) and passive range of motion of the hip were investigated using multivariable analysis., Results: A total of 307 players (80.2%) participated in the 1-year follow-up survey, with shoulder and elbow pain reported in 75 players (24.4%) and 119 players (38.8%), respectively, during follow-up. After adjusting for factors associated with shoulder pain using logistic regression modeling, significant associations between LBP experienced during the last year at baseline (odds ratio, 2.18; 95% confidence interval, 1.23-3.87; P = 0.0078) and new-onset of shoulder pain were noted., Conclusions: Baseline low back pain impacted future shoulder pain in high school baseball players during the 1-year follow-up. Management of shoulder pain warrants careful attention to low back pain., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Subacromial pain syndrome (SPS) is the most frequent shoulder pathology. The aims of this prospective randomized study were to evaluate the effects of some specific shoulder joint mobilizations ("spin correction"), and the effectiveness of a rehabilitation program, named Shoulder Global Concept, in SPS patients., Methods: 45 patients with SPS were randomly assigned to two groups, to benefit from a different first session of mobilizations: the experimental group received all specific mobilizations, while the control group received the same program but without the spin correction mobilizations. The second session was identical for both groups, with all specific mobilizations. Before and after the first two sessions, range of motion (ROM) in flexion, abduction, external and internal rotations, pain and functional status with Constant score and Quick Dash were evaluated. Evaluation was repeated with 24 patients after 11 rehabilitation sessions. Rehabilitation with Shoulder Global Concept included 13 mobilizations aiming at improving the ROM with passive and active-assisted mobilizations, static stretching, and muscle strengthening., Results: All ROM were improved at the end of the first session for both groups, but significantly more in the experimental group for glenohumeral (GH) abduction and external rotation (p < 0.05). Functional scores, pain and strength were significantly improved after 11 rehabilitation sessions with the Shoulder Global Concept., Conclusion: This manual therapy method was able to improve shoulder mobility in one session. The additional joint mobilizations (spin correction) specifically increased GH abduction and external rotation. Rehabilitation of SPS with Shoulder Global Concept allowed to improve functional capacity and decrease pain., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Individuals with rotator cuff-related shoulder pain (RCRSP) have altered proprioception. The relationship between shoulder pain and proprioception is not well understood., Purpose: This study aimed to investigate the relationship between shoulder pain and proprioception., Study Design: This was a cross-sectional comparative study., Methods: Twenty-two participants with RCRSP (mean age 27.6 ± 4.8 years) and 22 matched pain-free participants (23.4 ± 2.5 years) performed two upper limb active joint position sense tests: (1) the Upper Limb Proprioception Reaching Test (PRO-Reach; reaching toward seven targets) in centimeters and (2) Biodex System at 90% of maximum internal rotation in degrees. Participants performed three memorization and three reproduction trials blindfolded. The proprioception error (PE) is the difference between the memorized and estimation trials. Pain levels were captured pre- and post-evaluation (11-point Likert Numerical Pain Rating Scale). Relationships between PE and pain were investigated using independent t-tests and Spearman rank correlations., Results: Overall, 22.7% RCRSP participants indicated an increase in pain following the PRO-Reach (X̅ increase of 1.4 ± 1.5 points), while 59% did so with the Biodex (X̅ increase of 2.3 ± 1.8 points), reflecting a clinically important increase in pain. Weak-to-moderate correlations between pain and PEs were found with the Biodex (r = 0.39-0.53) and weak correlations with the PRO-Reach (r = -0.26 to 0.38). Concerning PEs, no significant differences were found between groups with the Biodex (p = 0.32, effect size d = -0.31 [-0.90 to 0.29]). The RCRSP participants demonstrated lower PEs with the PRO-Reach in elevation compared to pain-free participants (global X̅ = 4.6 ± 1.2 cm vs 5.5 ± 1.5 cm; superior 3.8 ± 2.1 cm vs 5.7 ± 2.9 cm; superior-lateral nondominant targets 4.3 ± 2.2 cm vs 6.1 ± 2.8 cm; p = 0.02-0.05, effect size d = 0.72-0.74 [0.12-1.3])., Conclusions: Individuals with RCRSP demonstrated better upper limb proprioception in elevation, suggesting a change to interoception (sensory reweighting) in the presence of pain., Competing Interests: Declaration of competing interest There are no competing interests to declare. No conflict of interest exists from any of the authors involved in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose of the Study: In this study, we aimed to evaluate acromiohumeral distance (AHD) and supraspinatus tendon (ST) thickness measurements and their relationship with pain and function in ST pathologies., Material and Methods: The study included 111 patients and 25 healthy controls (HC). Patients were divided into 3 groups according to their diagnosis: non-tear tendinopathy (NTT), partial thickness tear (PTT), and full thickness tear (FTT). The AHD and ST thickness of the participants were measured with ultrasound. The pain and functional status of the patients were evaluated with the Numeric Rating Scale (NRS), The QuickDASH shortened version of the DASH Outcome Measure - Disabilities of the Arm Shoulder and Hand (QDASH), and Simple Shoulder Test (SST)., Results: The AHD value was significantly higher in the NTT group (p=0.000). The AHD value was significantly lower in the FTT group (p=0.000). ST thickness value was significantly lower in the PTT group compared to the NTT group (p=0.000). There was a positive correlation between ST thickness and BMI (r=0.553,p<0.01). There was a negative correlation between ST thickness and SST and a positive correlation between ST thickness (r=-0.223,p<0.05) and QDASH (r=0.276,p<0.05)., Conclusions: We found that AHD and SST thicknesses significantly differed in the NTT, PTT, FTT, and HC groups. This difference may be important for diagnosis. In addition, the effect of obesity on ST thickness and the relationship between ST thickness and functional scores may be considered. Weight control may be effective at this point., Key Words: acromiohumeral distance, supraspinatus tendon thickness, ultrasound.

Background: Work-related shoulder disorders adversely affect the quality of life and lead to increased costs related to decreased productivity and injury treatment. Therefore, understanding the relationship between strength, upper extremity function and work ability contributes to the development of interventions aimed to improve the well-being of healthcare workers., Objective: Correlate shoulder abduction and handgrip strength with upper extremity function and work ability in healthcare workers with shoulder complaints., Methods: 67 workers with shoulder pain in the last year were assessed by Disability of Arm, Shoulder and Hand (QuickDASH), Work Ability Index (WAI), isokinetic shoulder strength and isometric handgrip strength dynamometers. Data were analysed with Spearman's Correlation Coefficient (ρ= 0.05), SPSS 20.0®., Results: 52% males, mean age 48.4 years, 42% physically active, most administrative and general services workers. Low correlation between handgrip strength and QuickDASH (r=-0.359; p = 0.004); low correlation between handgrip strength and WAI (r = 0.359; p = 0.003) and between shoulder abduction strength and the QuickDASH (r = -0.267; p = 0.049); no significant correlation between shoulder abduction strength and WAI (r = 0.001; p = 0.997)., Conclusions: Handgrip and shoulder abduction strength were inversely associated with upper extremity dysfunction. Shoulder abduction strength was associated with work ability. The inclusion of strength assessment in workers is important to guide strategies to prevent musculoskeletal disorders.

Background: Subacromial pain syndrome is the predominant cause of shoulder pain, accounting for approximately half of all shoulder complaints. This population presents with weakness of the involved shoulder. However, there is a gap in our understanding of how pain contributes to this weakness, and whether there are sex related differences., Methods: Regional and global isometric strength was tested at the involved shoulder joint and remote joints (uninvolved shoulder and both knees) in patients with subacromial pain syndrome. Data were collected before and after acute pain reduction with a subacromial injection., Findings: Patients demonstrated weakness at the involved shoulder while remote joints demonstrated normal strength. When compared to healthy controls, male patients were shown to exhibit greater levels of weakness than female patients at the involved shoulder, based on comparisons with sex-matched controls using z-scores. Pain reduction (through an anesthetic injection) had no influence on strength in the short-term., Interpretation: Weakness in patients appears to be sex dependent and is not resolved with reduction of pain. This calls into question the assumptions of the physiological causes of this weakness., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Shoulder pain may be related to biomechanical dysfunctions in the kinetic chain., Objective: To compare the mobility and muscular endurance of thoracolumbar spine and hip, and the neuromuscular control of the lower extremity of individuals with and without shoulder pain and to determine the discriminative capacity between groups of these variables., Design: A cross-sectional study., Method: One hundred and two individuals with and without shoulder pain were evaluated to range of motion (ROM) of the thoracolumbar spine and hips, the muscular endurance time of the thoracolumbar spine and hips muscles, and the neuromuscular control of the lower extremity, by the Star Excursion Balance Test (SEBT)., Results: Individuals with shoulder pain presented lower ROM and muscular endurance time in all tests evaluated (p < 0.01-p = 0.03), greater perception of pain during all ROM and muscle endurance (p < 0.01-p = 0.04) evaluations, and less neuromuscular control of the lower extremity in the compound reach (p < 0.01-p = 0.01), anterior and posteromedial (p < 0.01-p = 0.04) directions of the SEBT on both sides. The anterior reach direction of the SEBT of the contralateral limb to the shoulder pain (AUC=0.80, cut-off point=47.7%) presented excellent capacity to discriminate individuals with shoulder pain, while the other variables showed between acceptable and small capacity (AUC=0.58-0.76)., Conclusion: Individuals with chronic shoulder pain presented alterations in joint mobility, muscular endurance time of the thoracolumbar spine and hips and neuromuscular control of the lower extremity. The anterior reach of the SEBT of the contralateral limb showed excellent discriminative capacity., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The purpose of this study was to investigate the effects of neck and shoulder pain (NSP) and the position of the head and neck on the intramuscular circulation of the cervical muscles such as the trapezius and levator scapulae muscles in young females. Ten NSP subjects (mean age: 20.9 ± 0.5 years) and ten non-NSP subjects (mean age: 20.6 ± 0.7 years) were recruited to this study. Near-infrared spectroscopy (NIRS) was used to non-invasively measure total haemoglobin (Total-Hb), oxygenated haemoglobin (Oxy-Hb), and deoxygenated haemoglobin (Deoxy-Hb) of the trapezius and levator scapulae muscles. The measurements of Total-Hb, Oxy-Hb, and Deoxy-Hb were taken in the neutral position, immediately after the maximally flexed (extended) position, and after 30 s in the maximally flexed (extended) position. In flexion, no significant main effect or interaction was observed with Total-Hb and Oxy-Hb. A significant interaction was observed with Deoxy-Hb (p < 0.01). There was no significant difference in the changes over time in the NSP group (p = 0.91). However, in the non-NSP group, a significant increase was noted at the neutral position to immediately after the maximally flexed position (p < 0.01) and at the end of maintaining the maximally flexed position (p < 0.01). In extension, no significant main effect or interaction was observed with Total-Hb and Oxy-Hb. A significant interaction was observed with Deoxy-Hb (p < 0.01). In the NSP group, no significant difference was observed in the changes over time (p = 0.91). In the non-NSP group, however, a significant decrease was observed from the neutral position to immediately after the maximally extended position (p < 0.01). The results of this study indicate that maintaining either maximal cervical flexion or extension may affect venous blood flow on non-NSP group. However, no effect on NSP group was observed due to existing diminished intramuscular circulation., (© 2022. Springer Nature Switzerland AG.)

Objective: The purpose of this study was to identify important functional problems among individuals with shoulder pain using the Patient-Specific Functional Scale (PSFS) and to investigate differences between individuals receiving primary care and individuals receiving secondary care., Methods: In this cross-sectional study located in a primary and secondary care outpatient clinic, a total of 177 individuals seeking care for shoulder pain (84 from primary care and 93 from secondary care) were recruited. Background variables, pain, physical activity, and PSFS responses were collected using a questionnaire software package. Meaningful concepts were linked from the PSFS responses to the International Classification of Functioning, Disability and Health (ICF) according to established rules. Frequencies for the ICF categories were estimated separately for primary care and secondary care. Differences between primary care and secondary care were investigated by calculating CIs for the sample proportions at ICF chapter level., Results: The primary care sample reported functional problems linked to 226 ICF categories, whereas the secondary care sample reported functional problems linked to 337 ICF categories. Of the linked ICF categories, 87.7% belonged to the Activities and Participation component of the ICF. Seventeen categories were identified in >3% of the individuals; of those, the most frequent categories were recreation and leisure, lifting and carrying objects, doing housework, hand and arm use, and remunerative employment. Categories included in the ICF chapters of self-care and domestic life were significantly more frequent in the secondary care sample, whereas there was a trend that neuromusculoskeletal and movement-related functions were more frequent in primary care., Conclusion: The present findings indicate that individuals with shoulder pain report a wide range of functional problems, from basic functions related to mobility to activities related to work and leisure. This study also discovered differences between patients in primary care and secondary care. The large variation in the experiences between people supports the use of an individualized measure in assessments., Impact: This study adds new knowledge about problems in functioning among people with shoulder pain and how the individual experience varies between primary care and secondary care settings. Moreover, the content analyses used in this study showed the full potential of the ICF classification and should have potential for further application., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

Background: People with chronic shoulder pain have been shown to present with motor adaptations during arm movements. These adaptations may create abnormal physical stress on shoulder tendons and muscles. However, how and why these adaptations develop from the acute stage of pain is still not well-understood., Objective: To investigate motor adaptations following acute experimental shoulder pain during upper limb reaching., Methods: Forty participants were assigned to the Control or Pain group. They completed a task consisting of reaching targets in a virtual reality environment at three time points: (1) baseline (both groups pain-free), (2) experimental phase (Pain group experiencing acute shoulder pain induced by injecting hypertonic saline into subacromial space), and (3) Post experimental phase (both groups pain-free). Electromyographic (EMG) activity, kinematics, and performance data were collected., Results: The Pain group showed altered movement planning and execution as shown by a significant increased delay to reach muscles EMG peak and a loss of accuracy, compared to controls that have decreased their mean delay to reach muscles peak and improved their movement speed through the phases. The Pain group also showed protective kinematic adaptations using less shoulder elevation and elbow flexion, which persisted when they no longer felt the experimental pain., Conclusion: Acute experimental pain altered movement planning and execution, which affected task performance. Kinematic data also suggest that such adaptations may persist over time, which could explain those observed in chronic pain populations., (© 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Background: Patient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores., Question/purpose: After controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?, Methods: Fifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05., Results: This model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r2 = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.65; p < 0.001)., Conclusion: Our results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan., Level of Evidence: Level II, prognostic study., Competing Interests: Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

The purpose of study was to determine and compare electromyographic activity of selected shoulder girdle muscles in elite swimmers with and without shoulder pain. Twelve professional swimmers with shoulder pain (mean age: 18.55 ± 3.16 years, body mass: 74.33 ± 2.91 kg and height: 179.00 ± 5.29 cm) and 12 swimmers without pain (mean age: 18.11 ± 1.61 years, body weight: 73.33 ± 6.06 kg, height: 178.33 ± 5.07 cm) were recruited. Surface electromyography signals were collected from seven upper limb muscles during a task: participants were instructed to mark points with a pen within each of the three circles counterclockwise. The normalised root-mean-square value was used to determine the muscular activation. Swimmers with shoulder pain demonstrated greater activation of the upper trapezius (pain group mean: 28.04 ± 10.37, control group mean: 13.40 ± 06.04; p = 0.002, η p 2 : 0.455), serratus anterior (pain group mean: 30.78 ± 20.09, control group mean: 13.30 ± 5.52; p = 0.023, η p 2 : 0.283) and latissimus dorsi (pain group mean: 27.05 ± 17.87, control group mean: 4.99 ± 3.90; p = 0.002, η p 2 : 0.450) muscles. There was no difference ( p > 0.05) in the activation of the middle and lower trapezius, middle deltoid and sternocleidomastoid. The altered muscle activation patterns may contribute to the painful shoulder in elite swimmers and need to be considered within the rehabilitation interventions.

Purpose: Previous studies show no difference in clinical outcomes between patients with healed and structurally failed rotator cuff repairs. The objective of this study was to assess ceiling effects when reporting surgical outcomes of arthroscopic rotator cuff repair using four of the currently most popular clinical shoulder outcome scoring systems., Methods: Ninety-two patients who underwent arthroscopic rotator cuff repair were examined. The simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder rating scale, and Constant-Murley shoulder score were completed 2 years postoperatively. Demographic data of the subjects were analysed using descriptive statistics. The ceiling effects in the outcome data assessed for each scale were estimated based on two previously reported definitions., Results: The number of patients with the maximum possible score was 31 (33.7%) with the SST, 26 (28.3%) with the ASES score, 28 (30.4%) with the UCLA scale, and 18 (19.6%) with the Constant-Murley score. The standardised distance of the outcome data assessed by the SST, ASES score, UCLA scale, and Constant-Murley scores were 0.92, 0.97, 0.96, and 1.18, respectively., Conclusion: The SST, ASES score, and UCLA scale evaluated at 2 years postoperatively have substantial ceiling effects showing that the proportion of patients with the maximum possible score is > 20%, and the standardised distance is < 1.0. Researchers should be aware of possible biases due to ceiling effects when interpreting the results of studies investigating the surgical outcomes of arthroscopic rotator cuff repair. It could increase the likelihood of a type II error., Level of Evidence: IV.

Purpose: Neck and shoulder pain (NSP) is very common in the general population. However, scarce information exists on the relationship between NSP and health-related quality of life (HRQOL) outcomes in this population. The present study described NSP prevalence and its impact on the HRQOL of middle-aged and older persons undergoing a routine medical checkup., Methods: This study recruited 318 subjects (125 males and 193 females; average age, 63.4 years) in good health, collected underwent anthropometric measurements, physical function examinations, and blood testing. This study defined NSP as the presence of muscle tension, stiffness, pressure, or dull pain in areas between the neck and the arch of the scapular. Study subjects were divided into two groups (NSP (+) and NSP (-) groups). The subjects completed questions on the Medical Outcomes Study 36-item short-form health survey (SF-36) and the EuroQol 5-dimension, 5-level version (EQ-5D-5L) tool., Results: Of the patients, 150 and 168 were NSP (+) and NSP (-), respectively. The NSP complaint rate was 47.2%. The NSP (+) group had younger and more female participants than the NSP (-) group. In the multivariate regression analysis, the NSP (+) group had lower physical QOL based on the SF-36 physical component summary (odds ratio (OR), 2.45) and lower mental QOL based on the SF-36 mental component summary (OR, 2.05). Overall, the NSP (+) group had a higher risk of having low QOL scores (EQ-5D-5L index; OR, 1.76)., Conclusions: The NSP (+) rate in healthy middle-aged and older persons was 47.2%. Furthermore, NSP (+) status was directly related poor HRQOL. NSP is a predictor of suboptimal physical and mental QOL. Therefore, NSP prevention or intervention for NSP may improve middle-aged and older adults' QOL., Competing Interests: The authors report no conflict of interest except for the national grant., (Copyright © 2021 Masaaki Machino et al.)

Our prior studies identified a high-risk phenotype (ie, high pain sensitivity variant of the catechol-O-methyltransferase gene (Single Nucleotide Polymorphism [SNP] rs6269) and pain catastrophizing scores) for shoulder pain. The current study identified sensory and psychological predictors of heightened pain responses following exercise-induced shoulder injury. Healthy participants (N = 131) with the SNP rs6269 catechol-O-methyltransferase gene and Pain Catastrophizing Scale scores ≥5 underwent baseline sensory and psychological testing followed by an established shoulder fatigue protocol, to induce muscle injury. Movement-evoked pain, pain intensity, disability, and strength were assessed 24 hours postinjury. Demographic, sensory, and psychological variables were included as predictors in full and parsimonious models for each outcome. The highest variance explained was for the shoulder disability outcome (full model R 2  = .20, parsimonious R 2  = .13). In parsimonious models, the individual predictors identified were: 1) 1st pulse heat pain sensitivity for isometric shoulder movement-evoked pain and pain intensity; 2) pressure pain threshold for shoulder disability; 3) fear of pain for active shoulder movement-evoked pain and shoulder disability; and 4) depressive symptoms for shoulder strength. Findings indicate specific pain sensitivity and psychological measures may have additional prognostic value for self-reported disability within a high-risk phenotype. These findings should be tested in a clinical cohort for validation. PERSPECTIVE: The current study extends previous work by providing insight regarding how poor shoulder outcomes may develop within a high-risk phenotype. Specifically, 1st pulse heat pain sensitivity and pressure pain threshold were sensory measures, and fear of pain and depressive symptoms were psychological measures, that improved prediction of different shoulder outcomes., (Copyright © 2021 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Residual intra-peritoneal gas may be associated with post-laparoscopic shoulder pain (PLSP), which is a frequently and disturbance compliant after surgery. Herein, we aimed to examine whether expiring residual gas via a surgical drain reduces the frequency and intensity of PLSP in the first day after laparoscopic cholecystectomy. 448 participants were enrolled in this prospective cohort study. The incidence and severity of PLSP after surgery were recorded. Of these, the cumulative incidence of PLSP in the drain group was lower particularly at the 12th postoperative hour (18.3% vs. 27.6%; P = 0.022), 24th postoperative hour (28.8% vs. 38.1%; P = 0.039), and throughout the first postoperative day (P = 0.035). The drain group had less severe PLSP (crude Odds ratio, 0.66; P = .036). After adjustment using inverse probability of treatment weighting, the drain group also had a significant lower PLSP incidence (adjusted hazard ratio = 0.61, P < 0.001), and less severe PLSP (adjusted odds ratio = 0.56, P < 0.001). In conclusion, the maneuver about passive force to expel residual gas, surgical drain use, contributes to reduce the incidence and severity of PLSP, suggesting that to minimize residual gas at the end of surgery is useful to attenuate PLSP.

Objective: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is widely used to assess patients with symptoms of subacromial pain syndrome (SPS). No study has analyzed the DASH by using the Rasch model in these patients and related the level of difficulty of the items with the International Classification of Functioning Disability and Health (ICF) domains. The purpose of this study was to evaluate the measurement properties of the DASH in individuals with SPS and to describe which ICF components are influenced by SPS based on the DASH., Methods: The full version of the DASH was used to assess upper limb pain and function in individuals with SPS. Responses were assessed using the Rasch model. DASH items were grouped according to the level of difficulty and associated with the ICF domains to identify the most compromised aspect in these individuals., Results: Reliability and internal consistency for the DASH were shown to be 0.93 and 0.95, respectively. Item 3 ("Turn a key") was the easiest and 25 ("Pain during specific activity") the most difficult. Only item 30 ("Less capable/confident/useful") was as an erratic item. Item 15 ("Put on a sweater") showed differential functioning by age and item 11 ("Carry a heavy object") by sex. Seven items showed differential functioning related to the angular onset of pain during arm elevation. Sixty percent of the most difficult items belonged to the "Body function" domain of the ICF., Conclusion: Although some psychometric properties of the DASH are adequate according to the Rasch model, adjustments to some items are necessary for individuals with SPS. Clinicians should be cautious when interpreting the DASH, especially in patients with angular onset of pain above 120 degrees of arm elevation., Impact: The information contained in this study should be used by clinicians to interpret the results of the DASH when assessing individuals with SPS. The DASH may not be adequate to assess those with shoulder pain above 120 degrees of arm elevation. These results are not generalizable to other shoulder pathologies., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

A tightness of the posterior structures of the throwing shoulder has been hypothesised to be associated with injuries and pain because of alterations of the scapular kinematics and muscular imbalances. The aims of this study were to identify the clinical and biomechanical profile of symptomatic and asymptomatic overhead athletes with a tight shoulder and to evaluate the efficiency of a self-applied stretching program. Twenty male overhead athletes were recruited. Half of them reported a painful shoulder at the beginning of the study. For four weeks, the volunteers performed daily stretching exercises. Before and after the stretching program, gleno-humeral mobility, scapular kinematics, rotator muscles strength and pain were evaluated. Before stretching, the main difference between the groups was more impingement syndrome and rotator cuff tendon lesion positive tests in the symptomatic group ( p  < 0.027, effect size = 0.51). After the program, pain reported by the symptomatic volunteers was reduced by approximately 40% and the gleno-humeral internal rotation bilateral difference was significantly reduced by 77.6% ( p < 0.009, effect size = 0.84). In the symptomatic group, the scapula at rest was significantly more posteriorly tilted ( p = 0.027, effect size = 0.69) after the stretching; a position that has been shown to limit the risk of impingement. The absence of significant differences of the profiles of the symptomatic and asymptomatic overhead athletes before stretching may indicate that the initiation of early prevention programs, including self-applied stretching, should not rely solely on biomechanical and clinical parameters and might be recommended to all players with a tight shoulder.

Objectives: The study aimed to investigate whether the shoulder tendons changed their elasticity after ultrasound-guided peritendinous or intrabursal corticosteroid injections., Design: Post hoc secondary analysis of a double-blinded, randomized controlled study with 3 months of follow-up., Setting: Outpatient rehabilitation clinic., Participants: Patients with subacromial impingement syndrome (N=60)., Interventions: Patients with unilateral shoulder pain were randomly assigned to receive standard ultrasound-guided subacromial or dual-target corticosteroid injections. The supraspinatus tendons were exposed to 40 mg triamcinolone acetonide in the formal group, whereas the long head of the biceps brachii tendons (LHBT) and supraspinatus tendons were individually infiltrated by 20 mg triamcinolone acetonide in the latter group. Patients' bilateral shoulders were divided into group 1 (n=30, receiving standard subacromial injections), group 2 (n=30, receiving dual-target injections), and group 3 (n=60, without injections)., Main Outcome Measures: Strain ratio of LHBT and supraspinatus tendons using ultrasound elastography., Results: The repeated-measures analysis of variance revealed no intragroup difference of the strain ratio of the LHBT (P=.412 for group 1, P=.936 for group 2, P=.131 for group 3) and supraspinatus tendon (P=.309 for group 1, P=.067 for group 2, P=.860 for group 3) across the 3 time points. Treating group 3 as the reference, the linear mixed model revealed no significant changes in tendon elasticity after either the standard subacromial injection (P=.205 for the LHBT and P=.529 for the supraspinatus tendon) or the dual-target injection (P=.961 for the LHBT and P=.831 for the supraspinatus tendon)., Conclusions: Elasticity of the LHBT and supraspinatus tendons is unlikely to change after a single dose of peritendinous or intrabursal corticosteroid injections. Future studies with a shorter follow-up interval are needed to validate whether corticosteroid injections can cause transient changes of the tendon's elasticity., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether a composite metric of arm elevation and trapezius activity (i.e. neck/shoulder load) is more strongly associated with the 2-year course of neck and shoulder pain intensity (NSPi) among construction and healthcare workers than each exposure separately., Methods: Dominant arm elevation and upper trapezius muscle activity were estimated in construction and healthcare employees (n = 118) at baseline, using accelerometry and normalized surface electromyography (%MVE), respectively. At baseline and every 6 months for 2 years, workers reported NSPi (score 0-3). Compositions of working time were determined for arm elevation (< 30°; 30-60°;  > 60°), trapezius activity (< 0.5%; 0.5-7.0%; > 7.0%MVE), and a composite metric "neck/shoulder load" (restitution, low, medium, and high load). Associations between each of these three compositions and the 2-year course of NSPi were determined using linear mixed models., Results: Associations between exposure compositions and the course of NSPi were all weak and in general uncertain. Time spent in 0.5-7.0%MVE showed the largest and most certain association with changes in NSPi during follow-up (β = - 0.13; p = 0.037; corresponding to a -0.01 change in NPSi every 6 months). Among pain-free workers at baseline, medium (β = - 0.23; p = 0.039) and high (β = 0.15; p = 0.031) neck/shoulder load contributed the most to explaining changes in NSPi., Conclusion: The composite metric of neck/shoulder load did not show a stronger association with the course of NSPi than arm elevation or trapezius activity alone in the entire population, while some indications of a stronger association were found among those who were pain-free at baseline.

Objective: To investigate the association between propulsion biomechanics, including variables that describe smoothness of the applied forces, and shoulder pain in individuals with spinal cord injury (SCI)., Design: Cross-sectional, observational study., Setting: Non-university research institution., Participants: Community dwelling, wheelchair dependent participants (N=30) with chronic paraplegia between T2 and L1, with and without shoulder pain (age, 48.6±9.3y; 83% men)., Interventions: Not applicable., Main Outcome Measures: Rate of rise and jerk of applied forces during wheelchair propulsion. Participants were stratified in groups with low, moderate, and high pain based on their Wheelchair User Shoulder Pain Index score on the day of measurement., Results: A mixed-effect multilevel analysis showed that wheelchair users in the high pain group propelled with a significantly greater rate of rise and jerk, measures that describe smoothness of the applied forces, compared with individuals with less or no pain, when controlling for all covariables., Conclusions: Individuals with severe shoulder pain propelled with less smooth strokes compared to individuals with less or no pain. This supports a possible association between shoulder pain and rate of rise and jerk of the applied forces during wheelchair propulsion., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Shoulder pain and pathology are extremely common for individuals with spinal cord injuries (SCI) who use manual wheelchairs (MWC). Although risky humeral kinematics have been measured during wheelchair-based activities performed in the lab, little is known about arm kinematics in the free-living environment. The purpose of this study was to measure the humeral elevation workspace throughout a typical day for individuals with SCI who use a MWC and matched able-bodied controls. Thirty-four individuals with SCI who use a MWC (42.7±12.7 years of age, 28 males/6 females, C6-L1) and 34 age-and sex-matched controls were enrolled. Participants wore three inertial measurement units (IMU) on their upper arms and torso for one to two days. Humeral elevation angles were estimated and the percentage of time individuals spent in five elevation bins (0-30°, 30-60°, 60-90°, 90-120°, and 120-180°) were calculated. For both arms, the SCI cohort spent a significantly lower percentage of the day in 0-30° of humeral elevation (Dominant: SCI = 15.7±12.6%, Control = 32.1±15.6%, p<0.0001; Non-Dominant: SCI = 21.9±17.8%, Control = 34.3±15.5%, p = 0.001) and a significantly higher percentage of time in elevations associated with tendon compression (30-60° of humeral elevation, Dominant: SCI = 62.8±14.4%, Control = 49.9.1±13.0%, p<0.0001; Non-Dominant: SCI = 58.8±14.9%, Control = 48.3±13.6%, p = 0.003) than controls. The increased percentage of time individuals with SCI spent in elevations associated with tendon compression may contribute to increased shoulder pathology. Characterizing the humeral elevation workspace utilized throughout a typical day may help in understanding the increased prevalence of shoulder pain and pathology in individuals with SCI who use MWCs., Competing Interests: The authors have declared that no competing interests exist.

Objective: Although rotator cuff tear is one of the most common musculoskeletal disorders, its etiology is poorly understood. We assessed factors associated with the presence of rotator cuff tears in a cohort of patients with shoulder pain., Design: From February 2011 to July 2016, a longitudinal cohort of patients with shoulder pain was recruited. Patients completed a detailed questionnaire in addition to a magnetic resonance imaging scan and a clinical shoulder evaluation. The association of multiple factors associated with rotator cuff tears was assessed using multivariate logistic regression., Results: In our cohort of 266 patients, 61.3% of patients had a rotator cuff tear. Older age (per 1 yr: odds ratio = 1.03, 95% confidence interval = 1.02-1.07), involvement of the dominant shoulder (odds ratio = 2.02, 95% confidence interval = 1.16-3.52), and a higher body mass index (per 1 kg/m2: odds ratio = 1.06, 95% confidence interval = 1.03-1.12) were independently associated with rotator cuff tears. Sex, depression, smoking status, shoulder use at work, hypertension, and diabetes were not significantly associated with rotator cuff tear., Conclusions: In a cohort of patients with shoulder pain, we identified older age, involvement of the dominant shoulder, and a higher body mass index to be independently associated with rotator cuff tear. The mechanism of how these factors possibly lead to rotator cuff tears needs further research., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME., Cme Objectives: Upon completion of this article, the reader should be able to: (1) Identify factors associated with an increased risk of developing rotator cuff tears in adults; (2) Describe the current epidemiological trends of rotator cuff tears in the United States; and (3) Discuss the pathophysiological role of aging in the development of nontraumatic rotator cuff tears., Level: Advanced., Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity., Competing Interests: GDA receives all of his funding from the NIH or NCI grants. Ten percent of his effort is funded through the Center of Quantitative Sciences at Vanderbilt, which has a contractual agreement with a principle investigator who has a funding arrangement with Incyte Corporation. GDA is a journal editor for Journal of Elbow and Shoulder Surgery, receiving a stipend for his reviews. LDH is an employee of Arthrex, Inc. KMB receives speaking and consulting fees from Wright Medical and speaking fees from Arthrex (potential conflicts of interest are not directly related to this research). Others authors have no disclosures to declare., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To assess the clinical outcomes of transcatheter arterial embolization (TAE) for secondary stiff shoulder (SSS)., Materials and Methods: This is a retrospective analysis of prospectively collected data performed between January 2017 and December 2019. This study comprised 25 patients (20 women and 5 men; median age, 49 years; range 27-59) with SSS resistant to conservative management during at least 3 months. The median time of stiffness was 12 months. The etiology of SSS was postoperative in 14 patients (56%) and posttraumatic in the remaining 11 patients (44%). Periods of immobilization in all patients were associated. TAE was performed, and technical aspects, adverse events, changes for pain, and physical examination before and 6 months after TAE were assessed., Results: Abnormal vessels were observed in 20 of 25 (80%) of the procedures. Transitory cutaneous erythema was noted in 4 patients treated after TAE. Significant differences were observed in the median pain visual analog scale reduction between before and 6 months after TAE (8 vs 2, P < .001). Shoulder mobility significantly improved in both flexion and abduction degrees between before and at 6 months after TAE in (70° vs 150°; P < .001). No symptoms of recurrence appeared., Conclusions: TAE can result in pain reduction and mobility improvement in patients with SSS refractory to conservative therapy., (Copyright © 2021. Published by Elsevier Inc.)

Objective: Serratus anterior (SA) muscle activation may be decreased with subacromial pain syndrome. The purpose of this study was to determine whether the addition of real-time ultrasound (RTUS) visual feedback increased activation of SA in adults with painful shoulders in comparison to manual facilitation alone., Methods: This assessor-blinded, 2-period, randomized cross-over trial was conducted in a university medical imaging laboratory. Adults with mild-moderate unilateral subacromial pain received both interventions in random order with at least 1-week washout between interventions. Fourteen participants were randomized to receive manual facilitation with RTUS first, and 13 were randomized to receive manual facilitation alone first. Fifteen repetitions of a supine ``serratus punch'' were facilitated by RTUS visual feedback with manual facilitation or by manual facilitation alone. Levels of SA activation via surface electromyography were normalized to a maximum voluntary isometric contraction., Results: A total of 25 participants completed the full trial of both interventions. Data from 25 participant periods for RTUS with manual facilitation and data from 26 participant periods for manual facilitation only were analyzed. The predicted marginal mean difference between interventions was 55.5% (95% CI = 13.9% to 97.1%) in favor of the addition of RTUS feedback. No adverse effects occurred., Conclusion: RTUS visual feedback increases SA activation in adults with painful shoulders compared with manual facilitation alone., Impact: Determining if RTUS can improve SA muscle activation may help clinicians improve physical therapist interventions for subacromial pain syndrome., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Scapular focused exercise interventions are frequently used to treat individuals with shoulder pain. However, evidence for changes in scapular motion after intervention is limited., Objective: To compare the effects of scapular movement training versus standardized exercises for individuals with shoulder pain., Methods: This will be a single-blinded randomized controlled trial. Sixty-four individuals with shoulder pain for at least 3 months, scapular dyskinesis, and a positive scapular assistance test will be randomly allocated to one of two groups: Scapular Movement Training (group 1) and Standardized Exercises (group 2). Group 1 will receive education about scapular position and movement, and be trained to modify the scapular movement pattern. Group 2 will perform stretching and strengthening exercises. Both groups will be treated twice a week for eight weeks. Three-dimensional scapular kinematics and muscle activity of the serratus anterior and upper, middle, and lower trapezius during elevation and lowering of the arm will be assessed at baseline and after 8 weeks of treatment. Pain intensity, function, fear avoidance beliefs, and kinesiophobia will be assessed at baseline and after 4 and 8 weeks of treatment, and 4 weeks after the end of treatment., Conclusions: The results of this study may contribute to a better understanding of the efficacy of scapular focused treatments for individuals with shoulder pain., Clinical Trial Registration: NCT03528499., (Copyright © 2020 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To investigate the evidence of measurement properties of isokinetic dynamometry (ID) for assessment of shoulder muscle strength in healthy individuals and patients with nonneurologic shoulder pathology., Data Sources: Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Physiotherapy Evidence Database were searched up to February 2020 without restrictions. Reference lists and citations were hand-searched., Study Selection: Two review authors independently included studies that met the following criteria: (1) evaluated measurement properties of ID when used on the glenohumeral joint and (2) included individuals 18 years and older. Studies including patients with neurologic, neuromuscular, or systemic diseases or critical illness were excluded., Data Extraction: The quality assessment and data synthesis were performed according to the COnsensus-based Standards for the selection of health Measurement INstruments methodology., Data Synthesis: Twenty-one studies with a total of 597 participants were included. The results were combined separately for isometric, concentric, and eccentric test mode; for the velocities 30°/s-60°/s, 90°/s, 120°/s, and 240°/s; for the seated, supine, and standing position; and for internal rotation (IR), external rotation (ER), and the ER/IR ratio. The reliability of ID was overall sufficient with the majority of intraclass correlation coefficients ≥0.70. The quality of evidence was moderate or low for 20 of 30 strata examined. The measurement error results were rated as insufficient for all strata. The SEM ranged from 4%-28%. The quality of evidence varied depending of strata examined., Conclusions: The reliability of ID for measurement of shoulder strength was overall sufficient for all positions, velocities, and modes of strength. The measurement error was not sufficient. Because most studies used the seated position, the velocities 30°/s-60°/s or 120°/s, and the concentric test mode, the quality of evidence was highest for these conditions., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Abstract: The relationship between supraspinatus tendon thickness and the acromiohumeral distance (AHD) at both rest position and shoulder elevation is still to be explored in those with chronic shoulder pain. The aim is to compare supraspinatus occupation ratio (OR) at 0° and 60° of shoulder elevation measured by ultrasound imaging in the symptomatic shoulder, the contralateral asymptomatic shoulder and in healthy subjects. This was across-sectional, observational study. A sample of 56 participants with subacromial pain syndrome in their dominant arm was recruited in 3 different primary care centres. Forty participants without shoulder pain were also recruited. The AHD at 0° and 60° of active shoulder abduction as well as the supraspinatus tendon thickness were measured by ultrasound in these groups. Supraspinatus OR at 60° was significantly greater in symptomatic compared to asymptomatic shoulders (P = .04) and healthy shoulders (P = .008). The percentage of change in supraspinatus OR from rest position to 60° was also greater in symptomatic shoulders when comparing with asymptomatic (P = .01) and healthy shoulders (P = .03). No other statistically significant differences for the rest of comparisons were found. Supraspinatus OR may explain shoulder pain in chronic conditions. Further studies at acute and chronic conditions after a physiotherapy treatment are needed to explore its usefulness in clinical practice., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: To appraise the quality of clinical practice guidelines (CPGs) for physical therapy management of nontraumatic shoulder pain disorders., Design: Systematic review of CPGs., Literature Search: Two reviewers independently conducted a search of 7 databases and 7 gray literature sources., Study Selection Criteria: We included systematically developed CPGs for physical therapy management of nontraumatic musculoskeletal conditions of the shoulder in adults that were available in full text in the English language. We excluded CPGs for physical therapy management of surgically treated shoulder pain disorders., Data Synthesis: Three reviewers independently rated the quality of included CPGs using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Data were compiled into tables that displayed AGREE II domain scores for each CPG and mean item scores across the CPGs., Results: We included 9 CPGs. Five CPGs focused on rotator cuff disorders, 2 focused on frozen shoulder, and 2 covered a range of soft tissue shoulder diagnoses. Three CPGs were judged as high quality (all were 5 or more years old) and 6 were judged as low quality. The quality domains in which CPGs were rated highest were "scope and purpose" (all CPGs scored greater than 50% and 4 scored greater than 80%) and "clarity of presentation" (all CPGs scored greater than 50% and 7 scored greater than 80%). The domains in which CPGs were rated most poorly were "applicability" (6 CPGs scored 40% or less) and "editorial independence" (4 CPGs scored less than 40%)., Conclusion: There were no high-quality, contemporary CPGs to guide physical therapy management of nontraumatic shoulder pain. J Orthop Sports Phys Ther 2021;51(2):63-71. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9397 .

While previous studies have revealed factors affecting the progression of rotator cuff tear (RCT), none have yet described factors affecting its onset. The purpose of this longitudinal observational study was to analyze factors affecting the RCT onset and progression in the general population. The present study included 185 shoulders from 93 participants who completed all the examinations in both 2012 and 2017. Participants received a questionnaire with age, gender, arm dominance, and presence of pain at rest, in motion, and at night. The range of motion (ROM), simple shoulder test (SST) were also examined. Anteroposterior radiograph of the shoulder joint was performed to evaluate the degree of osteoarthritic changes by the Samilson-Prieto (S-P) classification. The degree of RCT was examined by ultrasonography. There were 132 shoulders without RCT and 53 with RCT in 2012. RCT occurred in 21 of 132 shoulders, and the factor affecting the RCT onset was S-P grade 2 osteoarthritic change in 2012 (odds ratio [OR] 10.10). RCT progressed in 22 of 53 shoulders, and the factor affecting RCT progression was the presence of motion pain in 2012 (OR 13.76). These results added new knowledge regarding the natural course of RCT onset and progression.

Objective: This investigation measured the reproducibility and discriminant validity of the Posterior Shoulder Endurance Test (PSET) on painful and non-painful populations., Design: Reliability and validity study., Setting: Laboratory setting., Participants: Thirty subjects (male = 11; female = 19)., Main Outcome Measures: Time to failure (TTF) was the primary outcome measure to determine reliability of the PSET. Discriminant validity identified with receiver operator characteristic (ROC) curves utilized TTF separately in men and women since they used different loads., Results: There were 25/30 subjects (painful = 12; non-painful = 13) tested a second time. ICC, SEM, and MDC90 ranged respectively from 0.77, 13.1 s, 30.6 s in the painful group to 0.85, 7.3 s, 17 s in the non-painful group. The male ROC curve AUC was 0.833 with 47 s resulting in the best combination of sensitivity = 0.833, and specificity = 0.80. The female ROC curve AUC was 0.633 with 46 s resulting in the best combination of sensitivity = 0.600 and specificity = 0.889 at 46 s., Conclusion: The PSET is a reliable way to measure shoulder girdle muscular endurance. These data suggest that the PSET discriminates painful and non-painful individuals better in men compared to women., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Subacromial pain syndrome (SAPS) defined as pain of nontraumatic origin localized around the acromion, is a debilitating, common, and often chronic condition. Among many proposed underlying causes of SAPS, hypoperfusion and hypoxic conditions in and around the tendons may be an intrinsic cause of SAPS., Purpose: This study aimed to determine if adding high-intensity aerobic interval training (HIIT) of the rotator cuff to usual care was feasible in SAPS and improved shoulder endurance more than usual care alone, as well as to examine the influence on shoulder pain and disability and the response of tendinous microcirculation after HIIT., Methods: Twenty-one subjects with chronic SAPS were randomized to two groups: experimental group (EG; n = 13) receiving HIIT in addition to treatment as usual and control group (CG; n = 8) receiving treatment as usual. Before and after 8 wk of exercise therapy, endurance performance was assessed by an incremental abduction exercise of the arm to exhaustion (TTE). Pain and disability was assessed by the shoulder pain and disability index (SPADI). Contrast-enhanced ultrasound of the musculus supraspinatus and tendon was utilized to indicate tendon blood flow., Results: Endurance in the TTE test improved by an estimated 233 s more on average in EG than in CG (P = 0.001; 95% confidence interval, 102 to 363). The SPADI score was reduced 22 points more on average in EG (P = 0.017; 95% confidence interval, -40 to -5). The change from pretest to posttest was significant in EG for both TTE test and SPADI improvement (P < 0.001). EG also experienced less pain during exercise after the intervention compared with CG (P < 0.001). Contrast-enhanced ultrasound indicated an increase in tendinous blood flow in EG (P = 0.019)., Conclusions: HIIT rotator cuff exercise seems to be a feasible intervention in SAPS, increasing endurance performance more than usual care alone.

Background : There is limited information about the agreement and reliability of clinical shoulder tests. Objectives : To assess the interrater agreement and reliability of clinical shoulder tests in patients with shoulder pain treated in primary care. Methods : Patients with a primary report of shoulder pain underwent a set of 21 clinical shoulder tests twice on the same day, by pairs of independent physical therapists. The outcome parameters were observed and specific interrater agreement for positive and negative scores, and interrater reliability (Cohen's kappa (κ)). Positive and negative interrater agreement values of ≥0.75 were regarded as sufficient for clinical use. For Cohen's κ, the following classification was used: <0.20 poor, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 good, 0.81-1.00 very good reliability. Participating clinics were randomized in two groups; with or without a brief practical session on how to conduct the tests. Results : A total of 113 patients were assessed in 12 physical therapy practices by 36 physical therapists. Positive and negative interrater agreement values were both sufficient for 1 test (the Full Can Test), neither sufficient for 5 tests, and only sufficient for either positive or negative agreement for 15 tests. Interrater reliability was fair for 11 tests, moderate for 9 tests, and good for 1 test (the Full Can Test). An additional brief practical session did not result in better agreement or reliability. Conclusion : Clinicians should be aware that interrater agreement and reliability for most shoulder tests is questionable and their value in clinical practice limited.

Objectives: This study aims to adapt the Western Ontario Osteoarthritis of the Shoulder (WOOS) index specific to shoulder osteoarthritis into Turkish and to evaluate its validity and reliability., Patients and Methods: The WOOS index was translated and culturally adapted into Turkish, systematically. It was applied to a total of 68 patients (17 males, 51 females; mean age: 61.5±8.7 years; range, 45 to 80 years) with osteoarthritis of the shoulder treated conservatively. The reliability of the scale was checked through internal consistency and test-retest methods. Internal consistency was analyzed with Cronbach alpha value. Test-retest reliability was assessed using an intraclass correlation coefficient (ICC) with 25 patients. The Western Ontario Rotator Cuff (WORC), the Shoulder Pain and Disability Index (SPADI), and the Society of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) scores were used to conduct concurrent validity., Results: The Cronbach alpha value of the scale was found to be excellent as 0.92 (p<0.001). The ICC value was also excellent as 0.97 (p<0.001). There was an excellent positive correlation with WORC (0.847; p<0.001) and a very good positive correlation with SPADI (0.788; p<0.001). It was also negatively very good to correlate with the ASES (-0.754; p<0.001). Additionally, subsections of WOOS had a good correlation with the corresponding subsections of WORC (0.779-0.664; p<0.001)., Conclusion: The Turkish version of the WOOS index is a valid and reliable tool and is recommended for use in the assessment of patients with osteoarthritis of the shoulder.

Background: Teachers present with shoulder musculoskeletal disorders, which result in pain and poor shoulder function., Objective: To determine the effect of an eight-week shoulder rehabilitation intervention on pain and function, range of motion and muscle strength among teachers., Methods: Thirty teachers presenting with shoulder pain were recruited and divided into equal control and experimental groups. The intervention group participated in an eight-week rehabilitation programme. Pre- and post-intervention measurements included the scapular position test, range of motion, muscle strength measurements as well as a shoulder rating questionnaire., Results: There was a significant improvement in the experimental group's internal range of motion for the dominant (p= 0.006) and non-dominant arms (p= 0.003) post-intervention. Additionally, significant improvements were found in muscle strength in the experimental group in dominant and non-dominant flexion; abduction; external rotation (p< 0.001); dominant internal rotation (p< 0.001) and non-dominant internal rotation strength (p= 0.007). Post-intervention questionnaire data found a decrease in pain (p= 0.003); improved ability to perform daily activities (p= 0.006); improved overall score (p< 0.001) and satisfaction (p= 0.023) in the intervention group compared to the control group., Conclusion: The implementation of a rehabilitation programme in schools should be considered to manage the prevalence of shoulder musculoskeletal disorders among teachers.

Persons with spinal cord injury (SCI) are at high risk for developing neurogenic obesity due to muscle paralysis and obligatory sarcopenia, sympathetic blunting, anabolic deficiency, and blunted satiety. Persons with SCI are also at high risk for shoulder, elbow, wrist, and hand injuries, including neuromusculoskeletal pathologies and nociceptive pain, as human upper extremities are poorly designed to facilitate chronic weight-bearing activities, including manual wheelchair propulsion, transfers, self-care, and day-to-day activities. This article reviews current literature on the relationship between obesity and increased body weight with upper extremity overuse injuries, detailing pathology at the shoulders, elbows, and wrists that elicit pain and functional decline and stressing the importance of weight management to preserve function., Competing Interests: Conflicts of Interest The authors report no conflicts of interest., (© 2021 American Spinal Injury Association.)

Background: Shoulder pain from rotator cuff pathology and glenohumeral osteoarthritis is a common entity encountered in musculoskeletal practices. Orthobiologic agents are being increasingly used as a treatment option and understanding their safety and efficacy is necessary., Objective: To systematically evaluate the available evidence for orthobiologic use in rotator cuff and glenohumeral pathology., Methods: A systematic review was undertaken following PRISMA guidelines. Randomized clinical trials (RCTs) and prospective cohort studies evaluating non-operative treatment with prolotherapy, platelet-rich plasma (PRP), or medicinal signaling cells (MSCs) for rotator cuff pathology and glenohumeral osteoarthritis were included. Bias risk assessments used were the Cochrane tool and Newcastle-Ottawa score., Results: The search yielded 852 potential articles, of which 20 met the inclusion criteria with a breakdown of 5 prolotherapy, 13 PRP, and 2 MSC. Sixteen studies were RCTs and 4 were cohort studies. Six studies were deemed "low risk of bias or good quality". Efficacy results were mixed, and no serious adverse events were reported from orthobiologic treatment., Conclusions: Orthobiologics offer a relatively safe management option with inconclusive evidence for or against its use for rotator cuff pathology. No studies on glenohumeral osteoarthritis met the inclusion criteria. Adoption of standardized preparation reporting and consistent use of functional outcome measures is imperative for future studies to consider.

Objectives: To compare the change in supraspinatus tendon thickness (STT) following a high volume (HV) and high intensity (HI) swimming practice in shoulders of elite swimmers., Design: Cohort Study., Setting: Non-clinical, state swim team training facility., Participants: A convenience sample of eight non-injured state and national level swimmers from a regional swim team were recruited for this study., Main Outcome Measures: Ultrasound measures of STT were collected in response to the two swimming practice sessions. Measures were taken prior to each swim practice; immediately after practice; 6-hours post practice and 24-hours post practice., Results: A significant increase in STT resulted from both the HI and HV (p < 0.05) practice immediately post practice. For the HI practice, the STT remained significantly thicker than pre-practice measures at the 6-hour post practice test (p < 0.05) however no longer significant 24-hours post practice. The difference in the change in STT between the HI and HV practice was significantly different immediately post practice and 6-hours post practice (p < 0.05) however no longer significant 24-hour post practice., Conclusion: Ultrasound measures of STT following different swimming volumes and intensities may provide information on shoulder tendon loads., Competing Interests: Declaration of competing interest None Declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)